Protrusive Dental Podcast

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Dental Acupuncture made tangible thanks to our guest Dr David Johnson. We cover the basics of trigger points relevant to Dentistry and Temporomandibular Joint Pain, as well as the two main applications of acupuncture in for Dentists. https://youtu.be/sHGJcsIAses Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How I communicate an Oro-Antral Communication:  I will pull up the radiograph and show it to the patient and warn them that the root of THEIR tooth is so close to the sinus. “If your roots live in your sinus then there is a chance that you will have a new party trick: when you drink water through your mouth, it could come out through your nose via the sinus”, and that creates a memorable warning/consent. In this episode I asked Dr. David: What is a Trigger Point? What is the pathophysiology of a trigger point? What causes the trigger points to turn on? What are the uses of acupuncture in dentistry in terms of a gag reflex? What is the success rate of acupuncture? How does acupressure work? Implementation of acupuncture in general dental practice Please do check out Dr David Johnson’s Course and Implement Acupuncture on your practice Monday morning. If you would like me to organise another course with Dr Johnson, DM me on Instagram @protrusivedental If you loved this episode, please do check out Hypnotize Your Patients with 3 Quick Techniques with Dr Jane Lelean Click below for full episode transcript: Opening Snippet: Patients with a prominent gag reflex, patients with temporomandibular joint pain of muscular origin, in relation to that is headaches, migraines, and especially headaches, we know this one yet 60% of patients who have temporomandibular joint pain are getting regular headaches, we need to start coming away from it and moving as your stunts do down onto the neck because we know that most headaches are coming from muscles of the head and the neck.. Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati, welcome back to another Protrusive Dental Podcast episode. I feel like it’s been a long time since I had a PDP episode, we’ve had a couple of group functions, which I hope you really enjoy with Pav. Like I told Pav before I recorded those episodes, speak to me like I’m five years old, because like I said, in a recent Instagram post, I don’t know very much about implants. So that’s why I really enjoyed learning those basic principles from Pav and sharing them with you. And we had some great comments on YouTube asking for more of this kind of stuff, because it’s a confusing gray area, which Pav made very clear. Anyway, this episode is about acupuncture, and trigger points, and two really key uses of acupuncture in dentistry, even if you don’t proceed with actually implementing acupuncture into your care, then I think you’re still getting a lot of value from David Johnson, Dr. David Johnson did a fantastic job to explain the benefits of acupuncture but also how you can use something called acupressure to actually suppress the gag reflex on children and adults. So do stick around for that absolute gem of advice that he gives. And I think you’re able to gain even just from that. This area, you know, trigger points and acupuncture is yet another area, which is not really talked about much in dental school, especially trigger points, like the more I learned about trigger points, the more I’m like how do they not explain this in dental school? I can actually think back to patients at dental school, which were having issues around trigger points and referred pain. And we and the dental tutor and I as a student, we couldn’t figure out what was going on. But now I look back and I think yes, it must have been referred pain. And it makes so much more sense to me and you find it, once you know what you’re looking for, you can find it a lot more. I think on a monthly basis, I find patients who’d benefit from this. And I think the role of acupuncture is great two main functions of acupuncture that Dr. David Johnson explains. One is suppressing the gag reflex. And you hear all about that, including that acupressure pearl. And the other main one is trigger point therapy. So when people have trigger points, I’m not gonna ruin the podcast episode, I’m gonna let David Johnson explain what trigger point is and why they’re important, how they were discovered, how to palpate one, what relevance they have, and something that we should I think we all should know, as good general dentist specialists, we should know that. So before we joined that, I owe you a Protrusive Dental Pearl. Now what’s going to make a whole episode about this topic, but I thought, let me know, let’s not drag it out, okay? Let me just give you this cool pearl, okay? Now, the pearl I want to give you is how I communicate an oro-antral communication, how to communicate an oro-antral communication. And notice how I’m sharing with you how I communicate, I’m not saying this is the best way to communicate an OAC. Because really, when I stick this up on social media and whatnot, I want to hear from you guys. How do you communicate OACs to your patients? Do you have a way that you’d like more than what I’m about to share with you? Now when I think back to things that are I create that original, which is like 1% of things, and things which I have plagiarized over time. This is probably within the plagiarize category, 90% out of things that I share with you guys, I’ve learned from people really clever, and mentors and whatnot. Now I can’t credit who I learned this from, I feel as those prejudices sometimes, you know, I think it could have been me, but it’s too intelligent for it to be me. So let me share with you the pearl. So when I’m communicating an OAC risk, so any upper, maybe sometimes second premolar depending on the radiograph or molar for sure. And the roots are anywhere near the antrum. Anywhere near, okay? I will always do the same thing, I will pull up the radiograph and show the patient, “Hey, do you see this white line over here? That’s your sinus.” And I point to my cheek and I say “Hey, you know we got two of those, we have two of these either side. And the roots of your molar are very, very close. In fact, can you see this X ray that overlapping. Now this doesn’t mean that the root is living in the sinus, it could just mean that it’s close and is overlapping. If your roots are living in the sinus, when I remove the tooth, I will take a look. And if I can see your sinus, if I can see into your sinus, I will do a few things to make sure you don’t get something called a communication, an oro-antral communication. Now what that basically means for you is you’d have a new party trick and the party trick would be is that you drink water through your mouth and it could come out your nose, okay?” And I just look at the patient and I make a like a kind of like a serious face but also like a wow, that’s kind of weird, right? And then usually get like a laugh or something. You know, I think most people tend to laugh at this and they say, they memorize it. And I think part of consent that’s powerful because it’s something that the patient will not forget. So even if an OAC does happen and does become something in the future and you see them again a few weeks later then they will remember, Oh yeah, Jaz warned me about this link, okay, because my roots were close to sinus and just to go back a bit when I’m sure showing the patients their radiograph. And I’m showing their roots, I say, your tooth, your roots and making them take ownership of their problems and their teeth and the anatomical considerations. It’s not my problem, it’s their problem. I’m just there to do a nice safe job for them. So anyway, so I will tell them, you’ll have a new party trick that’s very memorable for them, they laugh, creates a positive sort of interaction, and then say, and then I say, don’t worry to make sure that doesn’t happen. Once I remove the tooth, if I can see this sinus area, then I put a special stitch inside, and then we’ll see how you heal. And you know, sometimes people say that, Oh, if you give warnings like these to patients, then they might not have their tooth out. Or they might No go ahead with treatment X, Y and Z because you scare them away from treatment. Well, Lincoln Harris always taught me that that’s the whole point of consent, right? If your patient doesn’t consent to a risk, then they shouldn’t be having that treatment. So I don’t worry about if the patient is going to suddenly back out the extraction never happened to me. It’s important for them to know because the time that you don’t want them, that’s sods law, that’s what’s going to happen okay, so it’s not the end of the world and when I communicate an OAC, I’m you know, when I’m talking about it, I’m not acting all like scared and worried I’m like, you know, it could happen is your mat is your tooth is close to sinus. It could happen, don’t worry, I’ll deal with it. So I’m instilling them with confidence as well at the same time. So how do you communicate an OAC please do let me know, type it on the Facebook Instagram page app because of dental our telegram group or the protrusive dental community Facebook group, please let me know I’d love to know how you do it. And let’s see if anyone has a way that I like to pinch and steel and improve the way I communicate. Anyway, I will stop blabbering. And let’s join Dr. David Johnson, and all about the two important things you need to know about acupuncture and trigger points. Main Interview: [Jaz] Welcome, Facebook, welcome YouTube, welcome Protruserati to a very special live, you know, I get to do about four or five lives a year. So not that many. It’s an absolute pleasure to have you on the real day the dentist from Wales. Welcome to the show, my friend. How are you? [David]I’m very good. Very, very good. Thank you again for the invite. As I was trying not to do too much in the that little bit of chat that we do when we’re testing the feed earlier I am you know, a short time viewer I’ve only just discovered you about a month ago with some of the stuff that you were talking about with some patients you were to but yeah, I’m a big fan. It’s just that we are on the same page with some of the stuff that you were talking about. So your podcasts blow my mind. So for the fact that you have invited me along, you know, and I’ve given up a Friday night of sitting with the kids and having a movie to talk about some of those close to my heart is great. So thank you again. [Jaz]We really appreciate it and the community appreciates as well and I’m looking forward to learning from you a lot because trigger points is something that I haven’t been in this area of learning this arena for that long, really fascinates me and my trigger points of journey is very much up here and down here and now moving to the sternocleidomastoid but not so much trapezius and stuff so it’ll be interesting to know where how you think that plays into that but also the role of acupuncture and how I got to bring you on as a guest is we must give a shout out to Imran Suida, hope I’m saying his name right. His instagram handle and that his Instagram page is, and Imran I think you’re watching this because said you’ll tune in. Imram, your Instagram page is the worst page ever. And I mean the worst page ever, because it’s actually a fantastic page. It just makes me so damn hungry. Every time I go onto it. So come in barbecue with me and just clipping so good makes me hungry every time. And he suggested to speak to you about trigger points. And here we are. And I’m so happy to have this opportunity, Dave, tell us about how you got to know Imran, and then your origin story. How did you get into this world of acupuncture and trigger points? [David]So Imran and his good wife they came on one of my courses that I was asked to do by Health Education England up in the Leeds area. So they come on and Imran is you know and his wife, but he’s one of those delegates who you can just see absorbing this knowledge that just like a sponge, it’s just like, you can see the osmosis drawing out of you. And he just took it and as anyone who likes to teach sees that someone who just then flies with it, and that’s what he’s done because, you know, his background, he’s an oral surgeon. So this greatly relates to oral surgery, but a lot of our courses what we’re mainly I like to see, you know, what our main delegates are so if it’s a lot of oral surgeons as I’ve done. I’ve taught down in Taunton, huge amount of oral surgeons down there, whereas sometimes a lot of what we’re getting along is general dentists and that’s where we want this, we want this out in general dentistry this is as we talked about, it’s an extra tool in the toolbox. Yeah, in the same way that you know, you’d learn your background basics of endodontics, so you learn the root morphology, you learn the anatomy, you learn the disease that you’re treating. And you may have learned, you know, I have been graduated 20 years now coming into my 21st. So we’re talking hand files in my day. And once you’ve done a quota, you could then move on to doing profile. So it’s, you know, that background you’ve got that but what we’re adding is something extra to treat these conditions. So patients with a prominent gag reflex, patients with temporomandibular joint pain of muscular origin, in relation to that is headaches, migraines, and especially headaches, we know this one yet 60% of patients who have temporomandibular joint pain are getting regular headaches, we need to start coming away from it and moving as your stunts do down onto the neck because we know that most headaches are coming from muscles of the head and the neck, so yeah, so that’s how Imran was on the course. And that I, you know, I got interested into I was, so I graduated 2001 from Cardiff. I did a year’s VT in North Devon, and then came back to Cardiff as in those days, we call it GPT. And I think it’s now called DCT 1 because there’s DF, and then there’s DCT1, but we used to go to GPT. General personal training. And you spent some time in the hospital, time in the community. So my time in the hospital was an SHO in oral medicine and oral surgery. And one of the lectures, was just a very short lecture that we got to do was anesthetist came over from Marsden Hospital in Swansea and did some dental acupuncture for us. And I responded really well. I just thought this is really good. I love the way it makes me feel, make me feel very euphoric, and chilled out for I’ve got to find more out about this. So you think [Jaz]Isn’t the experience of learning or was he? [David]Not just that but yeah, the way it made me feel, it just made me feel really good. I went and had that with just chilled out lunch. It was like I don’t you know, like I’d had a really good glass of wine. But no, it was just the acupuncture and these were points that I don’t use these points now, there are some far better relaxation points. And I’ll come to them later. And they’re great for using on patients. So I thought well, I’m going to need to learn about this you think well why are you going to learn about dental acupuncture so you know the internet was about and you can find it is as good as it is now with stuff like this. So where do you go? You go to Sheffield. That’s where you went. You went to Sheffield and you learnt from.. [Jaz]Dental School as well [David]Yeah, exactly. I have friends who are there. And I learnt from a consultant in medical acupuncture guy called Palle Rosted, who’s a Danish doctor, who’s working at the hospital there and had his own clinic and he used to at that point, he was the person who was teaching dental acupuncture courses. He’s now retired. So it’s got to turn to someone and I got asked by the British Dental Acupuncture Society many many years ago, if I would take over so generally if you see a course on dental acupuncture 90% of the time, it’s yours truly. But if you come to our courses we do in London, and with COVID many things we’ve slowed down a bit on those. It’s myself and my good friend Tom Fayer, who’s a consultant in oral surgeon and you get the two of us and we do these I think we’ve got one fingers crossed, all being well, Omicron wise then we’re looking I think it’s March, I’ll give you the exact date later on. So yeah.. [Jaz]Send me the link and put it in the blog when this does get and put on. I’d love to have this link because people need to learn and people need to know and then to, like you said earlier before we actually went live someone from Australia once flew to attend one of your courses, now that you know that just tells you about the volume of training that might be out there in the future [David]That’s going to be difficult now with the COVID restrictions and stuff like that but yeah, we used to have guys and girls coming over from France, Spain, Portugal, my good friend Jose, again he’s like Imran came over really took this and flew with it. Riga in Latvia, we had a couple over from Canada. No one from Oh, yeah. One guy from South Africa. And Peter all the way from Australia, which he regarded a flight you know, and we I’d arranged it because I honestly thought that Wales, we’re gonna do a lot better than we did that year in the Rugby World Cup. We did better than England. But Australia in the final and I thought, well, maybe he’s coming for that. No, he honestly flew over just for the course. So you know, I’ve been teaching these courses for 15 years because again, as because I was an SHO in oral medicine and surgery when I got to do this. I got paid for the hospital, paid for out of our study grant. And then I went into community four days a week, I was asked to come back and do one day a week as an honorary clinical lecture in oral medicine. So I got to treat a lot of patients with head and neck pain. And one of the majority of things that I was seeing was patients with temporomandibular joint pain. Now you call it TMD. I’ll call it temporalmandibular joint pain because, you know, there’s different Schools of Thought. I mainly go with what Professor Renton from Kings says. She says, you know, what we’re seeing, if it’s not dysfunctioning, she says it’s muscular pain. So we should call it that, which was she gave it once in a pain symposium, I was teaching for the BDA. And I was sat there thinking, Oh, God, my slides will say TMD and TMJD, I best change slides quickly. But from what you said, I think, yeah, it’s in the same way but when they change the classification of you know, you call a white patch, or white patch, instead of giving it a fancy name, like leukoplakia, or something, call it what it is. So she says, We should call it temporomandibular joint pain, because the ones that dysfunction, that’s when we should put that D word in. But that’s… [Jaz]It’s nice to know these terms in there. You know, at the end of day, we know it’s an umbrella term, we’ve actually read the RCD, the Research Diagnostic Criteria, there’s many diagnoses within this umbrella term. And I encourage you all to look at that. And the one where, which is so important in terms of the muscular origin, just like you mentioned earlier, and the reason why I think we need to learn now. So we’ve obviously talked about all these people that come to your courses from all over the world. But now let’s give these nuggets and pass them on to the Protruserati tuning in right now, the very fundamental bits information, which is important because so much pain that we see is non odontogenic, in origin, and it gets completely misdiagnosed, completely missed. And whilst I am a big fan of no diagnosis, no treatment, I am making much less diagnosis of no diagnosis, if that makes sense? Because once I’ve done the usual checks for, Is this odontogenic pain? Is this from the sinus? No. And then I move on to the other areas in the muscles. And very often I’ll palpate a trigger point. And that recreates the familiar pain. And when I started to do that, it was brilliant, you know, whereas you think some of our colleagues out there might be doing unnecessary root canals, extractions and various other procedures. So let’s just start from the very basics if you don’t mind, Dave, what is a trigger point? [David]Yeah, so a trigger point is basically a well defined anatomical area within a muscle that upon stimulation, usually pressure and that’s the way that that you’d be doing it in your examination, palpation of firm pressure, and definitely physiotherapists, the firm pressure that they use, you know, my wife’s a physiotherapist, even my kids say she’s got thumbs of steel, but a… [Jaz]Physical terrorists [David]Physical terrorists, that’s the one and I’m so glad she’s in the other room. And that upon the stimulation gives a specific pattern of pain radiation. And that’s what you’re recreating. And you know, when you start to look at these maps. So we’ve got, I’ve got Palle Rosted, great book, which is Acupuncture for Dentists, and it’s got these great maps in and the crosses is, you know, it depends on how big your screen is. But you know, I’ll find one of the bigger pictures. But what it’s basically showing is when you stimulate that trigger point, that’s when that patient gets that specific radiation pattern of pain. I found one earlier, there we go. [Jaz]One I’ve been finding the most. Now before, this is me before now feeling moving on to the sternocleidomastoid and how important that is, like, it’s one of the only muscles that can refer pain to the contralateral side, which I learned about some months ago, which is fascinating as well, and how the trigger point on the right scm could actually give a headache on the left refer it from above. [David]Yeah, just above it just above like a small circle here. But what, the main thing that trigger point does, and there are four main trigger points in the sternocleidomastoid is C shaped pain around the eye. And that was something, this is one of the things that as I was building up my portfolio of cases that I was seeing, I saw a patient on the oral medicine clinic when I was starting out as a clinical lecturer and she had C shaped pain around the eye which was you know, had been diagnosed as atypical facial pain, okay? So I was asked, and she’d been offered different therapists, she recently I don’t want to give away too much, but she worked over in the main hospital on one of the clinics over there, okay? And so she had some background knowledge and she didn’t want to take some of the medications that have been offered her. [Jaz]Amitriptyline that kind of stuff, the usual. [David]The fact that she didn’t want to be offered those. So I got asked what I have a look at it and see if acupuncture would help. So just went straight back to the beginning of you know, tell me about your pain, and she said what it was well, from reading books like Travell and Simon and Peter Baldry’s book, Peter Baldry was one of the founding fathers British Medical Acupuncture Society, C shaped pain I’ve just went straight to the sternocleidomastoid but a few needles into some light fit light needling, you know, found these trigger points. Light needling pain went away, took the needles out, pain started to come back. But instantly I know that’s the thing. That’s the thing. So yeah, it took a course of treatment say weekly. And that’s what we’d like to do. Again, we pressure’s on the NHS and pressure’s in practice, it depends how you can fit it in. Now I’ll come to that way up, especially if you’re an NHS practice where you can fit things in so it doesn’t eat into your time. But yeah, that was one of the first ones I saw, you know, and he presents that way we used to have a SWAG, the South Wales Acupuncture Group, which was mainly for doctors and I was the only dentist there. So you know, I went to them I said, oh, so I had this case in and talked about it into the all of them knew what it was, they would have done exactly the same. But for me, this was a new thing. Because otherwise, wouldn’t have known because, we talked about… [Jaz]Medicines or different routes, neurologist or whatever. The routes that they’re these patients may end up but I think it’s important for all dentists, all every single dentist to have knowledge that these trigger points exist, how to palpate them to some degree, and you need to go through a course to really do it properly, so that you can make better diagnosis because the most common one I found before I now move further I’m excited to learn from you tonight further is temporalis giving pain in a lateral incisor region. And also insertion of the masseter giving pain to a lower molar. I’ve got some great videos of patients and say, “Oh, yes, raise my hand, I’m feeling the pain.” And when you start noticing these things, it’s just brilliant. It really completes your ability to be able to get a good diagnosis. [David]Yeah, because sometimes we learn all these muscles and it’s you know, spend that first year at university learning you know, all of these muscles and even coloring in the muscles in different colors. If you’ve got the you know, the anatomy coloring, one of my favorite ones to do. But knowing about how they can, never taught it’s never but then I’m not blaming dental school because to be honest, you know, there’s so much out there it is just getting you out there as a safe but a, you know, a safe beginner, safe learner. So there’s so much that’s the exciting thing about it, but there’s so much more to learn. I’m 20 years out and then still learning everything. You know, it’s fabulous. So yeah, we need more of that out there to learn certain things of different pain because we’re not just the teeth, we are the whole head and neck and especially when that pain refers into our and can affect our treatment. And you know it, yeah, we don’t want to cause over treatment, but we don’t want to under treatment because our patients can be in pain. You know, Palle who used to teach me when he was teaching in Denmark, they do it slightly different especially they’d set up for headache clinics, and they’d get a dentist along, a doctor along, a chiropractor along and they teach them also, they’d be like a mini MDT. But, you know, if you as a dentist, have, you know, done the appropriate courses, done the training and work through a portfolio, then a lot of this. Personally, I don’t think the patients just coming to us about headaches is really our remit. I think it’s more in relation to tempomandibular joint, I don’t like that gray area. And I don’t want to get you know, the GDC or anyone like that too excited. But as we know, like I said 60% of patients with TMJ pain are getting headaches. So yeah… [Jaz]That’s what it should be. Yeah, this is why we should be screening for headaches. But you’re right, there is a gray area where we can’t diagnose, we can’t actually diagnose headache, it’s really important to say that we can’t diagnose it. But and it’s the same way when I give it a patient’s appliances, because I don’t do, I don’t offer acupuncture yet. And when I give appliances to help them with their muscles, and then their headaches go away, I never tell them that your headaches will definitely go away. I’m managing the force of bruxism, I’m doing all these other things. But some of my patients have found that their headaches gone away. And that’s usually when I’ve been, I’ve done my muscle palpation and it’s getting a positive response. And I’m there and there about and in the ballpark. So that is important as part of your palpation to figure that information out before you do anything. But I guess the next step for me is looking to acupuncture. Now, you mentioned about what a trigger point is, how do these trigger points actually formed in these patients? What’s the etiology? Or the, you know, the pathophysiology of a trigger point? [David]So yeah, so trigger points are always there in muscles, and we ever say that they’re so like, on or off, or some people will call them on and latent, okay? And the way they were really discovered was we’re talking going back 5000 years in China, okay, with traditional Chinese medicine. And so if I take you back to my clinic 5000 years ago, and so you might come in to my clinic, and I noticed that you’ve got this main sort like focus of pain, okay, I’ll use modern terminology. That’s just hearing the trapezius and it’s radiating up your neck, and I see another you know, 50 patients, I’ve got the same and I keep good contemporaneous notes. So dental protection love me and I start to notice this pattern of these main patients with this focus radiating up their neck, but then I’ve got another 50 patients who have got this main focus just where yours is radiating up to, and that’s radiating into the temporalis area. But for some another 50, it may be radiating down. So I start to you know, and we’re in China 5000 years ago, and the Chinese weren’t dissectors of the body, what they were was very good topographical observation list. And they didn’t know about Melzack and Wall’s Gate Theory of Pain, they didn’t know about myelinated and unmyelinated fibers. But they were really good topographical observation lists. And when you look at sort of like head and neck mapping of acupuncture points, and there’s an 85% correlation between acupuncture points, and trigger points, because trigger points roles in muscles, but acupuncture points aren’t necessarily always a muscle. So that’s why it’s never going to be 100%. But when you look at the mapping of acupuncture points, and you see these points, and what the Chinese did was, they came up with these Meridian maps. And when you look at these Meridian maps, what they basically did is join the dots. And that’s when you look at Meridian maps of acupuncture, you’re looking at them, looking at musculoskeletal referral patterns of pain. And it’s phenomenal. When you look at it, you know, you see patients who you know, have pain for their masseter, and you’ll see that it radiates up into the temporalis or radiates down the neck or along the jaw. It’s just really good topographical observation lists, and that they’ve mapped these out. So that’s where, you know, we think, you know, theory of acupuncture comes from, from the mapping of trigger points. [Jaz]But what is the thing that actually, you may be coming to this, but what is it that turns a latent or one that trigger point that’s off, what brings it on? Is it the whole bad posture, our stress, the things that we, the naughty things that we do, the poor posture that we adopt? Is that the kind of thinking? [David]So it’s basically injury, overuse, improper use, so that, you know, that could be from you know, whiplash from a car accident, it could be digging in the garden wet, and you always go off, I found some muscles that I, you know, didn’t know I had, they were always there, but what you’ve done is you’ve injured them. And we’re, in our case with patients with temporomandibular joint pain that could be you know, that overuse that clenching, okay? Now, one thing we know from studies that came out of Sweden, looking at the Masseters and doing micro assays of micro arrays in these triggerpoint areas, what they were noticing was increased lactic acid products. And decreased oxygenation, but you’re going to get one with the other. So when we find these trigger points, and we’re sticking this needle in what the acupuncture needle is doing into that trigger point, you get histamine release. So whenever you stick an acupuncture needle in your nose, you get that so like red wheel, yeah. And you get histamine release. Well, we know that histamine release causes vasodilation. So you’re going to get increased blood flow to that area. So you’re going to get increased oxygenation, and increased perfusion. So you’re basically going to wash away more of these lactic acid products. But one thing we do notice, and this is why I say on all of my courses, and it’s one of those things that you come on an acupuncture course, and you’re really keen to stick needles in, that’s all you want to do. You want to stick needles in. But the most important thing is the examination of the patients, and especially with the form of acupuncture that I like do, which is it’s called, you know, trigger point acupuncture, muscular skeletal acupuncture. And that’s the stuff I really love. And it’s a real Western acupuncture. [Jaz]And so this is dry. This is dry needling, right? This isn’t getting any fluid, yeah? [David]Yeah. Dry needling. Dry needling is also not cause bleeding, okay? So that’s dry needling as well. But yeah, basically dry needling. So you really got to find that trigger point. That’s why the good examination, and if you get the needle right into the trigger point, what you get is a Twitch, and then we, I basically see it as like, there’s really tight fiber so that then just go and they just melt down, you’d can take the needle out then, it’s like when you get that Id blocks spot on. Yeah, you know, you barely need to put any lignocaine in there. So yeah, it just goes but mainly what acupuncture is doing, like I said, increased perfusion to that area, you know, there’s that whole Melzack and Wall’s Gate Theory of Pain, which is happening in the second and the fifth layers of the dorsal horn. And that’s what we call a segmental effect, but locally, that’s the local effect. And then with the acupuncture point, if you really, truly in the acupuncture point, that gating of pain, a sense up through and this is where we get into the heavy stuff up through the lateral spinal thalamic tract into the higher centers of the brain into the pain centers of the brain. And that’s where on things like fMRI, you see those areas lighting up on fMRI, difficult thing with acupuncture and fMRI, metal needles, world’s largest magnet, it’s never get you’re never going to get on with those but you can use non ferrous needles, you can use gold needles, and again, the other thing that makes it limited is there’s nothing new in acupuncture. There’s no big company behind acupuncture, you know, funding it. And it gets expensive. The biggest, most expensive thing is your time unless you’re going to start using an FMRI machine, and they get very expensive to rent, so, never rented one myself, we’ve got one of the best ones in Europe here in Cardiff. It’s called Cubric, the 3d scans it does my friend Jeremy, works with a team on it down there, and it’s meant. [Jaz]But in your day to day practice, when you use it, do you use it as per like, people refer to you as because they know you now and the fact that you provide acupuncture, you get referrals for people in facial pain, and then they suspect there’s a muscular component, and then you get to see them. And then you get to do your examination and figure out okay, there is some sort of correlation, there are these trigger points and then you’d carry out with therapy? Or are these patients that you are Have you ever list and then you’re just going the extra mile to diagnose these conditions and offering your acupuncture, how’s it? How do you work in terms of pain clinic? [David]Yeah, so my clinic, my background is I treat I’m a general dentist works in the community treating special needs kids and special needs adults. And I’ve been doing that for 18 years. And the more you do the more you know, specialized you become within that, but I’m not a specialist. I still like you know, I love the fact that you said and I say the same. I’m a generalist, but I work within that field. And it’s great. So we’re a referral only practice treating, you know, special needs kids and special needs adults. So but yeah, if a referral came in, then yes, but I generally I’m, I don’t promote that out because that’s not what I’m there for. I’m there to do treatment under sedation, general anaesthetic and do more complex cases, stuff like that people who can’t accept treatment within general practice, but if one of my guys that I see needs it, then yeah, I use it on them. You know, I used to use this, there’s some lovely points just on the top of the head around the crown, which are really good for sedation feel just a nice, relaxed, sedative effect. And I used to use them a lot. And I still teach them a lot. But I have better things now. You know, I have different gases. And if my gases and drugs aren’t good enough, then you know, my colleagues, Simon or Tom in the hospital who are anesthetist, then there’s a better, so but you know, for those before I built up my sedation portfolio, then I were using these a lot. And you know, and they’re fabulous, nice, simple technique, you know, five needles, so, you know, your overhead like a box of acupuncture needles like this, 100 needles, 10 pounds. So each needle 10 pence. So, you know, your overheads for acupuncture are extremely, you know, extremely low, your most expensive thing is is your time. So I’d say to anyone starting out doing acupuncture, you know, you want to be doing it say, you know, at the end of the session. Or at the end of the day. Especially if you’re using it for someone with temporomandibular joint pain, and you’re not going to be doing anything else, you might be doing the splint and stuff like that. Myself, I like to use acupuncture to get rid of the muscular pain, I just see it as these sort of like magic little, you know, arrows that get right to that pain that target. And that’s how manufacturers of like ibuprofen always like that they like show a bull’s eye. And that’s how I visualize it in my head. They do. We are really targeting it. You know, my wife’s a physiotherapist. I was into acupuncture before we got together and she’s doing acupuncture courses, but she still prefers getting the thumbs in, she likes that even though she’s not muscular skeletal anymore. But me, you know, with the knowledge that I’ve done, because the amount that you can use acupuncture for within the dental field is finite, you know, we’re to around here. Yeah, I wouldn’t expect patients to start stripping off any loan there. So I’m working on the top of the shoulder, you know, for headaches in relation to temporomandibular joint pain, but I still read around it and we get to do other courses. So once you’ve done a course like our one with the British Dental Acupuncture Society, there are some great ones with a medical acupuncture society on headaches, back pain or stuff like that. It’s not for us to treat, it’s great for yourself and the trigger point ones are great. So you know, for our I was getting some plantar fasciitis, some pain and at one point during the I think we’re on our second lockdown, it could have been a local lockdown that we had here in Cardiff, in Wales so you could only go about five miles so at the weekend, you know when you weren’t at work, the only thing you could do is be going out for walks with the kids. If you’ve got plantar fasciitis and that’s really hurt and making it painful to walk so some lovely, so you research around it, look through the text and some lovely trigger points just up on the calf. Sticks of needles in there. Did a treatment one day, does treatment next day, fine. I was fine to go walking.. [Jaz]And it’s almost instant relief? [David]Yet near enough. With patients if I was doing more intense treatment I would do one day on, one day off. It’s up myself. I, you know, I really go at it with myself and also did some points right in. I wouldn’t recommend it. I was chatting with my friend Mike who is the director of the British Medical Acupuncture Society And he said, What you put it right in the arch of the foot. He said, that must have been painful. I said, I have no words for it. I said, it worked. The distal points, they’re the ones away from it. They worked really well. But I did do some local needling on I’m so glad I did. Because otherwise I wouldn’t be able to go out but it was. Yeah, when I put the needles in, it was like, my hand wouldn’t allow me to do it. It was it but it works. So you know, whenever I go away, we always take acupuncture needles, I’ve used them, you know, when I’ve been here, there and everywhere on different things when I’ve been on Expedition training and stuff like that, and someone’s bound to get a little bit of back pain. And you know, I’m not in the UK. You know, also I might do some manipulation with my fingers, but a physio and stuff like that, but understanding trigger pointing, and in those areas and just, you know, works really well, that’s the basis of musculoskeletal physiotherapy. So more dentists getting into it, and working down, you know, coming away from this area, examining muscles of mastication, especially the masseter, temporalis, lots of trigger points in the temporalis, fits in with a line called the gallbladder line, it goes back and forwards and now lots there. But moving down the neck, the main ones that we look at, especially in relation to headaches are trapezius, that’s the big one for us, especially, you know, in dentistry, that we all lean forward. And we all you know, round in and we’re at the coalface and then we come away, and at the end of the day, we most probably haven’t drank enough fluid. And we’ve done this, we’re going to get headaches in our profession, and especially if people are, you know, not wearing loupes. But that’s another bugbear of mine, you got to have, [Jaz]I would love to see a survey of dentists and see what percentage of dentists and dental nurses in the dental team suffer from headaches compared to the general population, that’d be a real fascinating study to do. And obviously, they usually muscular in nature. And on that point, most temporomandibular joint pain to use the terminology you said about tyrant. And most of that, let’s call this TMD, the umbrella term is muscular in Origins, ie 65%+ then there’s less intracapsular. And a lot of it is mixed. But even in those mixed cases, the muscular component should not be ignored, it’s often the bigger component. And that’s where I see the role of these trigger points and acupuncture. And that’s why I like to refer to really good physiotherapist, like my friend Krina Panchal, who’s doing great things. She’s taught me a lot about a trigger points, actually, what are the other main uses of acupuncture in dentistry? So I know, I read on these forums, from colleagues who do acupuncture, lots of dentists raving about the ability of acupuncture to help with the gag reflex. Can you tell us about that? [David]Yeah. So I on the course, I say, if you go away from this, and we aim the course at generalists. We aim the course at generalists, because there’s no point teaching everyone, some of the really, you know, rare stuff that’s going to come into general practice. Yeah, the stuff that’s more likely going to be in oral surgeon, in oral medicine. So the main things were temporomandibular joint pain anxiolysis, the point on that, but gagging and if there’s one thing, one thing alone that you’re going to use for and this is what’s great for the again, the DCP so the hygienists and therapists who come on the courses, as well, because obviously, a lot of practices are this patient gags send it to the DCP. Whereas me, I like to keep stuff like this. And in our practice, you know, we’re offering sedation, so that synergistic effect of sedation, you know, inhalation sedation, and the acupuncture. So the point is, basically, if you know, your lateral calf tracing, it’s point B. Yeah, that most inferior point, as the lip comes in, and the chin comes in, just in there.. [Jaz]Mentalis muscle. [David]Yeah, just above it. So you look at the patient, like as an orthodontist would from the side, and it’s that most inferior, and even… [Jaz]Point B on the lateral calf. [David]Yeah, right there, the most inferior point in there, that most inferior point. And even on patients like us, you know, your beard is far superior than mine. And, but you palpate that area, and then it’s a very precise point down the midline. In it goes 15 millimeter needle, and it goes in until it stops. But that doesn’t mean you know, it’s basically just gently touches the bone, just okay, but it’s not in the sulcus, it’s below the sulcus. So you’ve never pierced someone through and through and that point is called conception vessels on the Conception Vessel Meridian that goes from the lower lip all the way down the midline, okay? And that comes, takes about five minutes to work, okay? [Jaz]And how successful is this? What percentage do you know either in the literature or from your own experience? [David]My experience, I’m quite persistent with it. And if it’s not working, then it might be that my aim is slightly off. So I will keep the original needle in, and then put another one alongside it. But yeah, you’re looking about 85-90%. You just got to give it a bit more time. But I don’t just use that one. And so what we teach is there’s a point just above the triggers. There’s just there’s this small triangle just in there. And it was rediscovered by Janice Fiske is one of the founders of Basically Special Care Dentistry. And it getting recognized as a speciality within dentistry. And she’s part of the Dental Acupuncture Society, just there. And we call that we named after her, the Fiske Point, and it has the advantage patients can’t see it. It doesn’t get in the way, even though it only gets in the way when, if I’ve marked up the rubber dam wrong. And there’s too much rubber dam here. But this one can with repeated opening and closing work its way out. If it does, you just reapply it. So CV24. The Fiske Point where we say bilateral Fiske points. And then there is another point and it’s one of the points on the wrisk that a lot of people so it’s the most distal wrist crease, and it’s three fingers down, which in an acupuncture measurement is called cun. Okay, three fingers is to cun. And it’s just that midline as PC6, pericardium 6, there’s a lot of research done on that one. Very good anti.. [Jaz]And then we, Dentists, we can poke needles on the wrist? [David]Yeah. You know, it was one of the first points that I was taught, I think, you know, because you’re using it, I don’t think it’s in an area that to risky, an all risky, and you get right, by the way, so we’re not asking patients to strip off the chair, it’s a good distal point and an area of easily accessible, you know, unless people have got, you know, an aversion to showing their wrists in public then fine, but the local points are far better. PC6, pericardium 6 is what’s used with Sea-Band®. Those are acupressure bands for seasickness, travel sickness, but again, takes about half an hour, and who’s got half an hour. So we generally go with the local points, which are a lot quicker. There are also there was a guy called Bob who came out to one of our courses over from Vancouver. And there are some points on the air. And you can get these like little clips that just clip just behind the lope just around here. And he came on one of our courses because someone had told him about these clips, and he wanted to just understand how this works. So he you know, he’d used him in his practice, still didn’t understand how he worked. He came on my course. And I went, Yeah, auricular acupuncture is not really my thing, I know about it. I do bits, I said, but I can tell him that these points but you know, I said if it works, it works. Yeah, I said I don’t do auricular stuff or ear acupuncture, as it’s called, but the local one. Acupuncture is great for them. And that’s something that in our practice, because we’re being referred a lot of patients with excessive gag. You know, you can take someone with a GSI of four, Gagging Severity Index, from a four down to one… [Jaz]I don’t even know that existed. [David]Oh, the gags. Remember, in dentistry, there is a grading system for everything. And if not, someone’s working on one. But yeah, the GSI, The Gagging Severity Index is what the gag is like, before you’ve done anything. And then when you’ve done whatever you do, whether it could be hypnosis, it could be desensitization, I’m not insulting of the tongue, because we’d like to keep it low. [Jaz]I was going to ask you about that [David]That again, that most probably works on a similar neural pathway. But for me, I do acupuncture, or it could be just be doing inhalation sedation, or the two combined. And then there’s GPI, a Gag Prevention Index. So what you’ve brought that gag down to so it’s just a before and after measure, you can give it you know, it’s quite useful, it’s easier, you know, especially if you’re doing research on them. So my first line, I will always well I’ll generally jump in with acupressure, firm pressure. [Jaz]So I was going to ask, okay, what if you don’t have any needle at the moment and you haven’t been on your course yet? I’ve read somewhere that you can use acupressure. So is that as simple as just getting the patient or you yourself? Ramming your finger in that space just under the lip just by the mentalis, just by the point B as we said, and then giving it some time to work? [David]Yeah, I generally, when I was doing my research, for my you know, to complete my foundation training in dental acupuncture, I did research because at that point, my main patient basis was kids. So I was doing a needle free technique to reduce the gag on pediatric patients prior to taking bitewings. Because I want my wings on kids. because it helps improve my treatment planning. But you know, even with the size 0 film, it can stimulate that gag because the main areas for stimulating a gag, lateral border, the tongue, posterior palate, lo and behold, what does the bite wing collector do? [Jaz]And also the way they swallow is it makes it even more difficult by placing a bite wing. So that’s fascinating. So any guidelines as to how many minutes and how hard? [David]For my study, I did it for a minute, why a minute? Because it seemed about righ. How firm? Firm enough to cause blanching so a bit like, you know, when you do like peripheral perfusion test, yeah, so I’m on the, so firm enough to cause blanching, but not firm enough to cause bruising, okay? For a minute, now I was doing a set, it was a single blinded study. So I wasn’t telling the kids why I was doing it. But I knew why I was doing it, okay? Now, I tell the kids, this is the Ninja point. It’s a ninja. So I’m flying, I’m doing some ninja magic. And we’ll apply it to Ninja point for a minute. Most kids, you only need to do it once. But if you got to do it for a minute, prior to each bite wing, then fine. In some study, I did. So 90% success again, because it was a short amount of thing. But I also make sure whether you know, good techniques are making sure they’re in good position, they sat back, the chin is up, you know, and also instruct them what I want them to do close slowly and gently, not quick, like a crocodile slowly and gently. So yeah, so works very well. If that doesn’t work, then fine, then we need to move on to the needles, and that’s for kids and for grownups, especially with grownups. You know, in my time, I’ve only had three cases that I’ve not been able to treat with a combination of acupuncture and sedation, and these are men in their 50s, all three of them, men in their 50s previous heavy smokers, previous heavy drinkers, I don’t know why, I’d like to know more, I’d like to, you know, I can tell, there are characteristics. So if anyone out there goes, Yeah, that’s why I’ve had the same. And this is the reason why it doesn’t work. It’s like, Thank you, that explains it for me, because I really want to, but they’re three previous heavy smokers, previous heavy drinkers, not being able to do a thing with their gag, not being able to do a thing. [Jaz]So you’ve talked about the use of acupuncture. And we talked very much about trigger points, and how they’re related to myofacial or myalgia of the umbrella term of TMD, talked about acupuncture and the gag reflex, and you gave some great pearls about using acupressure and in children, I think that’s something that we can all do on Monday morning. So thank you for that brilliant tip. Any point, we just wrap up now and welcome any questions from the audience. Any other uses that you think general dentists are missing out on by not implementing acupuncture as part of that practice? [David]No, I think they’re the main things, they’re the main three things that we like, you know, start with the, you know, with the basic cases, and then after that, you know, start with temporomandibular joint pain. And once you’re moving from that, that’s when you start to come down onto the neck and everyone when they’re first put needles in into the masseter and the temporalis, they’re all a little bit weary. And we do it as a two day course over a weekend. And on day two, we move down onto the neck and I say to the delegates, once you’re down on the neck, and you’ve learned and you’ve been doing the big muscles on, on trapezius, splenius capitis then you just, everything pales into comparison, because you’ve had to, you’ve got to go on to the neck, you’ve had to lift the trapezius and hold it up, you’ve had to go in a different angle, very good safe technique, because that’s the most important thing, good examination and safe needling technique. And that after that, you know, the needling of the masseter. And if you want to do you know, there is a trigger point from the masseter that goes through to the pterygoid then you can do that most people you know, I don’t feel that I need to needle through to the pterygoid I think it’s the big muscles that causing those main problems. But if once I’ve turned them down, there’s still some, then it may be that there’s something a little bit deeper. But yeah, it’s that whole thing of building up your portfolio. It’s one of those things come on the course, build up your portfolio, the more you do, then just learning more as I say is, you know, learning more about musculoskeletal pain because it is a very interesting thing. You know, because [Jaz]I’m actually gonna, definitely committing to, I’m gonna join you on your course. We just had a question. Right. So, and actually one of the questions from the same person. So Sherry, hi, Sherry, Sherry Abu Turabi. So after one minute of pressing, so back to the acupressure, yeah, just for the gag reflex. One minute of pressing and do you see the effect immediately? [David]Well, the gag is reduced so I’m able to take the bite wing. So that’s a success what we’re talking you small amount of stimulation. There are some patients who are referred in And just to examine them, what I’ll do is, I won’t be able to use both hands. It’s that thing where, you know, it would have been nice if when we had that first COVID Jab that we grew that third arm because it would have been so useful because I could apply the acupressure. And then I could have the mirror and the probe. But yeah, so I often apply that, I generally like to apply the acupressure myself. But you can especially for patients who gag when they’re brushing, talk about them applying it, you know before they’re brushing, yes, but it fits in with that that whole thing. There’s lots of different tips, you know, the one of them is applying firm pressure. The other thing is, for some patients, I say, if you shower in the morning, brush your teeth while you’re in the shower, because when you’re bending over that sink, you’re already in that position getting ready to be sick. I said so just changing the press. And that because you can breathe better because you stood up, if you don’t have to worry when you spit it out showers gonna wash it away, but you know, good firm pressure for yourself, and helping, you know, we’ve been doing it in our house when we’ve been doing our lateral flows every day, and especially with the fact with the Omicron variant, you know, you’ve got to be swabbing the back of the mouth. And, you know, without so yeah, so we make sure that one finger on, and then back we go with that swab, but yeah, firm pressure, if it brings it down, so it doesn’t feel like when I’m swabbing myself that I’m gonna sick myself inside out, then that’s good, it’s done its job. [Jaz]Next time I do a lateral flow, I’m gonna give this a go as well… [David]Firm pressure [Jaz]Firm pressure. Well, I remember a patient I see about five years ago, and I felt really bad for him he actually hadn’t, it’s the most severe gag I’d ever seen. He’d make himself gag, every time he’d brushed to the extent that we actually had to remove, there are non functional but still remove the second molars which are to anyone else’s are very accessible only because of early decay. And the prognosis was so bad because there’s extreme gag to remove teeth under sedation, which is a real shame and to be able to teach that patient just like what you said, in the shower, and to use the acupressure is something that could really make a big difference. So I think that’s a very implementable, [David]Well, the other thing is also timing as well, because especially when you’ve woken up in the morning, your stomach, just not fully settled. And you know, when I, you know, we now say brush at nighttime, and one other time. The nighttime brushing being the most important, you are less likely to gag at night. Yeah, it’s that you know, your stomach small settled, you just, whereas first thing in the morning, and I speak from personal experience. And from chat with patients, that’s when they’re more likely to gag. So sometimes it’s just about, well, maybe wait till later on in the morning. There’s nothing wrong with taking a toothbrush to work and then just assume that five minutes, go off and brush your teeth. And if you’re less likely to gag and you’re able to get just work that into your day and just alter that time, we will get that brushing in but just later on in the day. And it means it’s less of a task, you know, I’m forever I’m to bring up sort of like altered brushing plans for carers who are brushing foot for Special Needs patients. And you know, if you’ve ever had someone else, brush your teeth, it’s a strange thing, having someone else do it. So I was trying to teach them that, you know, it’s, you know, it’s no wonder they might be pushing weights China is, you know, involve them in it. There’s different techniques we can use for that. That’s for another day. That’s off the subject. [Jaz]No, but that’s really something that we can implement in practice. And Sherry also asked, there’s a last question, and I was going to ask you anyway, is and I know you’re gonna send me brochures or links or whatever. Tell us about your course date. And you give us a website, maybe and then Sherry is really keen for that. And so am I. So please let us know. [David]Yea, I’ll look it up on my calendar. I live by my calendar. So if I don’t, so yeah, we’re looking at fingers crossed. Saturday, the 19th and Sunday, the 20th of March. So it’s a two day course. I think the price is around 450 pounds. But that’s for the total weekend obviously doesn’t include your accommodation, but it includes the… [Jaz]For a two day course that is phenomenal [David]For a two day practical course. And the main reason for that is the philosophy of those of us that are in the society, the society is there for the education, and it’s not about us making loads of money. So it’s there, we have to charge it at London prices because you know, we’re college and it costs more whereas if we did it somewhere else if we came to reading it might be half that. [Jaz]Well, I’m gonna have to host you in Reading because I can’t make that day because I’m in Dubai, hopefully all day as well. [David]We are most probably doing because we haven’t, we didn’t do one last year and we generally do them in October, but we haven’t done for the last two October’s, we all know why we haven’t done them. The only thing that we’ll be looking at is with anything flow before you go so we asked people to lateral flow before you know, they come in for the course, that’s fine, because that’s what we’ll be doing. Because obviously people are coming in this was out, you know, for the course and they’ll be coming from multiple practices. So everyone wants to know that after the weekend that they are fine to go back to work. So it’s that mutual respect thing. So yeah, so we’ll be looking at doing one, doubling up this year, and doing one, a couple of months later, we’re just sorting out the dates with regents colleagues [Jaz]Please do. I would like I said, I’m not just saying this, because you come as a guest, I generally want to come to this course, I think it’s the next string to my bow, in terms of the management of temporomandibular joint pain that I do. I do quite well with splints, and using physio techniques and referring to my physio colleagues, but I think I would love to have for just even just the gag reflex, and for a simple trigger point areas to help people with their facial myalgia, I think it’s a great thing to be able to [David]It’s that extra tool in the toolbox, that’s what it is, it’s that extra tool in the toolbox, and you can use it in combination, you know, with other therapies. So when you can approach it in the, you know, multifaceted way and you know, to get that and different cases will need different things. And also, you get some patients who, you know, needles are not their thing. So it’s not like, I go well, I can only offer you acupuncture, I want to get them pain free. So Fine. We’ll talk about acupressure, we’ll talk about firm massage in that area, you know, using something like bio oil, or just even just a simple you know, face cream and just giving themselves self physiotherapy in that area. You know, when I was a student, one of the Oral Surgery consultants used to talk about this stuff called Coal Tar paste, really thick, and you get the patients put a small dot of it over where we say the trigger point is, and you’d get them to massage it in. Well, this stuff was extremely thick, and they’d have to massage it in until it dissipated. Well, it took a decent amount of time. So by the time they’d finished, they’ve given themselves physiotherapy over that trigger point. You know, so we’re talking, you know, we’re maybe explaining things a little bit more scientifically. But you know, things go back, you know, way before them. You know, I spent a bit of time with the San Bushmen in Namibia on an expedition survival course, when we were looking at the women from from the San Bushmen, a lot of them to treat sort of headaches and facial pain, what they would often do is they take a small blade and just cut over that area, and then they would take ash from the fire and rub it in. And the way you could tell is because they had some sort of like tattooing in that area. And that’s how they would do, they would basically use a noxious stimulus, basically to help with the pain that they were having. And that goes back, you know, for them, most probably centuries, if not more. So you know, we’re just explaining things a lot more scientifically now, because we’ve got far better machines, better understanding of anatomy, neuroanatomy, and how thing all links in, but yeah, for looking at the courses, just Google British Dental Acupuncture Society, the BDAS. Yeah, British Dental Acupuncture Society. [Jaz]Amazing. Sherry says thank you very much. I find it very interesting. And even though it’s Persian New Year, she said she’s going to come. Sherry, I’m sorry, sorry, I won’t get to meet you because I’m not be able to make that date. But I’m going to be pestering Dave, for his other dates, especially at that fee is amazing deal. And I can’t wait to learn more from you actually, hands on. So really excited for that. Dave, thank you so much for giving up a Friday evening to be live with us, with the Protruserati and to teach us some things about trigger points, and how we can implement acupuncture in practice for temporomandibular joint pain and for the gag reflex. I really appreciate you coming on. [David]No, I and again, once again, thank you for the honor of being part of it. Like I said, when I saw your site, just Yes, he’s on the same page. He understands trigger point is, [Jaz]I am on the same page but I have so much more to go to be able to learn. I’ve got so much to learn from you. So appreciate you initially, I will say one so thank you. [David]Yeah, it is a great journey to understand muscular skeletal pain. My wife and I talk about this a lot. So what happens when people don’t understand it and she says, they walk about in pain for a long time. All they have to you know, from the rest of it, they have to alter their posture and stuff like that. But you know, this feeling with medical colleagues, they just say, you know, really the good health model would be to have the every general medical practice has physiotherapist who does acupuncture and something like that there because 70% of what comes in of pain is musculoskeletal pain and musculoskeletal pain response so well to acupuncture. [Jaz]And it’s the second most common cause of pain in the face. So after odontogenic, after you know tooth pain, it is the next most likely thing. So this is something that most dentists when they qualify they don’t have no knowledge of and I actually remember being in dental school and patients come in and the tooth to be there and I’d be there and we just don’t know why this patient’s getting pain for the molar, you’ve done your vitality testing, you’ve done your check TDP, you’ve done your probing depths, and you just can’t figure out why they’re getting pain. And then I truly believe the next step, which the tutor didn’t know about at that point, I definitely know by that point was to then actually look beyond the teeth and look at the muscles. And that would have given a huge clue or gonna get us closer to diagnosis. [David]And all it takes is just a couple of lectures just with some nice diagrams going. And if one thing it will show you, especially looking at the muscles on the neck, improve your posture because when you look at these trigger points, everyone will go. We most probably all like this, just midline of the neck, which is a point called bladder 10, and a half, on the bladder meridian. It’s named the head areas are none of them relate when you cover the course you’ll see how none of them relate to the underlying anatomy and I’ll explain why they’re given the names that they are, their medical names, and who came in and said, We’ve got to have something so we’re all working off the same terminology. So people don’t stick needles in the wrong place. But yeah, bladder 10 and a half, in between bladder 11 at the top, bladder 10 down the bottom. That’s where people like to be massage, that sort of area that you think, if I was a tiger cub, that’s where I’d like to be picked up on my neck. It’s just, ah, yeah, that’s the area you go. That’s just a few little needles in there. A few on the trapezius. The worst thing is the ones on the trapezius, you can’t do yourself. So it’s always good when someone comes along, you bring someone else from your practice. So you can do them, and they can do you. And when we do the course Tom does me and I do him. And we both like this afterwards, Oh so much better, it’s reset. It’s reset all that badness of the year. [Jaz]Excellent. I just want to say some more message coming through a Radner. Hi, Radner. I hope you’re well, she said thank you and Miles says thank you so much both of you. Ready for that course. Amazing Miles, I hope you’re well buddy, hope Movember went well, and I see your photos. David, this was absolutely brilliant. And thank you for telling us about these bladder points as well. I really appreciate your time once again, and have a lovely weekend. Jaz’s Outro: And guys, thanks for joining this live. I’m going to be ending the live stream now. So thanks so much for joining. And this will be a properly produced episode on the main podcast very soon. If you want to listen to it again or watch it again. That’s coming soon. And for the YouTube guys again, thank you guys for tuning in as well really appreciate it. Oh, there we have it, guys. Hope you enjoy that with Dr. David Johnson. David, thank you so much for just being a brilliant communicator in this really helped make clear about the role of acupuncture and maybe you’ll be able to use acupressure on Monday morning to sort of get you started about tricky gag reflex patients. I hope that gem was useful for you. I’m actually looking forward to joining David on one of his courses because will complement the kind of work I do already with facial pain and TMD and I think to have acupuncture to my list of treatments I can offer will probably be good for my niche term development and hope some of you guys feel the same way and we’ll find somewhere local to you, no matter where you are in the world, someone who you can learn dental acupuncture from, and I hope this episode helped you to spark the interest in that journey. And thanks so much for listening all the way to the end. Really appreciate it always. Do hit that subscribe button if you’re watching on YouTube. And if you’re listening, give me some stars, okay? Spotify rating and Apple rating here and there means a lot to me. Thank you so much. Bye

Today we pick up where we left off on the 1st part of Group Function Episode 13 “Can I Probe This Implant?” In this episode I asked Dr Pav Khaira about bone loss around implants – what is normal and when should I worry? Another very interesting and controversial issue we tackled is how to manage implant screw loosening as a GDP? https://youtu.be/C1Y_AdDhLzU Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “If every single year you’re losing one millimeter (of bone) that’s obviously an issue and we need to intervene and do something,” Dr Pav Khaira In this episode we discussed: Normal bone loss for average implants 1:53 Guidelines for GDPs managing loose implant screws 5:03 Universal Implant Drivers? 10:45 If you liked this episode, be sure to check out the first part of this series Can I Probe This Implant? Click below for full episode transcript: Opening Snippet: Because screws become stressed and they become strained. That may be one of the reasons why it's come loose. And if you retighten a strange screw you can you can cause it to break, then you're in trouble because you may not be able to retrieve it from the implant head... Jaz’ Introduction:Hello, Protruserati. I’m Jaz Gulati and welcome back to this second part of the group function. So we split it into two. On the first group function, if you haven’t listened to it already, it was “Can I probe that implant?” Is it cool to probe around implants? Because there was a myth that you may scratch the implant? So is there any truth to that? Should we be concerned? That’s all covered in part one. In this part two, we’ve got Dr. Pav Khaira, we’re talking about What is the normal amount of bone loss around implant? So when I am reviewing patients who had implants placed elsewhere, potentially, and I take a peri-apical radiograph, it’s been five years since they had the implant and my expecting bone loss. At what point do I get concerned? And what point should I refer? So we’re gonna find that out. And another very interesting controversial issue is, how do you as a GDP manage a screw loosening? So if the implant crown is loose, is it cool for us to be going in and tightening it? What about if you don’t have the right equipment? Or how to even identify which system it is. You have to stop every single driver there is? The very real world question there and I think Pav does great justice. So let’s hear it from Pav, and I’ll catch you in the outro. Main Interview:[Jaz] When you see a radiograph of an implant, let’s say a peri-apical. And I don’t know when this implant was on, I can ask the patient, the patient like a long time ago, five years ago, 10 years ago, they give me a vague answer. But anyway, am I expecting ever, is it acceptable to have threads exposed supracrestal, ie, all the threads are not in the bone, some of the threads are outside the bone, Is this acceptable? And be what amount of bone loss is normal? Because I understand that after you place an implant, after about a year, you expect to lose “some”, you’re probably gonna say yes, by do all this crazy voodoo magic that they don’t lose any bone. But for the average implant, what is normal in terms of bone loss. [Pav]So historically, what’s been considered acceptable is as a rule of thumb, bone loss down to the first thread, then about 0.2 millimeters per year, as you quite rightly said that these is, the modern techniques, the modern concepts, were really shouldn’t be seeing anything at all. But you know, I see loads of patients where they come in to see me where they’ve had implants placed 20 years ago, okay? And I think the issue is in the absence, in the absence of any inflammatory responses, like what we’ve discussed about before, there’s no bleeding, there’s no suppuration, the implants been there 20 years, if you’ve got a 15-18 millimeter long implant, you’ve got three millimeters of thread exposed, I’m really not bothered about it, okay? If an implant was placed last year, and I’ve got three millimeters of threads exposed, all of a sudden, I am bothered about it. So I think it very much depends on the case. And with regards to how many threads are acceptable to be supracrestal, again, that depends on the implant, okay? Because some implants like the Southern that I use, the top three or four threads, it’s actually a machine surface. So if there are threads exposed, it’s not really that impactful, it’s not really that significant. But if you had an implant, such as Nobel, they integrate nicely, but if you look at the surface topography of them, there’s tiny little caves. So what happens is, as soon as that’s exposed, and you start to get inflammation, it zips down the surface of the implant. So it depends as to the surface treatment of the implants. As a general rule of thumb, you should see a bone off down to the first thread in the first year, but even then, I wouldn’t be overly happy with that. But I think if you’re taking consecutive radiographs, and you see everything’s nice and stable, then why should we bother and intervene and do something right? If you’re taking PAs once a year and over a five year period you know, if in year one you’ve had two millimeters bone loss and no bone loss since then, it’s a stable outcome. But if every single, year you losing one millimeter half of it, that’s obviously then an issue we need to intervene and do something. So again, I’m sorry, it’s not a you know, clear cut but… [Jaz]Nothing is clear cut but that’s a useful guideline, Pav. I really appreciate that because it’s a bit like a periodontal patients, age is a factor and obviously age of teeth. In your case age of implants, we can apply similar logic to that, so that makes perfect sense and I think that’ll help on the Protruserati and th, have you got a word for the dental implant podcast listeners? Have you listeners have they got like a fan word? [Pav]I’ve used the term titani-nerds a few times. [Jaz]Say that again? Titani-nerds. [Pav]Titani-nerds. Yeah. [Jaz]Okay, I love it. Titani-nerds. Okay, so Protruserati, Titani-nerds, I hope you’re getting some value from that. I imagine the Titani-nerds are just know all of this stuff already. But maybe someone who’s interested in implants, interested in getting into implants. And this might be helpful because they’re seeing patients in their helping to maintain implants, which is what this episode is about. So my last question is now that emergency phone call you get, the nurse says or the reception says okay it’s a patient with a loose implant. The first time I had this is embarrassing, the first time I had this as a DF1, patient came in, and the crown was spinning. And in my head I thought, wow, this is like a grade three mobile tooth. I don’t know, I think the implant’s spinning. So I call my trainer and I said, Hey, Reg, I think the implants are like, fully loose. But the X ray looks okay, what’s going on? And he just like took-took-took, took out the access cavity restoration, just tighten it by quarter turn. And that was it. And I was like, wow, that was so easy. And then later on when I got to do this, one, the implant dentist told me that Jaz, you know, I read your notes, you tighten it too tight. And I’m like I didn’t know, what was I supposed to tighten it to? Because that’s what Nobel taught me when I went on course once. So A) Do you think all general dentists should know how to manage this emergency and be any guidelines, any helpful things that you can tell us, is there a standardized number of Newton’s that were tightened to for example, is the kit standardized? Am I expected to have all these kits. [Pav]So this is a real bugbear and it’s a real pain in the backside for me, because there are literally hundreds, if not thousands of different implant systems out there. They all use different screw heads, they all use different torques, it can be due to a number of different problems. It could be screw loosening, it could be what’s called a titanium base that’s come loose, it could be the hex that’s threaded, it could be the implant head that’s fractured. And you’re basically taking a shot in the dark with this type of stuff. While probably recommend to a general dentist who doesn’t place implants, the only thing that you should really be looking at doing is at the most is tightening it finger tight, and then sending it to somebody else to deal with, okay? Because I had a patient come out to see me. So what I never do is I never just re-tighten screws, always have to order a brand new screw, okay? So I’ve had a couple of patients recently, come out to see me, the works absolutely beautiful. It’s come loose. So what I’ll do is I’ll hand tighten it, I’ll say, I’ve got to order new screws, I’m going to swap the screws over, because screws become stressed and they become strained. That may be one of the reasons why it’s come loose. And if you re-tighten a strange screw you can cause it to break, then you’re in trouble because you may not be able to retrieve it from the implant head. So you only want to tighten it at finger tightness, and then you want to refer it on somebody else to deal with. So the issue that you have is certain systems like Ankylos, they’re quite happy to take 15 to 20 Newton centimeters. The Southern implant that I use take 14 Newton centimeters, if you get it wrong, you’re going to give yourself a problem. So you need to know exactly which system it is. And there are have been a number of occasions where I haven’t known what system it is. And I’ve had to take an educated shot in the dark. And that’s all that I can do. So the answer to that question is, is are you going to see it? Yes, you are. Okay? And I think another big aspect, another big problem that this is caused by is very frequently, when dentists get the lab work back from the lab, they’ll use the same screw that the labs been using, they won’t order a new screw. And I’d say historically, that’s what I used to do, because I didn’t know any better. But people like why should I spend another 40, 50 quid on a new screw and all that one, there’s one that’s here. Thing is the lab has been screwing it on and off, on and off. And that screw’s strained, it’s not appropriate to use anymore. So this is something that Riaz and I discussed in our podcast as well, Is the lab should order a brand new lab screw and you should get a brand new prosthetic screw for every single case. Not be reusing impression copings you should not be reusing lab analogs, you should not be reusing healing abutments everything should be fresh brand new for every single case. The other issue that you can have, we spoke about this lollipop type appearance on a number of occasions. So another issue that you have is particularly monocytes is if you’ve got a narrow implant, which has had a small healing abutment on it. And the lab is they’re trying to create some sort of contour to the crown. Quite often the lab will put in a little bit of compression onto the gums to try to give it some sort of contour as it’s coming out. And what happens is as you’re torquing it down, let’s say you’re torquing it down to 35 Newton centimeters, that compressions going on to the soft tissue not onto the actual interface itself. So you get patients back quite quickly with loose crowns. [Jaz]Yeah because all that’s happening is a soft tissue is getting compressed, but the screw is not engaging where it should be, right? [Pav]Yeah, so the screws not fully seated. It’s partly seated. And sometimes you get away with it but a lot of the times you don’t, so my protocol is A) make sure that the crown’s completely passive is going in. I will then torque my abutment to whatever torque it is, depending on which implant it is that I’m using, I will then wait 10 minutes, and then I will re-torque it. Because re-torquing after minutes, make sure that everything’s really nice and secure. [Jaz]Amazing. I think that makes perfect sense. But I think the message for someone like me, which I took away from that is, if in doubt, which I’ll always be in doubt, because I don’t know which system was used, I’m going to finger tight in it, and send it back to the person if I don’t know who, you know, what brand of implant it is, and I’ve got my implant placing dentist comes in once a week, they can easily deal with that. And I’m sure they’d be grateful that they get an opportunity to properly deal with that. However they would and like you would. So I think finger tightening is something that a lot of dentists can do. And the drivers, the universal ones. Are they as universal as the name suggests? [Pav]No, they’re not. They’re just called universal drivers. But they’re just… [Jaz]Oh my goodness [Pav]It depends what or what extent you want to go to, you can get little kits for about 300-400 quid, which you’ve got loads of different drivers in and you just try whichever one so the case that I had today, I knew which implant brand it had. But when it was originally placed, it was over torqued to the head of the screw it stripped. So getting it on and off was really, so even with the correct driver getting it on and off was really difficult, okay? So you can have 0.9 drivers, you can have 1.2 millimeters drivers, you can have 1.22 millimeter drivers. Straumann have got their own driver, Nobel have got their own driver. Neodent, they’ve made their driver similar to Nobel, it’s called the Unigrip driver, okay? But Nobel’s, Unigrip driver, and Neodent’s uni driver, they look almost identical, but they don’t fit in the same way. If all companies said, we’re gonna have a standardized universal driver, that’d be one of the best things ever, but it’s just not gonna happen. It’s just not gonna happen. [Jaz]It’s not gonna happen, just like Apple’s not gonna switch to the USBC and get rid of that white thing that you have to buy. It’s just not gonna happen. And you can see why. But mate, that has been so helpful. So we have covered in this episode probing, Can you probe? Yes, you can. But take a look at the radiograph first because those lollipop ones good luck, it ain’t happening. Threads are exposed kind of like perio, you have to depends on the patient’s age or ie the implant age, not the patient, the age of the implant and that should guide you. And the loose implant, perhaps consider finger tightening it and sending it back to someone who can deal with it in a more comprehensive manner. Like you would. So Protruserati, I know you found that helpful. Titani-nerds, I hope you did, because you guys are like you know, you’ve been following Pav. Pav taught you so much already. So you know, we could have easily gone on for like five hours talking about each minutiae. You just have so much knowledge and I want to distract. But please, for those people who haven’t heard your podcast, Pav, tell us, remind us how we can listen, how we can tune in, and what’s next on the horizon for your podcast? [Pav]So it’s The Dental Implant podcast on Spotify, iTunes and Google podcasts. And, you know, obviously, inspired by yourself Jaz, you know, I’ve said this before, you know, you’re the one that seems to be probably got a lot of knowledge, you need to get it out there. So it’s aimed at kind of like beginners and those kind of like partway through the implant training pathway. There is stuff on there for more knowledgeable people, but they tend to know a lot of this stuff already. And I just cover so many different topics. I mean, as you said, you know, I could write a lecture just on screws, which could last two hours, I can then write a lecture on how to tighten screws for another two hours. So you know, it goes into.. [Jaz]All the complications in there and whatnot. [Pav]Yeah. And, you know, how to avoid complications, and, you know, what we should and what we shouldn’t be doing, you know, taking a part, the bad signs, et cetera. So I just tried to, again, I always say, look, it’s my perspective, you know, this is how I do things. This is my interpretation of the data. You don’t have to agree with it. You don’t have to like it, you know, but as you know, you can take one topic and you got two people arguing both sides of the coin, they’re both right, you know, it’s just, but I just want to help people deliver better care for their patients. This is one of the reasons why, you know, I mentor people as well. So when people like, I want to learn how to place immediate molar implants, it’s like fine, no problem, I’d show you how to do and bring your patients to me. This is why we do the EVO experience at EVO Dental, where you just come shadow us for days and see what we do. Because before I start at EVO Dental I thought I was proficient at full arches. But what we do there is just I wouldn’t do a full arch externally because just because of the way that the place is set up. So I’m done. Just you know, I’m very passionate about dental implants and trying to help others be just as passionate and get better outcomes for their patients because you know, it goes back to what we were discussing today, you know, is if I can teach dentists how to develop emergence profile properly, you’re not going to have these issues, if I can teach them how to place crowns properly and have soft tissue adhesion to the neck of it. We’re not going to have these issues in the future. So you know, that’s just my passion. That’s the reason why I’m doing it basically. [Jaz]And if anyone needed one more reason to listen to Pav’s podcast, he hired Morgan Freeman to do the intro. Can you believe it? He got Morgan Freeman. If you haven’t listened to it, you have to listen to it right now. Scroll on, go to Spotify, type in The Dental Implant Podcast. Listen to the intro. You will love it. Pav, thank you so much. Thank you so much for giving your time, really appreciate it. Thanks for all your mentorship and help and I think I won, I gained so much value I know what to do a little bit more now around those three scenarios which confused me every time, so I’m not going to, no longer gonna have my head in the sand now. Really appreciate it and hope you have a fantastic weekend. Jaz’ Outro:There we have it guys hope you enjoyed this group function series. As always a pleasure to do this and Pav is just amazing. He answered it really well, both parts of them. So Pav, thank you so much. Do check out The Dental Implant Podcast if you haven’t already, and I’ll catch you in the next episode guys. Be sure to join the Protrusive Dental Community on Facebook

“Don’t probe implants with a metal probe or you’ll scratch it!” – and so for years I was afraid to check the gingival health around implants. Crazy right? Dr Pav Khaira is here to bust that myth – but like with everything, it’s not a simple answer – it has some interesting anatomical considerations. His answer is so eloquent, check it out! https://youtu.be/pLDfqe8liLE Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “If you can get to the neck of the implant, you SHOULD be probing to the neck of the implant…but you don’t want to do it too aggressively, it should just be very gentle pressure.” Dr Pav Khaira In this group function we discussed: Can you probe implants? 5:33 Screening Periodontal Health of Implants 11:14 Referring patients with Peri-implantitis 16:22 Check out The Dental Implant Podcast! If you liked this episode, you will love revisiting Implant Assessment for GDPs: from Space Requirement to Ridge Preservation Click below for full episode transcript: Opening Snippet: You just got into the cuff just sweeping it backwards and forwards and you seeing whether that triggers any bleeding because that's a sign of inflammation... Jaz’ Introduction:Hello, Protruserati. I’m Jaz Gulati and welcome to this group function. Now if you’re new to the podcast, welcome, great to have you. A group function is where we work together as a team to find out a solution to a common problem. And the problem I’m presenting today and I’m hoping to get a good answer from Pav today is ‘Can you probe around implants?’ And what I mean by that is, I was fed a lie or a semi lie at dental school, like someone told me, I don’t know who it was. But if you use a metal probe, to do a periodontal probing chart of an implant, you will scratch that implant and therefore that will harbor bacteria. And therefore you should not be probing around implants. So for the longest time, I didn’t check the periodontal health of implants and it sounds really bad. But as a GDP who doesn’t place implants, not much to do with implants. I thought that was the right thing to do. I thought I was doing less harm by not inserting my Williams or WHO or CPITN probe in the sulcus to check for the periodontal health because I didn’t want to scratch the implant. I was scared of scratching the implant if you like. So I was expecting this to be a really quick group function. And I thought Pav was saying Yeah, you totally can. It’s all good. But Pav of being Pav, an amazing guy he is. The only does he give us a really good definitive answer at the end, where he talks about the rationale of what the concerns are maybe and how each actually look a little bit deeper than Can you probe? Can you not? Because there’s some anatomical variation, so I’m not going to spoil it for you. Let’s join this group function with Dr. Pav Khaira. That man again. Pav Khaira. Main Interview:[Jaz] Dr. Pav Khaira, welcome back to the podcast, my friend. How are you? [Pav]I’m very good right now. How you doing? [Jaz]Yeah, great. So it is Pav Khaira from The Dental Implant Podcast. And I’m gonna just pick your brains. You need to teach us something today. You need to speak to me like I’m five years old. Because this, the following questions I’m gonna ask you on this group function today is very much basic things that you’re probably gonna laugh at me like Jaz, why you asked me these basic questions? But I’m sure with the referring dentist that you’ve met and your colleagues, like when it comes to implants we come out in dental school, like a lot of other topics. And we’re like, where do we even begin? So just before we dive into that, just reminder on people who perhaps didn’t listen to our episode on finding your niche. I think it was episode 76 from memory. Do listen to finding your niche, it’s a cool one where we discover what is like your calling in dentistry. So do check that one out. But just remind us what is it that you do other than these amazing transformations that you posted on our telegram group. [Pav]So thank you very much for having me on Jaz, I’m going to be cheeky and just upload this as the next dental implant podcast episode as well as your record. We have the same video editor. So it’s an easy way. Firstly, I just wanted to say that there’s no such thing as a silly question. This is something that I learned really quite early on, either you know, or you don’t know, it’s really that simple. And I think anybody who doesn’t know who’s asking questions at that point that then they shouldn’t feel embarrassed or anything along those lines. So if I am being overly complicated with my answers, please feel free to remind me because obviously, for me, this is fairly straightforward stuff. And you know, when I get excited about implants, that’s it, mouth starts. Okay? We all know. [Jaz]We’re going to start talking about at the cellular level, biological level. No, we’re gonna go way simpler than that today. I know the kind of stuff that you talk about you love that you absolutely love that. And that’s amazing to see though your passion is so.. [Pav]I’m gonna make it really tangible for you guys as well. So a little bit about me. I graduated in 2002. I did loads of different things. You know, I ended up getting bored quite quickly. It was one point I was doing endo for smile makeovers. And ironically, I just didn’t make surgery. I didn’t make implants. And then I ended up getting into implants. And I was like, Oh, actually, I really love this a lot. I’m now at a position where I am fortunate to be at EVA dental four days a week, and I mentor other dentists and I started working at another practice one day a week as well. And I placed approximately 1800 to 2000 implants a year. So that’s actually quite a big number. And yes, you know, when you when you place big numbers, you learn to prevent a lot of mistakes, but you still see them, you know, anybody turn around and say you have 100% success rate. This is something that I’ve alluded to before, they are either lying or they’re only placing one or two implants per year because if you place one or two implants per year, it’s quite easy to have 100% success rate. So yeah, I mean, that’s just a little bit about myself, I do the surgical aspects of it. I also undertake the restorative, because you can’t separate them. You know, it’s that intrinsically linked together. So that, you know, that’s just a little bit about me. [Jaz]Amazing. I mean, it’s crazy. That number you mentioned, you probably do more implants than I do checkups. You probably do more implants than I do composites. You do. You do more implanst than any procedure. That’s pretty spectacular. So you’re totally the right man for this. So question number one of three in this group function is m, can I probe that implant? Now to give you some background behind this question, it’s something that you may have heard before. Now, I don’t know whether it is a myth or not. And I think it is, but let’s just find out the whole thing about if you use a metal like a Hu probe, or a CPITN, a metal probe, or an implant, you will scratch the implant, which will then harbor bacteria, and it’ll be a never ending spiral of peri-implantitis in future. And therefore, dentists all over the world. I’m sure they are. I’m sure they are, are doing their BP and they skip the implant and they carry on. Tell us about this. [Pav]So the question that I understand is can you probe around implants? [Jaz]Can you probe with a metal probe aroung implant? Or is it a myth that you shouldn’t, you can’t, or just tell us generally about how to check the periodontal health of an implant in a safe way. [Pav]Okay. Do you want me to be really unhelpful now? Because you know, what I’m like, it’s one of those. Okay, so the answer to your question is, yes, you can, and no, you can’t at the same time, I’m going to expand on that right now. Okay? [Jaz]Sure. [Pav]I think we need to take half a step back and understand what’s happening a little bit. Okay. So when you receive the final outcome of or, let’s just say, restored single implant crown, okay? So there’s a number of ways that it can be done. The way to get the best outcome isn’t done very often, because it’s more time consuming, it’s more difficult to do, okay? So the kind of the standard way that most people out there do it, which is kind of accepted is you have quite a narrow implant in relation to your ridge, which is the same height as the alveolar crest. And then radiographically, it looks like a lollipop, tomato on a stick is what it’s called. So you get this sudden, you get this sudden, really, really extreme what we call emergence profile, okay? Now, so probing around implants is different to probing around teeth, okay? Because when you’re probing around teeth, you’re immediately going into the periodontal ligament. If you imagine you’ve got this really wide implant, sorry, really narrow implant, or really wide crown. If you’re probing straight down the side, you’re not actually going to do anything, you almost want to be at 90 degrees, and it ends up being really difficult. Okay, so in those instances, when you’ve got an internal connection, the implant actually needs to be deeper. So you’ve got running room to have a natural emergence, but then you need to condition the soft tissue with a, instead of just a standard healing abutment out of the pocket, you can make custom healing abutments so you get a really nice smooth transition. Okay? Now, the reason why that is important, is because when you’ve got a very acute and sudden emergence angle A) it becomes virtually impossible to probe to the neck of the implant, but it actually answers the bio flora, the biofilm next to the implant neck itself, unfavorably, it becomes anaerobic as opposed to aerobic. Okay? So you’ve actually snookered yourself. So because what you’ve done is you’ve created a situation where you need to probe but it’s actually difficult to probe. Okay? So the other way of doing it is once you place your implant deep enough, the way that I do it, is I use external hex and I use quite wide implants. Because then it’s… [Jaz]Only because I think everyone’s like listening like wow, they’re like gripped by this because this is very interesting in terms of the different connections and how to have that runway room to get the best emergence profile. But like if I’m a GDP and which I am, and I see a patient and implant was put in, I don’t place implants. So patient comes in, they got an implant. I’m not going to pause and say, Okay, what kind of connection is that? Now I will because it’s great point you raised. Now I look at the radiograph and I’ll see okay, is this a lollipop or is this not a lollipop? And then but you know, what am I gonna do? [Pav]Okay, fine. That’s exactly the point that I was getting to. So first thing that you do is you take a radiograph. Okay, if it looks like a lollipop, there’s not really much point in trying to do it because the angle that you’ve got to get to, the pressures that you’ve got to apply, you’re not really going to be able to approach the neck of the implant, okay? [Jaz]Of course. [Pav]And now it is my opinion that you know, if you can get to the neck of the implant, you should be probing to the neck of the implant, okay? So you don’t want to do it too aggressively, it should just be very gentle pressure, okay? And what you’re looking for is you’re looking for the same thing as what you would do when you have a tooth. Is there suppuration? Is there bleeding? Okay? Not so much about the depth of the probing itself, okay? Because you don’t have a true periodontal attachment. It’s like a long junctional epithelium. So you’re applying much lighter pressure, you’re automatically going to have pseudo pockets going deeper. But the question is, Is it bleeding? Is there suppuration? And as I said, is if you’ve got this lollipop type appearance, so you’ve got this skinny implant, all of a sudden, really, really big crown on top, I don’t think you can probe those pretty well. So why bother? [Jaz]Still probing just to check if there’s bleeding or suppuration? [Pav]So no, I mean, the test that you can do in that area is you look at your radiograph to see A) is there any bone loss around the threads? We’re gonna come back onto that in a minute, because I know that’s one of the topics, Okay? The next really, really, really good test is just with a finger, just push the gingiva either side, because if you push the gingiva, either side, you see suppuration coming up one side, that’s a problem. Makes sense? [Jaz]I see. So you’re kind of like milking the implant. [Pav]Yeah, massage. Exactly what it is. If you’re massaging the gingiva, either side, and you’ve got bleeding, or you got pus coming out without even picking up a probe, that’s a problem, that’s absolutely a problem. Okay? So let’s say you’re looking at the radiograph and you get this nice transition from the implant to the crown, it just looks like nice and smooth. Yeah, pick up a probe, it’s not a problem, just don’t be heavy handed with it. So what you’re not trying to do is you’re not trying to sound down to the neck of the implant, lots of bone, all you’re doing is you’re just going kind of like into the cuff a little bit, you just go into the cuff and just sweeping it backwards and forwards. And you seeing whether that triggers any bleeding, because that’s a sign of inflammation. So there’s not so much probing is you just seeing whether it triggers an inflammatory response, that’s all that it is. But you what you will notice as well is particularly with implants, is you get this little purpley band around the neck of the implant when in early stages of inflammation. So and in those instances, when you’re looking at those perfectly bands should immediately be thinking to yourself, something may not be quite right here. Okay? So I have no problems with people gently probing if you could use a plastic probe that’s better. You got a metal probe, you know, there’s not too much data to go in between because it swings and roundabouts. If you don’t probe, you don’t know what the problem is. If you do probe, but you probe too hard, you’re going to scratch things, you’re unlikely to get to the neck of the implant, or you shouldn’t be able to get to the neck of the implant. I think it also comes into play, what restorative material has been used as well. Okay? So without going too much into it, there is a very good researcher called Tomas Linkevičius, he has done a fantastic textbook called Zero Bone Loss Concepts. He teaches on it. And the restorative protocol that he use is highly polished zirconia on the fit surface against the soft tissue itself. And when you do that, and when you autoclave it and clean it properly, you actually get soft tissue adhesion to the neck of the implant. Okay? So allow me to break this down a little bit more. I know we’re going a bit more advanced, but it’s actually really relevant for what we’re talking about. He did once a day where he did restored single implant crowns. Okay? Using Zirconia. On half of the fit surface against the soft tissue, he used a zero bone loss concept which is highly polished, no glaze, okay? On the other half of the same implant, he used glaze over the surface, and if it’s, and six months later, he programmed the implant, okay? The average probing depth of the polished area was one to two millimeters, the average probing depth around the glazed area was two to four millimeters. So you can actually get a division of the soft tissue onto the surface of an implant if you do it properly. So I think it’s also important to know what material has been used, okay? Because if it’s a PFM, you’re not going to get that adhesion, you need to be much more gentle with your probing technique. The other thing that you can do as well is if you’re going around is as you put the probe in, you take it out and you wipe the probe clean with a clean gauze so you’re not transferring bacteria from one position of the implant to another. [Jaz]Wow okay that is a dedication. [Pav]Yeah, that’s dedication. But you know that’s something that I heard, but then I thought so that, you know, then I was thinking to myself, you know, you’re talking about not transferring bacteria from one part of an implant to the other, it still sat underneath the implant. It’s still a problem, right? So it’s a, and this is why I’m saying that there’s no 100% correct answer. But I think what you need to do is you need to look at the radiograph. And make an appropriate decision. If you see that lollipop on a stick, you’re not going to get to the neck, forget about it. If it looks like a really nice, what we call emergence profile, that really nice, soft, flowing type thing, then you think to yourself, yeah, I’ll gently probe this. And to be honest, is if I have, like my own implant crowns, now, the zirconia ones, I’m less bothered about probing them, because I know I’m going to get soft tissue adhesion. So I look at the adjacent teeth as well, right? So if the patient’s cleaning everything really, really, really well, you’re unlikely to have a problem with the implant. So don’t take the implant as a standalone thing. Look at everything else around it as well. [Jaz]Well, before we now come on to the radiograph, because you touched on that and that was it. Next question about the thread exposure and what is a normal bone loss before I get to that, I mean, when you find if and when you find bleeding, when you’re doing the probing on implant, I think that lends itself to a diagnosis of Peri-implant mucositis I believe pus would mean, I know it might not be a hard and fast rule, but pus usually what I’ve been taught and I’ve read Peri-implantitis. Should I be referring to someone who’s more clever than me in implants? Every time I diagnose Peri implant mucositis, just bleeding or just simple local measures? Improving OH is enough or do you think I should be actually sending him back to the dentist? So Peri-implantitis with pus I definitely would be not, I would not be ignoring that. [Pav]Yeah. Local measures. So improve the oral hygiene, explained to the patient what’s going on. And just treat it like a Perio case. So you’re monitor it over. And you assess it over a number of months. And it is really important that the patient improves because the other issue that you have is the crown cement retained and is it cement underneath that’s causing this in which case, no amount of oral hygiene, you can do this. And what the data shows is if you do a cement retain crown and you can’t get rid of the cement, the cement may cause an issue seven to eight years later, sometimes it’s not straight away. So you know, a lot of people are doing well, there’s nothing wrong with cement retained crowns. And you look at this paper and it goes Oh, yeah, you know, after three years, cement retained crowns, I’ve got no issues. There’s that Yeah, but the peri-implant cementitious can be triggered seven or eight years after when you actually cemented it. So I think it’s important to see whether there’s a scratches in it. If there’s scratches in it, then you know, it screw retained. If there’s no screw access, and it just looks like a normal crown, then it’s cement retained. And then we come back to the original issue that we spoke about, if you’ve got this lollipop type thing, being able to get a probing towards the neck of the implant to get rid of all of the cement, never, it’s not going to happen, there will 100% be cement there. So when you have just a little bit of local inflammation, by all means start local measures first, really good OH, there are some products called blue®m, okay? I think that there’s a mouthwash, there’s a gel, they actually worked really nicely. They are oxygenating, they’ve got oxygen in it, and it is ` the biofoam for that to be more favorable. And what you should notice is once you implement those measures, it should maintain, like with gingivitis may get the odd flare up now and again, but you shouldn’t have anything persistent. [Jaz]For me your word is gospel, you know, for me, you’re the guy who doesn’t you know, if you don’t know something, it’s not worth knowing when it comes to implant. So I will definitely look into that product for, to help my patients supportively but on to question two now. Jaz’ Outro:There we have it, guys. Hope you enjoyed that group function on can you probe that implant? The next one is going to ask about what is the normal amount of bone loss around an implant? So as a GDP when I see a radiograph, a PA, and I’m seeing a little bit of bone loss around an implant, Should I be worried? I don’t know at what point I should be referring on to the person who placed the implant or someone who a periodontist maybe? So that’s the kind of flavor I got. And the third question which all be covered in part two of this group function is what do you do when you get an implant screw loosening? So as a GDP if someone’s implant crown is loose, I now know what that is a screw loosening. You can hear about our use of thing that was but it’s a screw loosening. And is it cool for me to just enter the access cavity and just Yeah, finger tight or tighten it to what I think it should be torque to, is that a good thing to do as GDP? Well, you’ll find out very soon, either a few days or a week, depending on my workload. But anyway, thank you so much for supporting and listening. I really appreciate it. I’ll catch you in the next one.

Learn the challenges dentists face with back to back Class II restorations and the value of pre-wedging. Dr Chris O'Connor shares his restoration protocol and troubleshooting tips. Discover the use of sectional bands for tooth separation and the importance of pre-wedging for successful restorations. Also, explore the educational benefits of Instagram for dentists.

Happy New Year, Protruserati! In this episode we geek out with Dr Dev and Jaz as they discuss the initial stages of a Full Mouth Rehabilitation. In this 3-part series we will go on to describe the step-by-step stages for an Adhesive Full Mouth Rehab . Before we dive into the meaty part of this series later on, Dr Devang Patel will take us to the journey  of the clinician’s mindset who’s doing full mouth rehab and how to communicate effectively with patients. https://youtu.be/Dnj0PDe0ulc Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Write down one good thing that happened each day of 2022 on a post-it note, fold it and put it in a jar. By the end of the year, you’re gonna have 365 post notes of all the good things that happened that year. Check out the RipeGlobal Facebook Group that inspired this pearl! “However, learning is nothing without action. So you can learn and learn and learn and learn…but if you don’t take any action, then you’re not going to get anywhere.” Dr Devang Patel In this episode we talked about: The mindset of the dentist doing a full mouth rehab 12:19 The three step technique 25:32 Appointment 1: Diagnosis and Treatment Plan 26:00 Communication with Patients 37:57 Reorganizing versus Conforming Occlusion 40:30 If you enjoyed this episode, be sure to check out the second part Adhesive Full Mouth Rehabs Part 2 – Wax Up and Temporaries and the third part Adhesive Full Mouth Rehabs Part 3  Click below for full episode transcript: Opening Snippet: Were you looking at step one is your diagnosis and treatment plan. That's the biggest step ever. The second step would be your anterior reconstruction and third step is posterior reconstruction... Jaz’ Introduction:Happy New Year 2022. Protruserati, welcome back to your favorite dental podcast. I really appreciate you coming back. And if you’re a new listener, welcome to this podcast. Hope you get lots of value from it. And today’s episode is part of a three series. So this first part is about full mouth rehabilitation, adhesive dentistry, so an adhesive rehab, ie using some sort of composite resin, either direct or indirect, and how to transfer that from the wax up to the mouth. So we’re gonna break it up into three different episodes with Dr. Dev Patel, who came on before, and he talked about private dentistry versus public dentistry and how we can be comprehensive in public dentistry. So in today’s episode, we’re looking at the mindset of the clinician who’s doing full mouth rehab, because we can’t just dive in talking about how to do these beautiful wax ups, and how to do all the big composites and indirect work as well, which we mentioned, that comes in episode three, actually. But we need to first start off on the right foot. And we need to know why you want to get involved with full mouth dentistry. What the mindset of the clinician is, how to diagnose, how to communicate, what to say, and how to say it at your treatment plan presentation appointment, to be able to then lead you with the correct patient, with the correct diagnosis to treat that patient in a full mouth manner. This series is titled 11 steps have a decent format rehabs and so really, this episode looks at appointment zero, ie your mindset, you as a dentist, and appointment one. And also when you bring the patient back and you speak to them. So those are the first couple appointments. The second part of the series coming probably in about four weeks time when we record is going to be appointments two to five, this is when you actually do, your mounting, your wax up, your transferring of the wax up to the mouth and you’re assessing the phonetics and the aesthetics and you send them home to test drive. And then the final part getting to there are really meaty bits. Okay, but I think it’s good for you to listen to these foundational parts one and two, before you come to that one, which will be around about six or seven weeks. And what we’re looking at the final one is appointment 6 to 11. Now the final few appointments are about splint provision and we don’t go too much into that, so we’re looking at appointments six to about nine, which is how to now bond your composite. What are the different ways to transfer the wax up to the mouth? Do you do anteriors first? Do you do posteriors first? Do you do left first? Right first? We cover all of those things in really great detail. I know you’re absolutely in for a treat. And I know you’re going to really gain a lot of value from this. So I’m excited for both of us. I enjoyed so much. I learned so much. And I know you will too. Before we joined Dev, wanna give you the Protrusive Dental Pearl for today, it’s kind of like a wishy washy one. Now we need these now. And again, it is looking at the New Year. Okay, so New Year, it’s January, it’s 2022. What can we do that can really make a big impact next year, so that we reflect at the end of the year. And we look back and we think wow, you know, that was a really good year. So my friend, colleague and mentor Michael Melkers, we are admins on the Ripe Global Facebook groups, if you’re not part of Ripe Global, please searched up on Facebook, it’s where a community of dentists post up their full protocol cases that you will learn so much by watching this full protocol cases. And this is a great community of dentist who are just hungry for knowledge and hungry to learn and hungry to share. So in this group, recently, Michael posted a photo of a jar of post it notes. And he suggested that every day, okay, in 2022, every day, we should write down one good thing that happened that day, and write it on a post note, fold it and put it in the jar. By the end of the year, you’re gonna have 365 post it notes of all the good things that happened that year. And so on 31st of December, you’re going to open that jar and just read it. Okay. And I love that. So I’m going all in. I’m doing it. And I hope you do too. So that’s my Protrusive Pearl, why don’t you get involved and it doesn’t matter if it’s March by the time you discover this podcast and you’re listening to this, start now. Start now and get perfect later. That’s always been the motto. So I hope you enjoy that little pearl. Hope some of you will act on it and start making these post it notes of positivity to reflect back on at the end of the year. Now with this episode and the future episodes if Dev or any of the guests share something like a PDF or a link, it’s always going to be on the blog on protrusive.co.uk or whichever podcast player you’re using, you scroll down something like Google, Apple, you should be able to see the links but you can always check back on the main blog. Let’s now catch Dev Patel. Main Interview:[Jaz] Dev Patel or welcome back my friend today Protrusive Dental Podcast. How are you? [Dev]I’m very well thank you, Jaz. I’m thrilled to be here. [Jaz]We spoke, man, you’re very welcome guests, we had you already talking about the complexities of NHS Dentistry and how to communicate better, how can we better communicators in that regard and NHS vs Private. We covered a lot of themes, we’re going to go a little bit more clinical now. So we just want to know the crux of this podcast. And we’re going for, we’re really going for the kill here. Because this theme that we’re going to explore today over that I think will be a two, maybe even three part episode is full mouth rehabs. And this is really the crux of occlusion for me. So the reason why I got more and more into occlusion is because I got to a point where I thought, hang on a minute, I need to treat more than one tooth here. And then suddenly, I’m like, Okay, I treat 6 teeth to 8 teeth. And then the biggest barrier or biggest issue that I had was, how do I make it fit, hencewhy I went to all these courses to learn how to make it fit and how to make it last. And for me occlusion just sums up in terms of how can we do a full mouth rehab, how we plan full mouth rehab, and expect it to last over a long period of time. Now, I know Dev, with how much experience you have, and the kind of case you post, you have got so many more full mouth rehabs under your belt than I have, which I’m so excited to learn from you. But I’m also hoping to break it down for all the Protruserati listening. And I love the way that you really, we’ve had some emails, we had a bit of chat so far, but how we’re going to break it down appointment by appointment, and you told me that it’s roughly around about 11 appointments or so. And obviously, that varies. But for those people who haven’t listened to our previous episode together, just tell us, give us a little bit flavor about you, the type of density that you love. And then we’ll build from there and we’ll start talking about appointment by appointment on the road to full mouth rehabs. [Dev]Cool. So let me start with my journey so far. So I was General, I started as being general dentist, as you know, as everyone do. And I’ve worked in NHS dentistry for six years, and I wanted to grow up my skill. During that time I did a lot of restorative courses. What I found that I want to do complex cases and could not do it because although I had knowledge, I didn’t have guts, basically. So I want someone to really mentor me, supervise me, because you know that first case is always very, very difficult. And you know, you don’t know 100 nuances, you don’t know what to do. So that’s why I joined the Masters MSC cons program at Eastman dental hospital. Now, if you don’t know what that is, it’s a one year full time program, where you do lots of full mouth reconstruction, but you also do your own lab work. I didn’t, I mean, I was aware of it, but it’s quite labor intensive. So I was I used to be there 7am to 11pm every day, seven days a week, I managed a caseload implant [Jaz]hencewhy this is called the divorce course, remember? So for those who don’t know, when I was considering, I was considering doing it, but then people told me it’s a divorce course. So that’s the reason I never did it. [Dev]Fortunately, my wife was very, very supportive. So you know, were still together. And so yes, I managed to do a lot of full mouth reconstructions, and lot of implants. But mainly someone was sitting next to me while I was doing bigger sort of biggest stages, you know, as it was. So if I’m doing full mouth reconstruction, and doing anterior posterior reconstruction, so on sort of consultant was nursing, with me, so you know, he was picking all the small things. And I think that gave me a lot of confidence. So once I finished that, I then started practicing, and the biggest hurdle was communication. And we will touch on that, to be honest, because it’s one of the biggest thing because as a dentist, we love to learn skills, you know, the hand skills, but it’s the communication skill, which will start your car going as if so you may have Ferrari, but if you don’t have fuel, you won’t go anywhere. So communications is kind of your fuel, so to drive your car. So I learned a lot about communication and I’m still learning you know, still in infancy, I believe. So started doing communication and then so I was quite confident full mouth reconstruction. The next step was to improve my surgical skills. So again, being me I mean, I quite scared of doing anything. So I had a mentor which was Fouad Khoury. I don’t know if you know him. He is the king of proffesional bone grafting [Jaz] Khoury plates, the chap who made the Khoury plates, yeah? [Dev]Professor was mentoring me when I was doing surgery. So I really have found that skill. I learned from sort of John West, who is the inventor of Protaper files. So went to San Francisco, learn the pros, sort of how to do re-root canal, root canal treatment from him, been to numerous courses basically. So invested a lot of money and time and effort into doing sort of all the skills. Meanwhile, I was also teaching, so I’ve been teaching occlusion and full mouth reconstructions in 10 years now. And what I’ve realized that I actually I started, I mean, I’ve been teaching but one of the VT who desperately needed a post, and I was in Devon working and there was no one providing sort of VT training for her, so I said, Okay, I will become your VT train [Jaz]I just because we have an international audience Dev, I’m going to just break it down VT. For those in the US, Australia, wherever it’s someone who’s just like a year out of dental school in the UK and then a vocational training or dental foundation training, it’s actually a stepping stone to practice. It’s like a residency kind of in general practice. [Dev]So you need someone to obviously mentor you for that residency, what that sort of a one year, and so no one was available. So I said, Okay, you know what, I’ll help her because she was very genuine. She was hard working. So I started teaching, but not just for during basic dentistry, I was training her for full mouth reconstructions, implants, placements, everything. And within two years, she started doing full mouth reconstruction, placement of implants, everything, full shebang. And so then I started realizing, you know, the impact I can have on the wider population. And that’s when I sort of started putting more effort into online courses, which is occlusion to already habilitation, where I will go through, you know, so from occlusion to full mouth reconstruction, and yeah, so I’ve been teaching now, and I love it that way. Because by teaching, I can have more impact, you know, you can have more patient treated, better quality treatment. And I personally feel that there’s huge underdiagnosis going on, you know, because dentists don’t have confidence in treating. And I just want to share my experience and show every dentist hopefully, that it’s not really rocket science, if I can learn it, anyone can learn it. And yeah, just start their journey in full mouth reconstruction really [Jaz]Well, I think what you gave to that dental foundation trainee, that young dentist is you gave direction, you gave knowledge, but you gave confidence, the same confidence that you craved, when you wanted to do rehab yourself or the upper level in surgery, I think the nowadays with education being so widely available, mentorships being so widely available, that this really is the rocket fuel for young dentists to be able to do the kinds of cases sooner and to a higher standard than ever before. So that is a great story. I love your why as to why you do this. So that’s amazing. So let’s take everyone on a journey, Dev of full mouth rehab, and very nicely broken down into 11 appointments. Okay, so Dev, we were emailing some ideas about how to structure this mammoth topic of full mouth rehabs. So let’s just give everyone a bit of a background before we get to that, but you told me that you typically would see someone for 11 appointments as a typical Now obviously, that could be 20, that could be eight, whatever, right? Like, you know, there’s small little nuances in there. But in terms of the big sort of themes of appointments, there’s about 11 stages. And I think that lends itself really well to make a nice podcast episode about the different stages, the different nuances of a full mouth rehab, from the planning, and even before the planning, I like how you labeled appointment zero, as the mindset of the dentist. So you know, not every dentist should be or wants to do this kind of dentistry. And I think that’s where you’re gonna allude to, like, you know, is this your type of gig or not, and then we can work to appointment one, and then we’ll talk about the mock up, and then the planning and the prep stages. And then the bit where I get very excited, and I’m still learning more about how to go from temporaries to definitives, in a predictable way, that itself can be a real challenge in working with a lab and whatnot. So I’ll be just throwing little curveballs at you, and all questions, thinking out loud and stuff. And I’m through that way, just like many of the other episodes, I hope to give lots of value to the Protruserati. So shall we start on appointment zero, the mindset of the dentist doing a full mouth rehab. [Dev]Yeah. So I always say that whatever you start, you need to start with why. You need to start why you’re doing you want to do full mouth reconstruction, because as you quite rightly said, full mouth reconstruction is not for everyone. Because it’s more involved than just a single restoration. Because patient can come in just in a single filling, patients gone done. Where as full mouth reconstruction, going to see that same patient again and again. And they a lot of involved, especially when you’re doing first or second case, you know, there are a lot of things involved. So first of all, you need to really, really, really know why you’re doing or why you want to do full mouth reconstruction. Now if financial is your reason, then I personally feel it’s not a big enough reason for you to keep going because you will hit a road where you will get frustrated and you know, you might have problem, complication, failures. And you might just think, you know what, I don’t, because financially it, to me it doesn’t make sense, in the sense that yes, you know, that is this financial aspect of it, but purely if you look at financial aspect, then you can just do general dentistry, do general dentistry and you will be fine. Because if you think about it, reconstruction is nothing but multiple single restorations, right? Coming in together in harmony because of occlusion. So, the only difference between single restoration like 28 single restoration, or full mouth reconstruction is occlusion really, how they’re coming together. And all this facade is to make sure they come together fine, okay, for that patient, not even one original [Jaz]Together fine. And they last as long as possible. Because I agree with you, Dev, I find that when I was venturing into bigger cases and full mouth rehab stuff, I found the aesthetic planning actually quite simple, you know, when you listen to like people like Frank Spear and the textbooks out there on aesthetics, and you decided about the upper central incisors, and you work your way around, and you level everything. And as the planning the aesthetics, I didn’t find that complicated is then how to make it fit together in harmony of the patient’s skeletal pattern, and in a way that the future excursions in the future function will be respected. And to get the most longevity possible. That is where the tricky bit comes in. But that’s all in the planning stages, then when you actually get to cut the teeth, you realize, hang on a minute, I’m just instead of doing one crown prep, I’m just doing lots at the same time or whatever, or adhesive rehabs. And then you find that actually, you can do it quite quickly. So it’s all, the all the hard work goes in front loaded at the beginning, what do you say? [Dev]And to be honest for everything. So if I’m doing full arch implant reconstructions, if I’m doing upper and lower full arch implant reconstruction, the planning is it takes much, much, much longer. And then once you plan everything, then everything’s like really smooth sale. But if I have any problems, and I’ve had problems, at the end of the treatment, it’s always because my planning wasn’t great in the beginning. So you know, I can always pinpoint, I would say, 80%, almost 90% of the problem to my planning, whenever I have had any problems, so I just take a long time in planning, to make sure that, you know, I know, I’m controlling no known factors, you know, which you don’t, what you don’t know, you don’t know, you know, but at least what you know, you’re controlling it. [Jaz]Well, we’re gonna cover that in a few appointments time. But like you said that the mindset is important. But I also want to just add in about, you may be probably gonna cover this anyway, when it comes to communication aspect is, it’s the mindset of the dentist, but it’s also choosing the right patient, because it’s a bit like, you know, what the orthodontist say to patients or what you probably say to your implant patients, that it is a marriage between you and the patient, you’d have to pick who you’re going to marry as a patient and who you don’t want to marry. And it’s completely okay, you know, even though the case looks like perfectly set up, and you can visualize the end result, and the patient got, you know, the money in the bank, and they want to start, but you get this funny feeling in your stomach that this patient is trouble, there’s red flags, and then you don’t want to treat it, that’s probably the best thing you’ll ever do not treating that patient [Dev]100%. And I’ll go through that actually a little bit more in detail later on. When I’m covering the treatment planning aspect, funnily enough, so we’ll go through that 100%. So, with regards to the mindset, you need to understand why we want to do full mouth reconstruction, I the reason I want to do is I want to help patients, because after doing full mouth reconstruction, the smile, you see that the relationship you develop is completely different than you treat someone with a single restoration, because you just changed their whole persona. And by teaching, obviously, then spreading the love to many more patients. And that’s one of the reason. The other thing is you need to have a positive attitude. Because if you are concentrating in this litigious society, about the complaints, about the problems going to have, about the failures going to have, then you will never start because there initially you will have more problems statistically, because, you know, you’re starting, you’re learning, you know, we are all practicing per se. So you are starting so you know, you will have more problem. And that’s where the direct mentoring comes through. And that’s where the learning comes through. However, learning is nothing without action. So you can learn and learn and learn and learn. But if you don’t take any action, then it’s not you’re not going to get anywhere. The third thing is [Jaz]It’s all about the implementation [Pav]100%. And the third thing is we all have limiting beliefs. And I personally do have as well, and I’m trying to break some of my limiting beliefs. But most of us we think we are not good enough. You know, and people who think we are not good there, they are actually the good people, the good dentist, they think they’re not good enough. Does that make sense? The people who are obviously just crack on most of the time. So it’s the people who are good, they just think you’re no good enough. So you need someone to tell you, critique your work, and then just improve and improve and improve and that where you will help. The other thing I get a lot that you know what, my patients are not right type of patients. And I get that a lot from dentists, or that I live in an area where there is not uptick, you know, no one will uptake that. I mean, I have worked all over UK in almost 11 practices. And I’ve proven everyone wrong, and they are different. None of them was highly influenced practice like that. None of them were like a high practices. So people need treatment, especially actually if you think about it, the lower socio economic area, that’s where the needs are more because you know, people come to you in a desperate situation and when you’re desperate situation, you will do anything. So and also they haven’t had been [Jaz]this is a recurring theme, Dev, by the way, I just want to say this is not just you telling me this on other podcasts, but other people have told me that they started these cosmetic clinics in these extremely deprived areas, like for example, Biju Krishna, and when he was starting out doing lots of CFAST up in Scotland in this dodgy part of Scotland, and they became this huge provider of cosmetic dentistry, busier than any other clinic doing lots of short term ortho, whatever, in an area where you would have thought I never want to buy a practice that. And it’s a theme that you hear again, and again and again. And it all boils down to communication and your limiting beliefs, just like you said, rather than just accepting that, oh, my patients won’t take it. If you accept in your mind that my patients aren’t there, they won’t be there. [Dev]Either way, I think it is that I just removed, if there are many patient who come to me now because I’m doing a consultation and someone would have referred me, they’ll come to me, sit on the chair and they say, Look, you know what I can’t afford what you’re offering. So that’s fine, you paid for consultation, I’m going to give you what, okay, and then you decide what you want, at least you paid for this, let me do my job. And then you know, I just get for I don’t even think that they can or cannot afford, my job is really to tell them what they need. And then it will be their decision whether they want to have this done. Now if I’ve done my job properly, to show them the value, I’m sure they will have something done because the reason they are usually to see me is because something’s not working, they broken teeth, and you know, quite worn down teeth, which other dental practice cannot, you know, treat. The last thing in the mindset is investment, you need to have a mindset of investor, because you do need to make sure that you invest in courses which are right for you. But also, I’ve seen many times, I’ve seen a dentist not doing Invisalign, because the principal would not invest into IPR strips. Now I’m thinking, okay, you’ve done the course, just buy the strips, you know, buying the strips is fine. Just you know, I understand there might be a reason why this is happening, but I just buy, even if I feel that this is something out of normal general dentistry, I used to just buy it, because it will pay me 10 times more, when I’m started doing cases, you know, so but many times, then it is sometime they feel that it’s quite unethical to buy it yourself while you’re working for the practitioner, you know, your boss, and you’re making money for him as well as you. So you know, but I think you just need to be a bigger person sometime and just get what you need to get you going [Jaz]Dev, I love that advice so much. I just want to just add to that I was doing an ortho diploma. And it was like a 20k diploma over two years, right? And one of the guys, I’m not gonna name him one of the guys messaged me saying JAz, like how you doing this with your principal, because my principal is refusing me, refusing to buy me the brackets and wires. And I’m like, Oh, my God, the patient is ready to pay you four grand, or whatever. Your total investment in education is 20 grand, and you’re disputing over 250 pounds worth of to get you going. And I’m like, that’s a mindset issue here. So yes, in an ideal world, your principal should be buying it. And that’s what the licence fee comes in. But once sometimes, just like you said, Dev, sometimes when you buy the stuff yourself, and then you produce the results, and then you put that piece of paper on your principal, just say, Hey, by the way, I did this case, and that was my investment. If you like this work, I can do all this for you but this is what I need. And that point your argument, because to put myself in the principal’s shoes, you probably asked for 10 other things in the past, he never used them, right? And so the principal’s might be little bit worried about putting more money into it. So you have to sometimes prove it. [Dev]Yeah, I mean, when I were coming out, my boss is, you know, is cool. Really, really forward thinking so you know, I mean, really fortunate position where I work, but you’re quite correct, because who which principle would not want to have profit, you know, it just doesn’t make sense. So when you do need to sometime prove, I many times give dentists the example of the pump, you know, what you call the pump the, you pump to get the water from the underground coming up, you have to pump the water to get the water out, but that you have to pump it a lot of time before your water comes through. Does that make sense? So you need to first work in order to show that you get the result. But yeah, so I think in my mind, the mindset is the main main main main thing and many times we don’t even, you just don’t even look at it as a mindset as a main factor of full mouth reconstruction and that’s why I really wanted to put that as appointment zero because without that, your other appointments will never start. [Jaz]I love that, Dev I’m going to add one more thing in terms of, because you shared your why and my why in terms of getting into more comprehensive dentistry, more full mouth kind of just viewing things with a lens of a full mouth rather than just a single tooth and moving away from single tooth but look, there’s nothing wrong from single tooth. Some of the The most humble dentistry, the dentistry that the public needs is single tooth, but the, I eventually will get bored. So for me, I start to have more fun when I’m thinking of the bigger picture, and then to see those big changes in the dentition, and then doing work that you can step back and then have a good night’s sleep and think, wow, you know, this was a journey. This wasn’t like a wham bam, thank you, man, this took a year or two years of hard work, and the patients are all made up. So that’s our why basically very similar to yours, Dev. But it’s about also enjoying and falling in love with those little details and the big changes [Dev]100%. So it’s life changing, you’re changing someone’s life. And that’s the biggest gift you have. So once we nail the mindset, that further appointment, I kind of break down into three steps. And that’s why I call it three step technique, where you’re looking at step one is your diagnosis and treatment plan. That’s the biggest step ever. The second step would be your anterior reconstruction. And third step is posterior reconstruction. simple three step. Okay, so let’s start with appointment one, where patients sitting in your chair, and I’ve said appointment one, because most of us are general dental practitioners, and you will see patients for a checkup. So the appointment one is really a checkup, which is less than 20 minutes checkup, you’re assessing patients mouth, you probably haven’t seen patient, but if you’re like me, and you know, after doing MSC, you’re seeing the same patients, by seeing them different eyes, you know, your eyes have changed. So you know, you’ve seen the same patients, and now but now you’re seeing the where all of a sudden you think, you know, this patient needs full mouth reconstruction. I mean, I don’t know about you, but how many cases I’m not can’t count the number of cases, which is referred to me for single implant, and they need full mouth reconstruction. I mean, almost 80% of them are like that. And I’m looking at it. And I’m thinking, Okay, I’m not saying 80% patient says yes to that. What I’m trying to say is they are in need of some sort of a more comprehensive treatment. Once I’ve shown them all the photos and everything, I will then tell them what are my concerns, because patient would have their own concerns, but I need to let them know that what am I concerned to give them maybe a reality check, right? So if their expectations is completely out of this world, they need to know that maybe I’m not the person to be able to give them that kind of results what they want. But usually, [Jaz]Can you make that tangible? Can you give example of a clinical scenario, what you mean by that, [Dev]I’ll give you an implant example actually. So patients comes to me edentulous, jaw lower, flabby ridge, there is not much bone at all. And they can’t afford fixed prosthesis. So I’m doing two implants and a locator based denture, but they don’t want denture to move at all. And they want it to be completely fixed, and they don’t want to be really really, you know, bite completely without any, you know, worrying about denture moving. So I have to tell them that look for what you want, I cannot give you a fixed teeth, you know, the denture will have some mobility in it. So they need to understand. Same thing with patient who has, let’s say, really high lip line, and nice teeth, and showing like four millimeter gum, right? So and then if they want the incisal edge showing just maybe 2 millimeter, I’m giving you example, quite extreme, but just the incisal edge showing like two, three millimeter, they want to reduce all the gum, maybe we can do lip repositioning to make it that awfully bit crown lengthening, but, you know, if they’re showing four, five millimeter of the gum after showing that 10 millimeter length of the incisor, it would be quite difficult to then correct it, you know, so you need to tell them. The other example is if there is implant attached them, you know, you need to tell them that there will be some recession, I mean, I will do my best to do soft tissue grafting and make sure that, you know, gum stays where it is. But there is a good chance that the gum will recede a little bit you know, so this is the time where and the more experience I get, the more I’m scaring the patients. I’m telling them from upfront because I don’t want to them to then have all the treatment gone through especially full mouth reconstruction and then look at the mirror and think this is not what I wanted. And then that’s the heart sinking moment where you know, you haven’t really educated patient enough or you haven’t listened to them properly. [Jaz]Everyone should do what I do and just only treat people with their low lip lines. [Dev]Yeah, or make them low. So when you take a photo, just don’t smile too much. [Jaz]That’s the secret. That’s the secret you give it [Dev]The photo’s fine, you know, Jaz, it’s all about the photos. So and then I will show them if they don’t have anything done. What will happen? Because they need to know that so do you know you would have, everyone would have the cases which is really quite a lot of them. But patient never gone ahead with the treatment, you know, you told them everything but you know, it is what it is, maybe I didn’t do my job properly in explaining the value of my treatment, and the patient will say, No, I don’t want to have the treatment done. Because finally, I mean, if someone tells you that your family is in danger, they need so much amount of money, you will find the money. So it’s really, it’s really whether you find that good enough for you to be able to invest in yourself, whatever you you telling the patient so. So patients always have resources, it’s just that whether they want to use them on their teeth or not. [Jaz]I think that’s a great point. I just want to elaborate on that, Dev, because Steven Hudson, who used to have a blog and stuff about dental law and ethics and communicating patients, and I remember him writing a blog post one saying that, just because the patient has got 50,000 pounds sitting in their bank account, doesn’t mean that they want to treat it and spend it with you on dentistry, because dentistry is maybe so low in their values overall, just like you said, everyone will do anything for their family. But a lot of patients could have no teeth, and they honestly have no aesthetic values or aspirations. They just don’t care about the oral health so much. So for them, it’s not a 50,000 pound problem. Whereas what they want, you know, in ideal world, what they may need, or what they would benefit from, it just doesn’t sit well with them. So that’s again, part of discovering what their goals are, discovering what their values are, so that we can actually make the right treatment for the right patient. [Dev]But the important thing is values can change. So not just because you had a check discussion with the patients on the last checkup, about full mouth reconstruction, looked at your notes, and you’re thinking I had a chat with them last time, they don’t want to have anything done, I’m not going to ever talk to them about this this time, then you because things change, people might, I mean my values changed, you know, the health is now becoming much more priority for me, which wasn’t five years ago, you know, five years ago, it was all about, you know, hustle and work, work, work, work, work 24/7 and improve your skills, and now I’m putting more priority on my health. So people’s value change all the time. So, you know, just because patients said no last time six months ago, it doesn’t mean that they’re the same person. So I think that’s something really, really important. [Jaz]One more thing actually is sometimes the reason that the values can change is because we’ve reframed the same problem in a way that speaks their language. So for example, we know that from a lot of the aesthetic rehabilitation that we might do, is going to restore their how they look and restore their function, how they can chew. But when you’re telling someone that we can make your teeth look better, look more youthful. And they’re really not listened to that, they don’t care about that. But when you tell them actually, if we don’t do any treatment, we won’t have any tooth structure left, and then you’re looking at dentures, or then you’re going to lose your teeth, then that same message speaks volumes to the patient, and then they’re both true, we can both make them look better, and keep the teeth for longer, but which one they resonate withI is the other ones, you have to pick and choose and speak in their own language, don’t you think? [Dev]100%. So it is, as I said, most of the time when patients say no, the treatment is my fault, because I haven’t really spoke, I haven’t spoken their language, if that makes sense? So you know, I’ve been telling them what I feel that is good for them, but not in their own language. So I think 90 or 99% of the time, really, it’s the dentist fault if the patient says no, I don’t want that treatment. And they really need that treatment if you think that they need the treatment. So I showed them, if they don’t do anything, what will happen to their teeth. So you know those cases, which didn’t go ahead, I keep them still as a photograph, and I show them that look, this is you know, 70 year old gentlemen, this is the teeth and you know, worn down so much. Then I show them what is potential, what can be done. So your previous cases, what you’ve done before, I’ve done before, and this is where I see the most conversion happening where when patients come to me I can pretty much do anything, now so I can do you know re-, I can do anything. So I’ve done re-endos, I’ve done full ortho, like conventional ortho, Invisalign. I can do autogenous bone grafting, full arch implants, you know, full mouth reconstructions, everything. So when I’m sitting with them, for me, it’s not what I can or cannot do. It’s really finding that right solution for them. So when I’m discussing the treatment plan with them, I show that confidence so the, if, to me, it wasn’t very obvious, but one of the associates while observing me, who did the my full mouth reconstruction course and he wasn’t converting. And that was like five years ago and he said, Look, can I observe you? Come on in and then he observed me he’s like, You know what one thing is, when you talk to a patient, you’re just having a chat with them, in your back of the mind, there’s no doubt that you can provide them the best treatment what they need, it’s just literally fitting into what they really want and how you can work around it. And I think that’s really confidence is really important. But that comes after experience. So you, again, you have to start somewhere. And what I’ve realized is, when I was referring cases out early in my career, I was much more confident, because I knew that the person I was referring to, was really good. So I knew that the patient would get the best treatment possible. So I was literally telling patient that, you know, you must go that and see them and you go, you will be good. Because of that I have quite a high conversion rate, although I didn’t get any benefit, financial benefit, but I had a quite high conversion. And I think that same thing shows, but now I’m discussing with patients, that confidence really helps. [Jaz]That’s a really good comparison, I like how you made that, that when we’re referring to someone that we trust, and then we instill confidence in that other practitioner, and the patient is more likely to go ahead and get what they know something that they need, and something they’ll benefit from, and something that’s gonna benefit them overall. And then now you’re just applying that same logic to yourself that you know, you can deliver a good result and you’re confident in your diagnosis and management plan, and you know, that you can give them so much benefit going forward, that you lose that confidence, and patients definitely pick up on that. So that’s a point well made. And I’m so glad you made it in this part one, because this is the crux of it, you know, if you start doing ortho, you start doing anything, you need to ooze confidence about what your aim is teeth whitening, if you can’t convince a patient, that teeth whitening is going to help them it’s probably because you haven’t probably whiten your teeth ever before yourself. And you’re trying to tell them something that you don’t really believe in yourself, actually. So it says things about showing the patient that actually yeah, I think this is gonna be really good for you, and believing in it, and the patient picking up on those visual cues. [Dev]So you know what, I never had a laser surgery done, because every time I went to see the ophthalmologist or someone, they all wear glasses, I’m thinking they’re wearing glasses. I’m not gonna have it done. So you know that was my thing, anyway. So that’s just I. So once I’ve done the assessment, I would then move on to stabilization phase, because it’s really important to make sure that the dentition is stable before you move on to full mouth reconstruction, even think about it. So when I’m doing their first full assessment, I will tell patient that this is the phase one, where I’m going to take the teeth out, which needs to come out, to re-root canal treatment where it needs to re-root canal treatment, to you know, remove all this old amalgam, clean that up, restore it with composite, and just a core build up, and just make sure that when I’m back, I’ll have a nice dentition. Now, if patient has crowns, I would take the crowns out and restore them with the temporary crowns. In the ICP in their own occlusion, no change of occlusion, just removing out and making sure that the crown’s fine before I start doing full fledged treatment. So first is always stabilization, which is a treatment they really, really need. Even if they’re having full mouth reconstruction or not. They really need these things. So I will start with that. [Jaz]So there before we continue on that’s going to ask you something about phase one and communicating finances as well. So something that we can learn about communicating finances. So when you are communicating phase one, and obviously to give the patient the estimate of the phase one treatment, but do you also, because many people do it differently, do you also give them a ballpark figure as a range as to what the future treatment may cost? Or do you think that actually don’t want to scare away just yet? Because regardless, they need the phase one anyway. So you’re going to just quote the phase one. And one thing I also said is that it’s an opportunity for you to learn about the patient as well. Are they a good patient or not as you do phase one, which is something I need for the health? [Dev]Yeah, so do you know what I’ve tried both ways, I’ve tried doing the just doing the phase one and telling patient that you know, you need all this and then we’ll look into it once we stabilize your mouth, because this is something you really really need, whether you have the phase two or not, that’s different, but you need this anyway. Or, I’ve done the other way around as well where I’ve told patient that this is phase one, and this is potential phase two, and this will be the whole fees. And in my experience, I haven’t seen any difference. So people who are going to say yes, they will just say yes regardless, to be honest. Having said that, some patients who when you break it down, it becomes a little bit more better for them because they can then, because many patients don’t think long term, they will they think like monthly how much I can pay, how much you know because they are living like that. So you know if you break them down, they’re okay we’re going to do phase one, if you tell them oh it’s going to be 20,000 pounds, then they’ll be like oh 20,000 pounds now whereas if you tell them okay, you know we need to do this crown which is temporary crown which is 100 pounds, we need to do this core builder, which is 120, everything will be to 3000 pounds. We’ll do that first and then you know move on to the next step and then next and then and that helps in just breaking things down. So I usually tend to break down nowadays everything but then give them full fees as well. [Jaz]Dev, thanks for sharing that. It’s good that you’ve done it both ways. So you can give us that feedback as to what’s worked in your practice, because these are the real barriers. There’s so many different steps to actually implementing full mouth dentistry. And one of those is having those difficult conversations about fees, which we have covered in previous podcasts well, but as part of the bigger picture, that’s one of the different challenges the actual dentistry is easy bit, but it’s the mindset, like you said, it’s about finding the right patient. It’s about phasing the dentistry. And now we haven’t even begun talking about the occlusion bit yet. Which brings me very nicely to wrap up part one. Is that, okay, I know some great dentists who will plan their rehabs in MIP, whereas traditional schools of thought and many dentists, including myself, I plan for, in most cases, from centric relation. What is your school of thought? Knowing you’re from Eastman, I can guess which but what is your school of thought? And how do you decide between reorganizing versus conforming? [Dev]There are a of lot of ways you can decide whether you’re going to reorganize or conform. For me, when I look at the mouth, I’m going to assess how many number of teeth I’m going to treat, right? So if you’re treating as you know, one or two teeth, which are nicely bounded with other teeth then Confirmative. Now, if you thinking full mouth reconstruction, for me, if you’re doing full mouth reconstruction, you’re touching every single tooth. [Jaz]Or at least one arch, right? If you’re doing at least one arch, then [Dev]Then a bit does automatically becomes a reorganized approach. Now, there are nuances to that. So let’s say conformity approach, the advantages of doing conformative. You can even do single arch Confirmative, right? in your mind? Because to be honest, once you dismantle everything, you’re kind of changing contact points, you’re changing a lot of things. So it depends what you think, what you’re defining as a conformity. And when you’re defining reorganize, for me, even though you’re not raising OVD, it could be reorganized, because you’re just changing your patients contact, the way they change, you’re eliminating slide a little bit so you know, it just changes, so for me, conformative means you keeping everything, keeping the slide the way it is, you know, ICP to MIP slide. So CO for American, CO to MIP slide. So you’re keeping the same, you’re just treating the way it is. And the best way to do that is treat the jaw in sections. So keep your teeth, few teeth, and then just do treat other few teeth and then treat other few teeth. The advantage of that is patient kind of knows that kind of bite. So they’re used to it, there’s less risk of you incorporating something in patients mouth there, which is completely different than what they had. But the limiting factors are that you don’t have much room to be creative and to change the teeth to shape forms, and eliminate some of the, Shall I call it interferences or non working side contacts, if patient has any. So for me, if I’m doing full mouth reconstruction or anterior reconstruction or any zone, dahl technique, or whatever you call it, it is a reorganized approach. Whereas if I am, if patient has one of the very rarely, when I do conformative, while I’m doing full mouth reconstruction is patients got TMJ issues. And I’ve given patient Michigan splint, and it got worse, right, because patient just cannot tolerate that open bite. And they just used to that. First of all, I wouldn’t touch those patients and do full shebang, you know, full mouth reconstruction on those patients until the symptoms are gone. But even some symptoms are gone, I’m looking into doing very confirmative approach where I’m not changing too much. Because the risk is you change things and then the patient back to where they were and start having issues with TMJ. [Jaz]That’s our concept of working within that adaptive capacity. Right? So someone’s got very narrow, adaptive capacoty. And deviates, even giving them a removal appliance, like a Michigan splint, made them in a position where they were not able to tolerate it. So you want to copy the features of the system that was working in a painless way for them, even though it may not be the gold standard, but need to actually conform to their adaptive capacity. [Dev]So yeah, so however, it’s not that common and people scare, you know, it’s quite, you know, Dentist get scared a lot. But I’ll tell you, I mean, I’ve done over 3/4/500 full mouth reconstruction, I can remember two patients who are like that where but they were telltale signs, you know, again, when we do the assessment, we will know when I’m doing treatment planning, I would know how I’m going to plan the treatment and we can go, we’ll go through with that. But one of the thing is the load testing if you’re doing low test, which means you’re using Lucia jig or you Using leaf gauge and patient bites, and patient feels pain, that’s an indication for me to stop, and then rethink, make sure that the pain is gone. Sometimes it’s their lateral pterygoid, just giving the firing wrong way. And sometimes you put a cotton ball roll, ask the patiet to bite, the pain goes quite instantaneously. So it could be but usually, if that happens, then you need to really re evaluate everything before you consider anything. The other thing is when patients got a slide, which is long horizontal, and short vertical, usually when patient closes their mouth, the study shows over 90% of the patient would touch one tooth first, and then slide their jaw forward and upwards and close their teeth. Now that forward and upward movement is not 50-50. Does that make sense? So some patients would go more forward and then less upwards. That’s called long horizontal, short vertical. And then some patient will go more vertical and short horizontal. Now those patients who go more vertical and short horizontal, they’re easy to treat, because if you remove that first point of contact, all they’re going to do is close their mouth, basically, more. Does that make sense? Whereas if you are the long horizontal slide, if you eliminate slide, patient’s going to not be able to do the horizontal slide and it will start closing more vertically. And then you develop anterior open bite. So if you remove that horizontal slide, which is which patient we’re doing in order to get their front teeth in contact, if you remove that they can’t move, they don’t moving their jaw forward. So they just move that you’re like that. And then they have anterior open bite. [Jaz]I’m sure you mean anterior open bite or do you mean increased overjet? [Dev]Increased. Sorry. Yeah, exactly. So increase overjet. But then the teeth won’t touch. Okay, sometimes or sometimes they teeth start touching on the gum. Okay, so now, if I want to raise OVD in that case, then all the OVD will be raised on the posteriors because patients lost that anterior guidance of the protrusive guidance from the centrals, we want to keep the protrusive guidance, if you follow Eastman mythology, then you want that canine forward. And if you want that, then that’s impossible if you remove that horizontal slide. So that’s something very rarely, again, I’ve treated so many. And thankfully, God is very great. So He has cured us more patients with long vertical and small horizontal, then long horizontal and small vertical slides. So most of the patient or 90% of the patient will fit fine into your normal routine. But there are some patients who you might get caught up by where there is a long horizontal, and those patients, I would still treat in CR, but I would not raise the vertical too much. Because if you raise it too much, you end up losing so much, so much space anteriorly, because of the overjet you create. [Jaz]I mean, every case will be independent, and it would work, you know, your workup and your occlusal planning comes into and is case specific is what we’re trying to get to. And and that will vary. So there’s no one formula for every patient, depends on where is their centric relation contact point to begin with? What is the extent of their slide? What is their existing malocclusion? What is their skeletal base? So there’s so much that goes into planning each case. But essentially, when you’re reorganizing case and you’re increasing OVD, you’re beginning from position of centric relation as per the Eastman School of Thought, and you’re building your bite from there is that fair to say? [Dev]Yeah, so it’s fair to say so. So my idea is, if I can start with CR, which is opening their bite up even ever, so slightly, I will do that, because then I have a plain sort of playing ground where I can just change anything I want. So I’m already increasing already even one millimeter, two millimeter, I have the full access to that space. And I can move teeth around restoratively as much as I want as possibly as I want. But as a few are even restoring patients in CO which is the first point of contact when patient contacts and that one first point of contact, because there are other theories, or other principles, they will just restore patient in CO because to avoid this TMJ issue, because if some people will say that if you open patient too much, then you might have issues with TMJ because you know, opening their bite up and freeway space, which doesn’t really apply to dentition to be honest, but and I’ll open patients up you know, I don’t even see how much opening I’m doing. I’m looking at the aesthetic result. I’m looking at the prosthetic I’m not looking at I’m going to open to let’s open this patient by two millimeter, I usually don’t think that way. I would think, Okay, how much longer I want the teeth, how much prosthetic space I want. And then I’ll open patient up. And obviously you do trials and you make sure that the patients can tolerate that. But yes, so the one concept is you open patient up in CR, which is patient non teeth occluding position. Jaz’ Outro:Well, there we have it, guys, I appreciate you listening all the way to the end. I hope that’s whet your appetite for part two. So part two of this is coming out in about four weeks or so we’re going to cover appointments two to five then, and we really go into a lot more depth in terms of diagnosis, mounting, wax ups, how to control your curve of spee, all those really important things I’m hoping you’re able to follow on that. If you’re a newbie dentist or dental student, I’m hoping we made in a way that you can follow along and we’re going to build you up in the next part. So stay tuned for that. And as always, I’d really appreciate if you can share this with a colleague who you think might find it useful and whet their appetite for the future part of the series. Anyway, thank you so much for listening all the way to the end and I’ll catch you in the next episode. Same time, same place.

Heated confrontations with patients are never fun. Nobody likes to argue, and no Dentist likes being pressured or micro-managed by patients! In this episode we cover a lot of communication gems with Dr Vy Phan that will definitely allow you to remain calm and be effective the next time you face a ‘difficult’ patient (you know who I mean!) https://youtu.be/vDP5wIaK3Ok Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! The Protrusive Dental Pearl: Never to say ‘No’ to patients. Instead, be tactful by pitching it and phrasing it in a different way – you are still saying ‘No’ but in a much less harsh and patient-friendly way. I give some concrete examples in this episode. “One of the ways of gaining patient trust is education – there’s a breakdown of communication often when the patients don’t trust you and they’re not educated enough” Dr Vy Phan This is the IntraOral Camera I was telling you about – inexpensive, high quality and a modern day necessity in my opinion. Available on Amazon In this episode we discussed: Big Challenges young Dentists might face in terms of patient interactions and communications 10:30 When to consider dismissing a ‘difficult patient’ 20:20 Advice to young dentists when a patient questions the level of experience based on age/appearance/sex 31:08 The ‘My Way or The Highway Approach’ 38:04 Communication gems with Difficult Patients 46:16 How to Write a dismissal letter to difficult patients 49:54 Handling Patients who continually ask for discounts 59:41 Check out Dr. Vy Phan on Instagram! If you enjoyed this, you will of course love Think Comprehensive – Communication Gems with Zak Kara  Click below for full episode transcript: Opening Snippet: (Vy) I think my way or the highway approach is really appropriate when it didn't the best interest of the patient, you know, you know that it would be different, it will be risky, you know, there'd be more long term (Jaz) Inappropriate, risky, just not the, it will land you in legal issues. (Vy) Exactly... Jaz’ Introduction:Hello, Protruserati, I’m Jaz Gulati and welcome to this or can I say it’s an awesome episode? Oh, my God Vy Phan will blow your mind. This is a real world topic. There are so many communication gems shared in this episode. And really, when it comes to communication skills, when do they really matter? I mean, yes, it’s good to get case acceptance and building value through user communication. But what really matters is so tough patients, those confrontations, those arguments that you might have with patients, you know the ones where your heart is racing? Words can really powerful. And I think communication skills are really tested in those tough scenarios. And we’re talking all about those in this episode. When it comes to the word difficult in difficult patients, I was really debating whether to use it or not. Because really difficult patients are just difficult people and yet difficult people in every walk of life. Like if you take an arbitrary figure, like 1 in 20 people, well, I don’t want to use the ‘A’ word. So 1 in 20 people are not nice people, right? And so 1 in 20 teachers will be not nice. 1 in 20 doctors will be not nice. 1 in 20 dentist were not nice, for example, right? So 1 in 20 of all your patients may not be the nicest people in the world. And so to deal with these patients, it can be tough. And these patients, we classify them as maybe difficult. But the funny thing about classing patients difficult is that what you might perceive as a difficult patient, your colleague, your associate, may find that they get along with a patient really well. And they think yeah, what do you mean, Mr. Smith is completely fine. What are you talking about? So it actually varies dentists to dentist and so our perceptions are equally important. When we decide who is “difficult”. There are lots of themes that we cover in this episode, like for example, patients who coerce you or bully you in doing into doing treatment that you don’t feel will work, patients who are rude, How to Write a dismissal letter to these patients and like what are the things that you should include in a letter like that. All the way to the end. If you listen all the way to the end, you will get Vy Phan talking about those patients who always always trying to twist your arm for discount, and how to handle objections like that. The Protrusive Dental Pearl I have for you is actually inspired by a conversation I had with Vy in this episode. This is something that was taught to me by Dr. Raj Ratan, who was my training program director during the f1. And he taught me never to say no to patients. Now, I know that sounds ridiculous, because actually, I’m saying we should say no to our patients. Because if someone’s being unreasonable, or you’re feeling bullied in treatment, or if it’s not in the patient’s best interest, then we should definitely be saying no, but what Raj meant by Don’t say no, is, let’s imagine a scenario where your patient wants to have some teeth straightening, maybe they want to have an aligner treatment, and you’d love to do that for them, but then neglecting their perio. And because of that reason, they’re not yet suitable for orthodontics. What you shouldn’t say is, No, we can’t do your orthodontics, because x, y and z. Patients just hearing the Word and seeing you as you say, No, it doesn’t leave a nice image. And they remember that. So why don’t we say in a different way? Why don’t we instead of saying No, you can’t have orthodontics because x, y and z? Why don’t you say I would love to do your orthodontics for you, I think we’ll get a great result, your bite will be better, your ability to clean your teeth will be better. I’m really looking forward to doing this to you, however, can you see and then you show the photos, can you see that your gums are looking a bit red, I want you to be proud of this result I want me to, I want us both to be proud of the result we’re going to get for you in the future. And so that we can get you a really nice result with the bells and whistles. We actually want your gums to be pink and healthy so that we’re ready to do this treatment for you. This is what we need to do first, we need to do some hygiene, we need to get you to some brushing, bloody bloody blah. And then we’re going to do your teeth straightening. How does that sound? Is that a much better way than to actually saying no, no, we have what have said to the patient is no, you can’t have it yet, because of your gums aren’t quite there yet. But pitching it and phrasing it a different way can be really powerful. Hope you enjoy that pearl. And hey, if you did, could do me a favor if you listen to Apple podcasts. And please do leave this show a rating but a new thing now, for my Spotify listeners. If you’re listening on Spotify, stop right now, go scroll up and give me a rating. I would really appreciate that because Spotify ratings are a new thing, and really helped my show to get discovered. So if you give me a rating, I would really appreciate that on Spotify as well. Anyway, I’ll stop blabbing and I’ll catch you in the outro Main Interview:[Jaz] Vy Phan, Welcome to the Protrusive Dental podcast. How are you? [Vy]I’m good. Thank you. Thank you so much for having me. It’s really exciting to actually finally be on one of the podcasts and listen to them for quite a while now. So thank you [Jaz]It’s so great to connect with you all the way from Melbourne and we’ve been exchanging emails and it’s been so great to have your listenership and your contribution now. So, I love getting people on who listen to podcast because I find that people who actively find something and tune in something they are connected in a way that you almost are like a self selective a bunch of people and what I find is that we are the geekiest dentist and this is a recurring theme. So I always love interviewing people who have actively listened to not just this podcast but all of the dental podcasts and stuff because I think it’s so much we can learn out there. So those people who don’t know you are Vy, tell us about your self, Vy. Where do you practice? What kind of interesting things which you told me about the email that you’ve done? And what we’ll be talking about today? [Vy]No, definitely. So my name is Vy, I’m from Melbourne. I actually do my university degree in Cannes, Far North Queensland. So James Cook University, I graduated 2016. I’m actually in private practice since then so sort of started running, imagined my own practice since I graduated. And now we’re fairly big team. So there’s about 6 dentists and our health therapist, we have three chairs running, and we open seven days. So fairly busy practice. And as you can imagine, post COVID, everyone’s coming in. But it’s really interesting, keeps me on my toes, and I do love it. But since then, I’ve actually got into a little bit of public sector work as well. And as I was telling you, and what really got me into this podcast was actually started listening to your podcast on the drive to the regional community clinics where I would teach fourth and fifth year dental students. So I drove to Ballarat, it’s an hour and a half. So your episodes actually worked really well, like about 52 minutes to an hour, and have a coffee. And you know, definitely such interesting topics. And it’s always changing to handle the different speakers. So I do a bit of teaching. And in Ballarat, I’ve also recently taken another teaching position. So one of the things that dentists at the Royal Dental Hospital in Melbourne, and there’s a dental teaching clinic in the dental hospital. So part of my role is sort of supporting the students and supervising demonstrators out there, and trying to create a better environment for the teaching clinic. So it’s really new to the role. And it’s super interesting to be able to say, I suppose the public and private facets of dentistry, as I told you, as well did a bit of extra studies after I graduated. So I recently completed my Masters of Health Medical law at Melbourne University. So [Jaz] Amazing [Vy] Thank you, thank you so much. It doesn’t mean that I can qualify as a lawyer or have you know, represent clients. But it means I have a special interest in medical legal, dental legal factors, I’ve got a bit of extra knowledge, it comes to that thing, it’s quite helpful in both private and public, I was lucky enough to be the president of the Melbourne Law Master’s Student Association when I was there. So that was a really great way to interact with different students, part of the university. And currently, I’m on the Australian Dental Association, oral health committee. And that’s mainly about promoting oral health, which I’m passionate about. So I do love dentistry. And I think for today as well, you know, having done my medical law masters, it is interesting to see things from a patient perspective. [Jaz]What I like to just extract the origin stories of people who come on, because some of the themes that cover is so relevant to young dentists listening. So one thing I just want to just uncover a little bit more on all the lovely things you said that is what inspired you to take your career trajectory, as someone who’s running a busy practice now as well, to also, I mean, the teaching bar I get, because I love that as well. But tell me about how you have now deviate a little bit towards the medical law side of things. What drew you to that aspect? [Vy]To be honest, if I hadn’t done dentistry, I would have done law. So I’d always had the interest in you know, I always been issues for me. But in year 12, or, you know, that’s when we finish high school to go on to do undergraduate studies. I actually got the privilege of working as a receptionist at a dental clinic. And I think that sort of took my interest out by being hands on and you know, I was assisting and the dentist that I worked for, he was super passionate about it. He’d make a filling be like a really cool thing coming like, oh, that’s the blue etch and the light cure and you know, for me being, you know, 17 year old, super excited. And I thought, you know, this is something I wanted to do. But I always wanted to do law, I loved reading, I found it really interesting. And so for me to be able to do something, and you know, when you’ve been a few years out, and you do all these CPDs you think, Well, can I do something that, you know, I’m really interested in? That’s a bit different. That’s a bit Dentistry related, but not really. So I thought, you know, take the plunge and do the law masters. And I did think maybe at some point I’d want be a lawyer and maybe I would do a law masters and see, but definitely getting a taste of that. I don’t think, you know, I would end up doing a JD or Bachelor Laws definitely not anytime soon. And I think I’m just going to take it back now and focusing on bit of the public sector work too. [Jaz]Great. Well, I think any dentist who’s thinking about in the next step in their career, it’s really good to have a level of self awareness like you had I think it’s a great thing to have, but figuring out you know, who you are, and what your interests are. And so you already knew about this potential law career that you could have had but you know, you got swayed by your appearances. But now you’re, it doesn’t mean that you can’t have aspects of that in your own life. So I love to marry those two together. And I think you said the message that for anyone listening is think back to before you applied in dental school, you might have had other interests, how can you now bring that in, to profession to keep that so that Fire alive in a different interest that you can have I think [Vy]Definitely. And I’m still lucky with dentistry, there’s a lot of flexibility in dentistry, you know, sometimes the hours we have, we have time to do part time studies. And there’s so much to dentistry like there’s such an artistic, my associate dentist, some of them are super artistic, you know, they’re doing pottery and things they like, I have a friend who pursued an acting career while being a dentist. And we have you know, that ability sometimes. So I was really privileged to be able to do something like this medical law masters and be able to sort of marry it, like you said, with dentistry. [Jaz]Well, today, I’m so excited to talk to you about a really, really crucial topic. This is something that’s gonna probably get people’s heartbeats racing, when they start thinking and recalling about certain patient interactions because it is about handling difficult patients. Now, if a regulator listened to this episode, I would like to say that all the themes covered in this podcast, all the scenarios are completely fictional. And this is for improving the profession and how we communicate with patients and how to get better rapport with patients. That’s the purpose of this episode. So any likeness to any patients who may listen to this, it’s completely fictional and coincidental. So I thought, you know, in movies, they have, it’s really cool to have that sort [Vy] Disclaimer [Jaz] Disclaimer as well. What a big topic, right? So handling, firstly, this this label, Vy, you know, I was when I was emailing I was reflecting afterwards, like, is it fair, that we label these patients as difficult patients because essentially, difficult in the perception of the dentist because one dentist might find the patient, very difficult, let’s say in quotation marks, whereas someone else might get along with them really well. So really, there’s something else going on? So the first question on opposes what are the challenges we face in terms of getting along with our patients in the view of especially the first five years because I can share some stories I’m sure you have as well, what are the big challenges young dentists face in terms of patient interactions, and communications, that makes us have this kind of conversation now about difficult patients? [Vy]Totally, the biggest things is comes to building rapport. And one of the first key things is gaining trust. So I find that the difficult patients we encounter, they come in straight off the bat through the door, Oh, I hate the dentist, you know, or the last dentist, he charged, rip me off for you know, always gave me so much pain, I’m so scared of the dentist, I really don’t want to be here. And it’s hard. As a young dentist, you might have had a long day yourself, receptions just booked in this toothache patient, you’re tired, you’re fatigued, you’ve had a complex case. And this patient walks in and tells you how much they hate you. And people don’t realize how tough it is, you know, for young dentists to deal with and you know, they come in upset. Now with these patients we have to think about is they’ve come in and they’ve most of them have had really bad experiences in the past. So they might be those patients that you know, they’ve been into with an older dentist or they whatever they say, maybe exaggerated or maybe completely true. So what’s really difficult is to be able to turn this patient around, completely change their perceptions of dentistry, gain their trust, make them like you again, and then still deliver a good clinical outcome. So it is really tricky. And I just want to say maybe, you know, a little note or a tip in these cases is, you know, if you really are trying to win these patients, so that you definitely needs to give them a completely different patient experience than what they’ve had before. And a unique patient experience because if you do, it really changes the perception and their outlook, and it’s tricky to do. But these patients who if they’ve genuine about, you know, how often the experiences are, it’s just the little things. Now, not every young dentist may have this no, not many at all. But you know, our dental chair is pink, and it has a massage in it. So that has a massage function. So a patient will come in, and you know, they’ll sit there and you know, for example, they say, oh, you know, I hate going for dentists, and I’ll just make a joke, keep it light hearted. And I think with these patients, you know, you really do need to do that. And I’ll just say, I bet your last dentist had never pink chair with a massage function. And you don’t need to have a massage chair, but whatever it is in the room or whatever it is that you’re doing, you know, and even scrub caps. Find something that’s a little bit different and just make it light hearted. Because do you see the expressions, their tone change when you do and I know, and I love your podcasts because you’re always, there’s a lot of jokes in them and you know, with the way you’re dealing with patients can be different. And I think with technology, what we have actually can make such a big difference. So something as simple as an intraoral camera. You know, I take and it’s not you know, you don’t have to get the whole kit and caboodle out which you can which is great. But if you want something quick intraoral camera, most chairs that have come with them now. Take little photos, even just your X rays that you put on the monitor in front of them. Some of these patients have never had a dentist go through and point out these things and it’s about interacting with them. I find the issues with gaining trust with patients is there’s a breakdown in communication somewhere. And it’s really easy to miscommunicate the patient, if you’re not interacting with them. If you’re talking at them, then you know, you don’t know how much they understand, you don’t know how interested or how involved they are. And when you interact with them, and you say, this is this cavity, actually what you really should say is you point to intraoral photo and say, what is that to you? What do you see? And then they think about it, they like, hold on, that’s Brown. That’s, you know, I think there’s a cavity, I think there’s a whole study, and they own the problem. And it’s no longer you know, Oh this dentist made me get 10 fillings, I don’t know why, it’s about, I need to go to the dentist, because I have these areas, this dentist show me and I know what they are. So it’s definitely making an experience. And it can be as simple as, you know, showing them these things. But I think one of the things gaining patient trust is patient education, there’s breakdown of communication often when the patients don’t trust you. And they’re not educated enough, because if they were, they wouldn’t hate going to the dentist because they know how important it is, they would value the visits, because they know it’s like going to a doctor, I need this. And patients just that wasn’t as opposed. They that didn’t come through to them. So I think gaining trust is really difficult. But there are definitely little things that we can do in order to help patients with that [Jaz]Trust is something that you gain in in tiny little drops. But when you lose it, you lose it in buckets , it’s one of those things. So it’s such a hard thing that we have to do. And you’re completely right, one of the key factors I found practice is the intraoral camera. And I think it’s just worth elaborating on that because a huge percentage, unfortunately, of a dentist, who ever listening right now, we’ll just never get around to getting their hands on intraoral camera. And like you said, it’s so widely available. So the one I usually recommend is like, it’s on Amazon, it’s like 150 pounds. So you know, as a for dollars or whatever. So inexpensive. Every time I drill into caries before I do will always take a pre op photo of that. As soon as I find the caries and I find the brown ADJ I will take a photo of that. And then once I’ve done the cavity prep, and I show the patient afterwards. And that is just amazing. Because you’re right, you have that patient that says, Oh, I don’t think I needed 15 fillings. It’s because the dentist never showed they’re working out. So something that we spoke about in communication before is show you’re working out. And I love it that you say that. It’s all about education. [Vy]Yeah, totally. And also show them the filling, like take a photo of the filling afterwards. And I like to put side by side, or as you do the stages they do before and then maybe in between. And in the final. And every filling even though you’re the adequate, they might have the best anatomy, it looks so much better. And patients are pretty wowed by it. Like you know, most patients and be honest see it and say look, they actually went in and did the filling like yes, they show me that needs to be done. But yeah, patients really appreciate it. And sometimes they you know, don’t know what they’re seeing went all the way back there. So it is really valuable. And look, it might be difficult if your clinic doesn’t have intraoral camera, but like you said it might USB once connected in, it seems that if you don’t have intraoral camera, you probably have the digital or a lot of I think even students I know habit, new go dentist, don’t use that type of camera. And if you know you really don’t have access to anything, you know, use the whiteboard, draw things out to patients, use the mirror, show them and I had them point out where you know, where are the cavities, show me, you can interact that way on also using your X rays. So there are definitely ways to, you know, educate patients. [Jaz]And just like you said, it’s about the co-diagnosis and getting them involved. You also mentioned about how when patients when they internalize the values, and that’s important, and you mentioned about doctors. Now one reflection I hadn’t. And sometimes I like to give my guests some questions advanced now this one’s a bit of a curveball I hope you don’t mind. But this is a higher level, I was really reflecting and I was thinking like if like the times I struggled the most with patients and thankfully doesn’t happen so much anymore is lack of rapport and the fact that patients personality type is so different to mine. So I mean it’s take taking one step back even further, I find that your patients will become a reflection of you. So if you’ve been practicing enough in one place, the patient’s come and the personality type of the patients that you attract and you retain are similar to you. So if you’re an introvert, quiet dentist, you’ll find that the quiet patients will come to you maybe and then if you’ve got the crazy patients at all my patients are crazy mad bonkers. And my nurses notice this oh hang on a minute your patients are like this. So your patients are a reflection of you. So if you’re getting poor quality patients that could be something down to the way you communicate and the image you project. So it’s important to A) be yourself and project your true self because otherwise, if you’re acting the whole time you’re not staying true to yourself, you’re being depressed and then you’ll find that you attract those patients. Now when I find a patient who I just don’t have that connection with. Here’s the dilemma now I’m gonna throw you, Vy, because when a cardiac surgeon has to see a patient, that patient may still be a difficult patient. But at the end of the day, they need this life saving surgery, right? And now you wouldn’t have a cardiac surgeon saying, No, I don’t like this patient, they’re difficult. I’m not going to treat them. It just wouldn’t happen. They need this life saving thing, right? Whereas in dentistry, one of the themes I want to cover with you Vy is, when do you think is acceptable? And then also, later on, we can cover about how do you tell the patient? Like, what kind of stuff do you write in a letter to say that actually, we’ve had a breakdown in relationship, we can’t continue. But then is it fair, that we do this to our patients when actually it’s healthcare? This is the higher level moral ground I’m coming here. So what can you, any thoughts that you have on this? [Vy]Yeah, totally, look, there are definitely cases where I think emergency cases and when I say emergency cases they’ve come in and they might not be the happiest patient. But if you can provide, you know, the provide safe treatment, for example, go to facial swelling, right, or, let’s say, Periodontal abscess, the tooth is not close to any, you know, difficult, you know, anatomical landmarks, you know, you can safely take it out, the patient’s, you know, not the happiest, not your type, not your cup of tea. But I think in emergency situations, you should always try and do the treatment, okay, if you can do it safely, if you know they need it, but it is really close to a sinus or whatever it is, then you should still consider referring whether, you know, do they need antibiotics, when you’re, whenever you’re not seeing the patient yourself or providing that treatment, you always need to make sure that they’ve got some referral pathway. And you’re not, you’re leaving out in the wind. So if there’s a patient that has emergency treatment, and let’s say they’re difficult patients, so you’re less likely to want to do a, you know, a procedure where that the higher risk, so I always say, right? I’ll call the, you know, the oral surgeon and say, Look, you know, I’ve got this, the patient has been, so I show the patient that I care, I can’t do this treatment for you. You know, it is, you know, I think that it’s a high risk situation, I want the safest and best possible outcome. Since I can’t do it for you, let me try my best to find someone who can. And they see me on the phone, and I talk them through it. And I say, look, he’s really busy. Just give me a moment. And they sense that and they think, Wow, this must be really serious, it must be really difficult that she’s going out of our way to call oral surgeon. And you know, I find that when they can see that you’ve done all these things, they’re less likely to care that you didn’t do it. You know, if I can’t get along to the private oral surgeon, sometimes I’ll call the reg at the local hospital, maxfacts reg, and just say, Hey, the Patient’s facial is swelling, or I just, you know, I write them a referral. And sometimes in some cases, when I know how bothered they are about something, and I couldn’t give something to them, I just don’t charge them the consult. And you know, and you’ve come all this way, usually I charge this fee. But you know, I’m sorry, I can’t do this for you. And usually when they see that they’re like, look, she wasted her time too or you know, and when sometimes patients do give you that they say, Look, I’ve come all this way, I’ve wasted my time. And I just nicely say, Look, this is your x ray, this is for you, you can take that, I’ll email it to you, you’ve got a copy. And I know it seems like a waste of time. But I think you’ve come out of this knowing your issue, what you need to do, I’m not going to charge you for the consult. And I’ve had patients take a step back and they say, You know what, no, I’m sorry, you’re right, I did get something out of it. Sometimes they sort of say things off the cuff. Now in non emergency situations, how you would deal with that is, you know, you deal with the emergency, or they’ve come in and they’re not in pain or whatsoever, then I feel like it’s warranted to you know, do your checkup, you know, come in for a checkup, what did you check up and clean. Most cases, I think something like that is fine. You come up with a comprehensive exam. And usually I sort of do like some multidisciplinary approach. So if it’s a patient, I don’t think maybe necessarily suitable for me. You know, there are specialists, so I give them options, sometimes the Perio I refer to different specialists, if I find there’s a certain type of patient, and because I’m such a big team, as well, I know a lot of us, we’re all sort of quirky and different personalities. And I think, look, this patient I think is going to gel better with my associate, they’re going to get along, they’ve got like, for example, when Alex you know, he likes computer games or video games, and like those patients, sometimes it’s hard for me to build rapport with them, you know. And you know, I get the crazy cat ladies, because you know, you might say to my cat on screen later. And I don’t know what you mean, there are patients you don’t gel with, but you might know someone who gels with them. And then there are cases where you might not be able to spin them off to someone. They might want to keep seeing. Those patients that you think you don’t actually gel with. They keep requesting you and they’ll come and sometimes [Jaz]AKA the HotSync patients. [Vy]You see the name in the books and you’re like, but I think with those patients, I keep it simple. I don’t do any complex work on them. Because I know for example, even if it’s endo or if it’s I have to come back. For example dentures. They’re not a good denture patient, you know, the ones that you look in, you know, and you know that they’re might even like the chip on outcome. Can I keep it really simple. So I might see that Every six months, if they’re not a patient that I feel like, they’re not someone that’s necessary rude, they just don’t, you know, they’re not your sort of cup of tea and your personal and so, you know, and I get sometimes, but oral health therapists might do the clean or the hygienists will do the clean, and I’ll come in bits and pieces. So they kind of work around that not everyone can necessarily be your cup of tea. And if you think about it, you know, we meet these people, you know, like, you’ll go to doctors will go to a maybe you know, a phone company or shop and you might sweep someone and they still you know, give you what you need. And they’re not the best person or that you didn’t get along with them. But you can still give this patient whatever it is that they want, if they want to keep coming back. But I think you should avoid doing a really complex treatment, or the ones where you go home at night, and you’re going to really have that weight on your shoulders. And if they’re completely unsuitable, like you said, Generally there’s, I feel some sort of maybe inappropriate, whether they’ve been really rude, or they’ve come in really late, I find it often not just the fact that you don’t sort of get along with or have a different personality clash, I find usually they maybe [Jaz] It’s more, it’s more than that. [Vy] Yeah, it’s usually more than that. Because I’ve had patients when you’re right, the introvert, the quiet ones, and I can’t ever will be chat with them. But they’re nice patients, there’s nothing wrong with them, they respect me. And that’s when they keep coming back. But then there’s patients that they still see you, but they’re rude about it, they’ll come in, and they’ll and that’s what makes it uncomfortable. Or they question your clinical judgment, there’s something else there. And those types of patients, they’re the trickiest one that, I find that the best way, if it really isn’t something that you can treat them, and then something that’s a little bit more like obvious, you know, it is about writing that letter, you know, you sometimes even have to offer and say, Look, these are the local practice around your area. And we really appreciate you putting that you know, in the letter, or whether you communicate verbally, and provide a written letter and say, we appreciate all the time spent here. But due to you know, breakdown in communication, or, you know, differing opinions and thoughts, and, you know, I can’t be the best person to provide the care. And I’ve heard of some dentists to just say that, you know, they’re Mr. Recall, whatever, they’re just too busy now in the books, then they just don’t have time to look at it. And that’s only a bit awkward and uncomfortable. Because sometimes they book online and this only so many things, you can say No, and sometimes it’s much easier to just say, Look, you know, and for me as well, since I do a lot of teaching, I do a lot of things, sometimes I’ll say the patient, Well it’s been great having you, I have a really big patient load. And I find that sometimes, you know, I really appreciate coming to see me. But when we communicate things you don’t, we’re not on the same page. And you know, and it doesn’t have to be because they disagreed with you, or there’s a big argument wherever. I think either I’m struggling to communicate this with you. And you know, I feel like I’m just as things are just not so getting through as much. Whereas I recognize those shit, or this dentist, you know, he could probably explain things better than I can. And patients don’t tend not to take it isn’t all honestly, it’s so awkward Jaz. But [Jaz]I think the approach that you’re gone for Vy is I think you’re alluding to the letter saying it’s not you. It’s me. [Vy]Yeah, totally. Or is it just we Yeah, like we’re not communicating well together. And yeah, and I think sometimes, you know, just, even though they stayed in writing, I mean, with some patients, if you tell them verbally, as well, and you document it in your notes, and you say, Look, you know, and put it in and then you know you I think legally, ideally, you probably should give them something, but I find you know, and that’s honestly I think that’s a gray area, that’s definitely not something that was touched on my medical law masters when it comes to really getting rid of, you know, difficult patients, if there’s not actual legal matter. But in private, you know, in the private sector, we are privily, we can pick and choose our patients in a sense, we are a business and you know, especially when it’s not urgent emergency outcomes, we do have that ability to not see a patient, as long as we’re giving them the right referral processes. And, you know, giving them the documentation so that they’re aware of it and you know, giving them their notes. So, yeah, I think at the end of the day, and also like, you know, with the health fund, sometimes I would tell a patient look, we’re not preferred providers, you know, how about trader, there’s, you know, other dentists that you save a bit more money out and just sort of adding little bits and pieces in it and I think, you know, patients, they get the idea. [Jaz]Well, I think you going out of your way to suggest not just that, hey, we’re not the best match for you, goodbye, but hey, we might not be the best match, but I think you still get really good care that’s appropriate for you from X, Y and Z. It there’s a different feeling towards that that okay, although they can’t help me they’ve signposted me to places that can help me so if you’re gonna be doing any kind of letter, and we’ll maybe we’ll make like a template or something but Vy I think that that is so true that you shouldn’t just say we’re not the best fit, it should be like a We’re not the best fit But these places are available so you’re not leaving them out in the lurch. But I like the way you answer this question, because firstly, I agree with all the points you made. And I like your risk based approach. And I’m completely with you on that, that if and you’re right, this is never just a fact that I didn’t have I had a personality clashes more than that they were also rude to my nurse, or they question my diagnosis and or they micromanage the way I’m going to treat them. So like I had a patient who there was a dentist, Shadow me and then the dentist comes it takes a little step closer. I’m aware had a pandemic stuff, but still further and now everyone’s got PPE on, that don’t come any closer, like, you know, like a rude way and that’s not nice. And then when I diagnose caries and communicate it, then they’re like, Okay, well, I don’t want LA and I would like an amalgam even though I haven’t placed amalgam in six years, and this micromanaging, dictating me, that’s where it’s never just one thing. It was like four or five little things. And then henceforth, when I email you back, say, Yes, this will make an amazing episode, because I’m going through this right now my head, and these are tough things to face as a dentist and add on to that we one thing that you kind of covered a little bit is that those dentists in the first five years and Vy you look so youthful and stuff like, you know, my wife had this old, she still gets this, she still gets IDs, she still gets ID for buying alcohol and stuff. Whereas I haven’t been ID since I was 16. Because of my facial hair, but like dentists were like, Oh, hey, are you experienced enough and when patients start doubting your expertise, based on what you look like, That is another layer of a breakdown and trust. So what advice would you give to dentists, young dentists, particularly who are youthful, youthful looking dentist, this very lucky dentists who age so gracefully, What advice can you give them when a patient questions, your level experience based on your age and stuff? [Vy]It’s difficult and honestly, question I’ve had and you know, my practice, actually really young practice and totally not You mean, look, I think for me, it made me feel easy, because I do cosmetic injections. So I’ll make a joke about that. And I’m like, Oh, well, you know, I do your muscle relaxer injections, anti wrinkle injections, fillers, don’t ask anymore, no, I’ll make jokes about that. Or I’ll say something really awkward, difficult ones, and they’re judging you. And they’re the same ones that say you’re a girl, don’t take a tooth out, like you can’t, you’re not strong enough, you know, those types of patients, and they look at you and they’re judging. And you know, you know, it can be, but I’ll say things like, you know, it’s rude to ask a woman her age, like, you know that and that’s, and sometimes, [Jaz] What a brilliant strategy. I love that [Vy] I kind of like I make a joke about it, sometimes I just like but it really depends on the type of patient we have. And some patients are a bit more serious, like the older patients, they’re not gonna appreciate, you know, they’ll not appreciate a joke. And, you know, I’ll say something like, you know, it’s a bit easier when you’ve had at least a few years, because you can sort of make it and be like, Look, I’ve been out for a couple of years. And or, you know, what I’d get my younger dentist say, is, you know what, you know, I’m a fairly fresh graduate, but I was lucky enough that I’ve actually come across these cases a fair bit, and especially the ones that, you know, we a lot of us went to James Cook. And, you know, we saw a lot up there. And I say, look, trust me, it is there’s stuff I hear that, you know, you’re never you know, you wouldn’t say up there. So there’s lots of stuff that I’ve seen that sort of thing. And I guess they just reassured because you know, you might be young, you might be a fresh graduate. But clearly you have some experience in these areas. And if it really is the point where they really there’s patients that won’t stop, they’ll say, when did you graduate, you know, and they won’t leave, you know, they won’t leave you to it. And look, you know, at that point, we can choose to be like, Look, you know, these patients, they just need to see a senior dentist, you need to refer them to someone more senior in the practice, because you can’t get to put up with this, you know that it’s going to be hard no matter how good your work is, it won’t be as good as whoever looks older than you. But sometimes you can say things like, you know, look, I only had, you know, a couple of years, we did this for five years, but I did three years of practical experience. And I was one of the fortunate ones that managed to get a couple of 100 extractions through my time. So it’s something I’m fairly comfortable with. And usually, you know, and sometimes it’s sad as long as you have to explain yourself that it you can do that. And you know, sometimes like I said, you can make a joke out of it, you sometimes can deflect it. And sometimes you can just refer them on to someone else. It’s really tricky. And I have an associate dentist that literally still looks like he came out of high school. And what sometimes patients make jokes about how young he is because we have a big sort of, you know, photo of all everyone staff. I’ll make a joke like yeah, he’s literally graduated high school yesterday, and now I just laugh about it. And they’ll think he’s probably older than you know, he’s clearly much older. So it’s just a bit light hearted patients come in with a question you sometimes they’re just a little bit agitated and anxious. And one funny thing I’ve had one time is with one of my dental assistants. I had a patient who said something like, you’re a girl, you know, don’t you know you’re not strong enough to take this tooth out. So I stood up, I may have been in a mood Jaz and I was like to the patient, Well, here’s my DA, he’s a guy, he’s a pretty strong guy, I’ll let him take the tooth out, and I’m just gonna go grab a coffee. [Jaz]I love that. I love that. [Vy]He’s really funny. As soon as all he’ll get on there, and he’ll walk, you know, you do it. And then you know, we just don’t have a laugh about the patient, like, No, I’m sorry, my bad. [Jaz]A fantastic story. I love how you did that. But what you also did is, and this will be very memorable. You know, when you say something funny people will remember this, and people will use these jokes. But what you’ve given us it is three or four tools, I was expecting such a brilliant answer. But you’ve got essentially, you’ve given tools that we can use. So it could be humor, it could be referral, it could be reassuring the patient cuz sometimes the patient is just scared, they’re just scared. And they just need that reassurance. And then when you just say that one sentence, like, Don’t worry, I’ve done this before. And that’s all I want to hear. And that’s all and that’s all it is. But then when the patient is being persistent, having the guts to stand up to them and refer them or to ooze confidence, I mean, I speak to you now, Vy, I love the way you communicate, I think you’re fantastic communicator. And I think it’s a confidence as well, it’s having just speaking with confidence, and patients love to see that. And like, really, they can smell it. So when you are anxious about that extraction, or when you are lacking experience, and you’re maybe not communicating confidently, because you’re not yet confident in that procedure, or in that type of scenario, yet, patients will sniff it. And maybe that’s the point to either get some mentorship and or refer that case, or just, you know, see the situation, be aware of the situation and use that as a learning curve going forward. I think, [Vy]Totally, you know, what else Jaz? It’s great to be confident in saying you can do something, but be confident when you say you can’t do something. So, you know, and, and I have had, you know, patients and you know, had students that have watched me observing, and I am fairly confident and I’ve been lucky enough to be like that since I think only child thinks since I graduated even. But I’m really confident when I say this is a really tricky case. Look at that root. Look at that sinus, look, I don’t think we you know, we should really be doing this. I think it’s a case for an oral surgeon. And when you constantly tell them how difficult it is, they’ll also really take it on board. So they don’t think oh, you know, she’s not doing it today. She’s saying no, to me, I have to go someone else. They think, Oh man, It must be really, really tricky. But if you stand there, like I’m being an, and think, Oh, we could give it a go. I’m not sure about this. Then they’re like, is it really that difficult? Or is it her or, you know, but if you really can’t do it, you commit to it and you fail, this is what you need, and I might not be an adult for you or this is beyond what a general dentist should do. And you really say that to them, you know, and love them my life? No, yeah, no brainer that that does. That sounds tricky. Yeah, of course. [Jaz]It’s communicating with conviction, just like you said, whether you can do it or you can’t do it. Just be clear in your communication with conviction, say with confidence, and that that is a great little pearl there as well. I love that. I’ve got so much to cover with you, Vy this is going really well. I’m really enjoying our chat. Let’s talk about the my way or the highway approach. So my background is that I’m at a stage now where I’m getting more selective my my patients and it’s going back to maybe 15 minutes ago, I mentioned that scenario about the cardiac surgeon, and ultimately just want to say to everyone and this is not to this is not to I guess underappreciate dentistry in any way. But it’s just teeth, guys. It’s just teeth. Okay? It’s just teeth, we’re not gonna, we’re not dealing with heart surgery, thankfully. And this is why the risk based approach that Vy said works. And remember that general dentist, I think most people listening a general dentist, we have the most difficult job in dentistry as general dentist. And let us appreciate that one of the best things about being a general dentist is being able to cherry pick, it’s okay to cherry pick it. If we didn’t cherry pick, we’d go insane. So it’s about knowing when to refer and wintry. And to remember that. But now I’ve come to a stage Vy where I’m very much like in not in all cases, like I give my patients the option stuff. And if they choose a reasonable option, then yeah, great, I’ll do it. But if my patients start micromanaging me, and making me feel uncomfortable in any way, I’m very much with that patient, listen, it’s my way or the highway. And I’m happy to communicate that confidently, it took me some years to get to this stage. So I’ve had some struggles and stuff and coming home and feeling like crap. Because of the communication struggles. We all go through that. But what do you think about this my way or the highway approach? And how can you do it in a way that’s not going to land you a negative Google review? Or land you in trouble? [Vy]Yeah. Look, I definitely think there’s a place my way or the highway. Exactly. Like you said, you know, and I think they’re places where is important is when you’re being pressured. Pressured or bullied into treatment. So you know, young dentist, you know, and especially when they’re saying just things like, you know, I want Invisalign, and they’ve got gum disease, you know, things like that. I just want straight teeth. I want white teeth, but they’ve got cavities everywhere. I think my way or the highway approach is really appropriate when it’s in the best interest of the patient, you know, you know that it would be different, it will be risky, you know, there’d be more long term [Jaz]Inappropriate, risky, just not the, it will land you in legal issues. [Vy]Exactly. And one, I just want to say it doesn’t matter if the patient signs a piece of paper or you document patient warned that they got, you know, they’ve got gum disease patient informed, patient persisted anyway, patient agrees, understands, it doesn’t matter what those what they write, and that they genuinely agreed at the time and the handler of the money, you are the professional, you’re the clinical expert, you do that treatment, you’re going to own it. And if something were to fail, it doesn’t matter, they will want your the professional with more knowledge expertise, and you should know better than to have done that. So it really, and even patients will say stuff like Oh, trust me just put the crown on, it’s been fine. And you know that there’s pathology on it. And he might have not been painful, like, just put on like, I love you, as a dentist, just go for it. But you know, down the track if something were to happen, you know, and they’re definitely not your friend when they’re in pain. Not no one’s your friend when you’ve caused them pain. And I think it’s a completely different situation. So I think [Jaz]Very quickly forget, don’t they? Vy, about the conversations that you had, or what they sign they very quickly forget when things go wrong. [Vy]Yes, they do. And honestly, even if they said to be honest, like I know, at the time, and it still doesn’t matter, because you should know better is the as so I guess Yeah, so I think my way or the highway is really important. You have to stick to guns, when you know that, you know, it’s the ethical thing to do. And I must say as well, though you do there is a way of doing it. And sometimes it can be difficult not to I guess be a bit too harsh. It’s about being firm, but I suppose not harsh or offensive. And it can be really difficult when they’re arguing with you, or you’ve been an hour explains on you know, when you spend some time now [Jaz] It’s a fine line, isn’t it? [Vy] It is and they come back and ask you the same question. So I can’t demand yours, one, you know, and you’ve gone through all the gum disease and the bone and the bleeding. And it’s really tricky. And I think you know, the best thing is, always listen to them. And don’t, I suppose speak that too long, because they don’t get the chance that I suppose ask questions or, you know, they, it’s too much information overload through through addressing each key point, have an open body language when you do this, because let’s say you’re trying to be patient, and you’ve got your arms crossed, you know, it’s a different situation, you’re leaning away from them, as opposed to, towards them and open and involving them, you know, and, and sometimes can make a bit light hearted, like, I really just don’t want you to fall out. That’s all it is, you know, or I take so much pride and show the passion I take so much pride in my work, you know, I just I couldn’t send off a treatment that I know is gonna fail. Couldn’t do that to you just couldn’t do that, too. You know, and you just I love and you really just sort of, you know, sort of empathy and you make it in a way that it’s my way the highway in the sense that, you know, it’s it’s for you. But I think one thing I really want to get emphasizes, we can be on my way the highway, but we can never ever take away patient autonomy. So even if you know what’s in the best interest of the patient, you still got to give them all the treatment options, they must make that decision, you don’t make it at any point. And you know, in most, you know, pretty much every general diagnosis, you don’t make that decision for the patient. You should never do that. And you know [Jaz]What it’s worth pointing out, Vy for the young dentist, lack of experience that okay, yes, we must discuss all the options, but it’s all the appropriate options which are suitable, that would fulfill the patient’s goals, and will be clinically appropriate as well. And so sometimes I find that when a patient comes in, and they say, I don’t want a denture I definitely don’t want a denture, and I need to do something right now. And then when I see the dentist letters, they say, Well, your options are do nothing a denture, and then they go the rest. Well, actually, no, that doesn’t that would they wouldn’t be appropriate. But I guess medical legally in the environment, and I see why they’re mentioning it, but remember to keep it appropriate for that case for your patient. [Vy]Yes, definitely. Yeah, I think it was one of the episodes as well, like how many, like 7-8 ways or something to fill So yeah, every possible thing. Yeah, of course, it has to be clinically relevant. And it was a medical legal case, if you’re offering silly, you know, sort of options or options that really aren’t clinically appropriate. You know, it’s not, it’s not great you want you know, it’s distinct, you know, in that type of legal setting. So yeah, so totally has to be clinically appropriate. But I think that the my way the highway, it would be pretty, I suppose inappropriately used if it was more of the highway, because that’s what I’m good at. And that’s the only option that you’re getting. So let’s say a patient, for example, we’ve been back to Design, they don’t offer fixed ortho, so every patient that comes to the door, in these lines, the best thing for you my way or the highway, take it or leave it. That would be pretty clinically inappropriate. It would be this is what I’m good at in my hands. You know, that’s my experience and clinical expertise. But it’s worth a second opinion because I don’t offer middle braces here. You know, and have the conversation with them whether they choose to take a second opinion or not. Sometimes I actually encourage them to Because in a medical legal setting, for example, if you’ve referred a patient with specialist or another, and they’ve come back to see you again, and you’ve gone ahead and done it, it’s a little bit different than if they’ve gone ahead. And it’s failed, because they are well aware that thought another opinion, and you said the best thing was, I always say, ideal option, you know, the orthodontist. Next one I can do this is within my expertise, but get a second opinion, and then they come back to you anyway. And it’s also that faith that trust. So it is, I suppose, well rounded in that sense, but definitely not my way or the highway because you don’t know how to do another treatment option. Or you don’t want to you don’t like dentures so that that patient gets the bridge. But it’s my way the highway, in the end, it’s more of an ethical thing. It’s what you’re comfortable with, you don’t want to be pressured. And you do it in a sensitive manner in an open manner. And sometimes it’s really hard to keep our cool, it can be especially we had a long day. But we do have to rise above it. As professionals, we are expected not to, you know, engage in arguments, unfortunately. And that’s the job you have to be patient about and you want to, but you just you know, that’s something that you chat over a podcast, or you call up a friend and talk about it’s not something that you do in the day. And it’s and it’s tricky. But yeah, I think that’s the best way to approach it. [Jaz]You mentioned those levels of consent, I guess. And it reminded me like with a patient if you only do Invisalign, and and that’s all you offer. I love that you highlight that. And we actually covered that in one episode, which I just remembered. And guys, you should listen to this, because I spoke with Mandeep Gosal, specialist orthodontist, and he spoke about that exact scenario via about the three levels of consent. So if you only just offer Invisalign, that’s like the worst level of consent, what he recommended was to say was that, okay, you can have Invisalign, you even if you don’t do it, you should know about fixed braces and talk about that. And then maybe if there’s a restorative option, there, like there is this restorative option, you can build up your teeth and stuff. Now you don’t tell them yet ideally, that you don’t do that yet. But you, you, you, you when they pay it, when the patient thinks, you know what, I quite like this idea. So great. I know exactly the right person for you, that is a really good way to do it. And just accepting the fact that you can’t be everything to everyone, you have your little micro niche. But just because you have that nice doesn’t mean that every patient, you know, if all you see is all you have is a hammer, everything looks like a nail, we’re definitely want to stay away from that time entry. And the other reflection I had, as you were saying, all those lovely things was in specifically, when you’re communicating with patients, we mentioned about having that difficult conversation about my way the highway and one thing I remembered is something that Raj Ratan seven or eight years ago, he taught me that don’t say no to patients, because patients remember you saying no. So when you said Vy to a patient that again, I want Invisalign, but then you’re like No, but that the gums unhealthy. A really, and you you actually do the same thing, because you mentioned it, the better way to say it was like, like, I would love to do this for you. So I would love to do Invisalign for you. But I want you to be have lovely gums, so that you get a fantastic was I want you to have a brilliant result from this. So that we can do this, we need to go for x y z process. So you’re not saying no, you can’t do Invisalign, you’re saying I would love to do Invisalign, once your gums are healthy. So it’s a different way to do it. So patients perceive that in a different way in a more positive light. And just like you said, in a sensitive manner. So I think all those little communication tips that we gain are so important. And that’s when your communication really gets challenged in those heated moments. [Vy]Yeah. And I haven’t actually since that podcast yet, so I really need to. It’s really good that you brought it up. Yeah, that’s really good. But yeah, and even when I say things went to root canal, or it’s a difficult case that I can’t do, or it’s a tooth that I think is needed oral surgeon, I would love to do it. But it’s in that tricky spot, and you bring it back to the patient as well. I would love to but you know, the gums and bones, it’s all the foundations, you know, your gums, the foundations of your teeth, and it’s just like, when you build a house, you need the foundations to be good. And yeah, so I think it’s, you know, analogies as well, instead of showing them like, you know, I would love to do this for you and putting the onus on them, you know, it’s not because [Jaz]One thing I do Vy is the way I make put the onus on a patient is when I’m saying that x ray of their banana shape root. And I’m very much emphasizing that your tooth is shaped banana and your gums. I like this. So that’s my little technique to really make it like that your and my eyes are like ‘your’ it works. [Vy]Yeah, it’s a shame that your root is right in the sinus. Like you know, [Jaz]How unlucky [Vy]Yeah, and then patients get that and be like, oh, and they’d like to see this very much or, you know, yeah, no, but it’s helpful and that’s exactly right. You put the onus on them as they start emphasis just be the eye contact. [Jaz]I have to say like the time there right now is like approaching 9pm and I love your energy. I don’t know how you’re bouncing must have had so much coffee today. I love it. Well, you’ve answered that the main questions and I guess I’m gonna go back to the letter because a big question I see on the dental forums all the time is like, Okay, I’ve had a breakdown in relationship and the patient, and I need to, I need some sort of letters of thinking that we’re going to make a little template letter just to help him run out there, and maybe a download or whatever. So you mentioned already about a few points in that letter and how to mention that it’s, you know, it’s not you, it’s me, it’s us the breakdown in relationship in total about offering alternatives. And I love that you mentioned that they actually care, or it might not be me, but here are, you know, I’m not gonna leave you out. And look, here are some places that you can go to, which I think would suit you really well. Or it might be an internal referral to your associate or whatever. Yeah, any other tips that you think would make a really good letter, [Vy]I actually had to write fairly. It wasn’t even a template. It was from a template, but it was a little bit tailored. And I think in some cases with these difficult ones, a one size fits all template may or may not work, but it could be some structure that you follow. And then it does have to be tailored because every patient particularly difficult, I remember this one. And I had my mentor helped me actually. And I had a mentor that I’ve worked with him. He’s actually 70. His name’s Harry Osen. And you know, he can help out one day a week. And he’s also helping with new grads out now. So it’s awesome. But I remember him writing something about Yellow Pages. Like I don’t know if you guys have, do you have [Jaz]Yeah, we have the yellow pages. Yeah. [Vy]But it’s like, they don’t ever use the yellow pages. Yellow Pages, like, go look at that. [Jaz]So year 1990 [Vy]Remember, like, it’s a big book. But, you know, for us, we have like health engine. So there’s like locals that they can look up and use. So Google, I think tips would be don’t make it too long. And don’t make it emotional. Don’t also talk about any specific clinical things such as, and you should never do this in a Google review. By the way, if you’re answering a negative Google review, don’t say, but your tooth is. So you presented with this, that’s clinical [Jaz] Confidentiality breaches. [Vy] Yes. Yes. It’s not something that’s appropriate [Jaz] In the public forum. [Vy] Yeah, yes, public forum, or, you know, even in this personal letter, I think, keep it non emotional, and don’t have it too long. And keep it simple. So do such and such. And I think for those that don’t present often, like they FTA a few times, they don’t make it to the appointment, they’re a little bit ease that you can just say, you’ve missed this appointment, that appointment, due to the appointment scheduling, etc, you know, we’ve had to unfortunately, discharge you or, you know, you can no longer have you present back to these appointments, you know, we more than happy to put you on a waitlist for future reference. Otherwise, in the meantime, you know, you can see such and such or have a look, and thank you for, you know, the visits you’ve had, or wish you all the best, that sort of thing. So that’s possible, if they present at every appointment, and, you know, for whatever reason, then you might have to allude to it say, you know, thank you for your continued support of the US, unfortunately, due to, you know, a couple of many incidents and breakdown and communication. You know, we’ve realized that when unable to offer you the best care, and such that we think it’s best that you just continue the treatment here with us. So it’s very simple, like a paragraph, if not, and we recommend that you visit these area, you know, these look for these sort of clinics or, you know, go on these search engines. Sometimes what else I do is, you know, you can refer to a specialist, as well. And in some cases where, you know, specialist management and you write them referred to a specialist, and then can even have that chapter specialist beforehand, and say, Look, these are the issues and, you know, the specialist can sometimes chat to them, but it does make it a bit complex, because they’ll still come back to you for the checkup. And if that’s something you really really don’t want to do, then you will have to discharge them. But I did think keep it simple, keep it non emotional, don’t put any clinical things and don’t have them read it, you shouldn’t be something that makes them I suppose, angry upset when they read it, it just is plain and simple. Unable to continue the care with you and, you know, thank you for you know, whatever support you provide us, and then you just sort of sign it and put it there and just you just break down communication or we’re unable to offer the complex treatment that you may require. And I think yeah, keep it like, I don’t think there’s a hard and fast rule. And I think [Jaz]I think it’s good yeah, you mentioned to keep it concise and non emotional because your default thing to do is that as you’re typing this or your emotions, you’re you’re you’re remembering those conversations and you definitely don’t want to be in that state of mind. And so I think the antidote to that is to keep it as simple as plain English as possible. So that’s a great tip and I think we should all remember that. Hopefully, you know, we’re not gonna be doing too many of these letters is the odd time which is why I think you’re right in your to have an element of you can follow a structure and make sure you’ve got a checklist so you don’t forget to recommend other places and you don’t forget these little things, maybe a checklist to be more appropriate, but definitely don’t Well definitely do make it tailored to that individual person. [Vy]I’ve heard of some practices, standing by registered post. Like you Some patients pretending they didn’t receive these letters and they just turn up. And you know, it gets really awkward because then you know, then you give it to them in person. But I think emails you know, you can do since receipt for you know they’ve received it. Because sometimes patient come back and say, Look, I never got it, you didn’t discharge me, I need you to do this for me now. So the fact that they’ve you’ve got Send Receive, it gets to that point. And then just documenting and putting your notes. Look, I’ve unfortunately had a patient that persistent beyond the letter, you know, and it’s unfortunate, and I had to record further and you know, there was text, even SMS and as they tried to send the surgery, so I had to put that documented, I had emailed screenshotted it sad. And that’s it’s hard when they persevere beyond that point. But I think just record everything, keep it concise. And if they’re one of those patients that might say they didn’t receive it, then just make sure you do it in a way where, you know, they’ve got read receipts, or whatever it is, [Jaz]I didn’t even consider that. So that’s a really good point. I thought my question is, what if a patient was rude to receptionist, your nurse or or to you? Now, you said, Don’t make it too specific. But is that I mean, how do you now put in a letter that, hey, you’re rude, we don’t want you because you’re not, you know, this is we don’t accept rude behavior. But then without making them emotionally charged, because the person who’s rude, they never truly appreciate how rude they were. Right? It’s one of those things that you didn’t know, they might have been rude, but they’re like, No, you guys were just unreasonable, or you guys, whatever. So how do you think it’s worth mentioning about the rudeness? It’s a difficult one. [Vy]It’s a difficult one, sometimes it can be miscommunication or communication breakdown with team, you can make it just broadly, we have a sign. And I apparently, and this is more so actually more from, you know, hearing bits and pieces and what I was actually taught, but you should have a sign that says, you know, we don’t tolerate verbal or physical aggression, whatever, verbal zero tolerance, zero tolerance policy, exactly, you’ve got that on the wall. And you know, you can remove it off the premises. So you can verbalize verbal aggression, or, you know, you know, whatever to the team members, or, you know, the team members may have felt, you know, uncomfortable. And sometimes those conversations with those patients, it might mean that if, especially if they route around, but you you just had a conversation with them verbally first, because when you’re the clinician, and they’re nice to you, and everyone else, they don’t realize that, you know, that they like this. And you know, and then you just and you just say to them, Hey, you know, like and they just do nice to see you say hey, look such and such and, and I think if you say something like, I know the way you are sometimes you know it might you might be at work and you we have a bit of a laugh, but the front desk or they might not know you as well as I do. So let’s is it possible? And you have to have this conversation with them. And it requires quite a mature approach. But you know, it can you try and just be a bit more respectable consider it, because it is a team environment. And you know, I need them in, you know, to help me out to fit your appointments. And we all need to work as a team, you and mean and whoever. And I think it’d be really hard to get you in and book those appointments if we can’t work around with everyone. And when there’s a bit confronted with that, usually, they’ll probably be more considerate. And they’re less likely. Yeah, usually. Yeah, I find that if it’s abusive enough, but you usually doesn’t want necessarily a whole lot of them out. I think it just needs that one on one communication. And they usually caught out because they don’t realize that you know, and then then I think they turn it back especially they’re really like you. So I actually have had conversations with the patients because I get I you know, and being a practice owner, I obviously love my team. I don’t, you know, I hate it when patients are rude to them. Because they’re like my family too. And they’re the ones that stick it out for you. So I have that conversation with the patient. And usually I think when they realize [Jaz]That’s the test. That conversation is the test. So how they respond to that conversation will make your decision very easy as to okay, do they get the letter or Okay, they’ve got their, you know, their their wrist slapped, and they gonna behave now. So that’s good. But I guess it also depends on the level of aggression that was shown to a startup. Yeah, like, sometimes it’s so much that you know, that case not even worth having that conversation. And then yeah, that’s because it was so bad. But if it was like a small one, a bit of aggression, maybe they had a bad day. And but you know, that actually in the chair, they’re usually quite nice. And you want to give them a second chance to redeem themselves and into Yeah, but to also get the message that hey, you know what, you’ve done it once, but never again. So it’s important to get that message and I think you explained that really well. The you’ve answered my main questions. Thank you so much for wow, I mean, I really enjoyed our conversations. I think it’s gonna give a lot of value to young, inexperienced dentist, but how to manage these awkward situations. Anything else you want to mention at all, in terms of this theme of handling difficult patients? [Vy]I think we went through most of it. One of the things I just want to suggest I think we are maybe one things we didn’t mention it. It can be really difficult when maybe patients bring up financial issues, just as a younger dentist and his patient brings up and they say look, but I can’t afford that treatment. Or you know, can you make it a little bit cheaper for me? And then they start saying, you know, I’ve got this young kid, and it’s really, really sad. And I think that’s a difficult one is to low SES areas, which you may have listened to faces where I know my new grad sometimes had, you know, that odd patient that comes in. And with those type of patients, you know, what I would suggest saying is, you know, never be judgmental, and at any point, just listen to them and say, look, and until I understand it, and I say words, like it’s an investment, I know all these feelings, it’s a lot to take in. And yes, definitely a lot of money, in the long run is gonna be investment in eaten shoe. And if we really think about it, you know, it’s going to cost you a lot more in the future, if you don’t do it now. However, I see where you’re coming from, you know, your pose is different. I don’t know what you’re going through. And I’ll offer alternatives. Like we can’t compromise on our fees, because they’re reflective of, you know, the materials we use the time we put in, you know, but how about this payment plan option? How about this private health insurance? How do we break this up a little bit, so we’re only doing the worst ones you said, give it a money here and there, and really just working towards them. And I think when they see that you’re trying, like you can’t compromise on those fees. And it’s a good standard to have. Because once you discount them once, once you say, Okay, once you set the precedent, so you you really shouldn’t compromise on your fees, but you find little ways to show that you care, and that you understand that they might not be able to afford the treatment. I think sometimes patients just need that. And also the ones that they wanted, you know, just to get that extra, now discount, or whatever it is, they know that it’s not going to work again, that’s probably another thing that I think we call it a fair bit. And it was so interesting to chat with you about it, Jaz, thank you for having me. [Jaz]It was absolute pleasure. And I also respect the fact that just now even when you answered that financial situation or the explain that again, you follow that principle that I mentioned Raj, he didn’t quite say no to the patient, you said, Actually, we still love to help you. But how about these alternative ways that might suit you better. And that sentence you said about our fees are reflective of the materials we use and our time, like, everyone should like internalize that. I love that saying because sometimes when you’re presenting us scenarios, it’s sometimes good to know a couple of canned phrases that you already got to sometimes give you that thinking time to give you your more tailored response. So that was fantastic. I love that. Where can we follow you on Instagram? And you know, now that you got your medical law stuff in the background? Do you have a website where he connect with you? [Vy]Yeah, I’ll actually need updated photos on our website. But my practice is sunshine Family Dental. So our Instagram I think is sunshine family dental clinic. And my Instagram is just veewhyp so like they whip but it’s like vyp? So that’s my Instagram but yeah, you know, awesome just to see the practice, you know, we try and put little, we try and post you know, a couple of posts a week and each of the posts we have Instagram would be one about a staff or personal one, one that’s more like you know about all periodontal disease or have a picture of their ad or opening hours and then little quotes so yeah, so that’s definitely where you know you can connect with me or the clinic. [Jaz]Amazing. Thanks so much, Vy, for your time and for your conversations. I really enjoyed them and hope to catch you again one [Vy]Thank you so much. I’ll keep listening to a podcast if I have to listen to that one though. The ortho one Jaz’ OutroWell, there we have it guys. How good was Vy’s energy. I hope that this episode gave you some tools that you can use when your next encounter that “difficult patient.” This is last episode of 2021 so I’m wishing you a very happy new year as we ring in 2022. I really appreciate your listenership guys. Honestly it means a lot to me. Hope we grow together during 2022 to help you smash all our goals and look forward to learning together in 2022. If you wanted to give me a New Year’s gift, like a 2021 goodbye gift, then I would love for you to share this episode with a colleague who you think might find the theme of this episode. Very useful. Anyway, thank you so much. Once again.

The role of tongue position, posture and the airway on the developing occlusion is hardly covered in Dental School. Let’s think BEYOND TEETH with Dr Bobby Supple, carrying on from PDP099. Follow Protrusive on Instagram! https://youtu.be/zfLK0qszdA8 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below!  Protrusive Dental Pearl: When checking someone’s occlusion after a restoration, do not just check it while they are supine (lying down), sit them up then check their occlusion again because posture does change our occlusion, even just a little. In this episode we covered: Skeletal Bite vs Tooth Bite 4:45 Trigger Points 13:28 Myofunctional Therapy 17:14 Dentistry and Other healthcare professionals 24:57 Neuromuscular Dentistry 38:19 Check out the book Dr Bobby Supple recommends: New Trends in Myofunctional Therapy If you enjoyed this episode, check out the first part Occlusion Wars: Which is the Best Occlusal Religion?  Click below for full episode transcript: Opening Snippet: Okay, so Teeth are together for long periods of time at nighttime, then the sympathetic nervous system stays on. The sympathetic is fight or flight. That's what apnea is. Squeeze, AH... Jaz’ Introduction:Hello, Protruserati. I am Jaz Gulati, and welcome to episode 101. It’s a continuation from Episode 99, which was Occlusion wars: Which is the best occlusal religion? And just to give you a flavor of that episode, like a quick recap, I wanted to find out, which is the best training institute for occlusion. Is it Spear? Is it Kois? Is it Dawson? Is it Pankey? Is it neuromuscular? That kind of thing, which is a common question that we all ask on our journey after dental school. And we think that, okay, we need to upskill and learn about comprehensive dentistry and how occlusion fits into it. Very often, we’ll be faced with this choice. And some people go for koiss, and some people go for Dawson. And I got someone on Bobby Supple, who continues in this episode. And he blew me away, because he’s done so much training with all these greats, he’s been in the same room, you know, Kois and spear and Dawson. And everyone’s together debating, and he’s been very much part of that. And it was great to learn from him. And essentially, it doesn’t matter who you train with, they argue and they challenge you on the different processes, the outcomes are going to be very consistent. So the answer is train with whoever you want, whoever is most convenient for you, best price for you, best mentors, maybe your principal, or your boss has also done Kois so you should do Kois. So you can speak the same language maybe, or maybe because your principal’s on Kois, you should do Dawson. So you can exchange notes about the how to, and how to get from point A to point B. But essentially, you will do your patient service. And you will do a great job, whoever you choose for your training partner, you make sure you implement it fully, and you do your best. And I think that was a really cool lesson. And going further now from that episode to this episode. The main thing I want to leave you with before we join the main interview is that sometimes, especially when it comes to occlusion, the first time you hear something from an educator, from a speaker, it doesn’t quite make sense. And sometimes you have to hear something like for the fifth time, and it’s eight years later, and then it clicks in your head because by then you’ve accumulated enough failures, you’ve got a bit more experience under your belt, you’ve got a bit more deep thought and experiences to reflect on. So if this episode is a little bit beyond you, because we do talk about higher level stuff, relevance of the airway, tongue posture, posture in general, this is all stuff that even I’m just learning, grasping more into, because very much, you know, my training was at the two teeth and the skeletal level. The teeth and bones, teeth and bones and how to make them meet together. But we’re and now I’m well versed are looking at the joint and the condyle and orthotic appliances prior to full mouth rehabs, that kind of stuff. But then looking even beyond that, and looking at airway. So this is a huge area, and even looking at children and prevention and how can we not just fix people up once they’ve destroyed that dentitions, but actually set them up at a young age so that they have a good chewing system, a good breathing pattern, and that actually has a huge influence on their anatomy. The Protrusive Dental Pearl for you is inspired by what we talked on this episode. It’s something that Kushal Gadhia taught me when I was doing some occlusion training with him. It’s basically when you’re checking someone’s bite, and they’re lying down. And we do this all the time, right? We fit a crown, we do some restorations and we get them tap tap tap while they’re lying down. We should also check it when you sit them up. Because there is a slight difference and what you might find that whilst everything is feeling okay to the patient, or is feeling okay according to your usual checks, which consists of articulating paper marks, checking for parameters with your fingers, checking for how it’s or listening to how it sounds, you know, listening to the bite and how it sounds. So once you’ve done those checks, it’s really good to check it when they’re sat up as well. And just to confirm, and every now and then you’ll realize actually, when they’re sat up, yes, the tooth is proud again. And he’s got to just adjust it there as well, because posture does change our bite. So let’s join part two of occlusion wars, and go deeper into areas where I’m exploring as well, like the book that Bobby Supple recommends in this episode is new trends in myofunctional therapy. I’ve been trying to get my hands on this book, but it’s completely unavailable everywhere. I think there’s some new ones coming in 2022, coined Amazon, and what so and stuff. So I’m looking forward to delve in deeper into this side of things, and was interested to learn about the Atlas and posture and the role of nasal breathing or things like that, which I’ve respected, but he puts it all together in terms of the occlusion. So you may find that Whoa, this is a lot more to take in because it’s stuff that we haven’t traditionally covered at dental school. But I think it’s really important to expose yourself to it, even if it’s for the first time for you. And then maybe sometime later, when you read a bit more or you shadow some mentors, who also practice this kind of stuff. It starts to make sense. So thanks so much for joining us on this journey and I’ll check you out in the outro. Main Interview:[Bobby] Now real quickly to your point going forwards the dentist, okay. Like you look at your child, I looked at my kids. And so one of them we actually did orthognathic surgery on I mean, you’ve talked about a gut check when you have your A child and you’re looking at it and going okay, wait a second Am I going to put my child through that but it was for a lot of different reasons. He was a soccer player and concussed and had some accidents and so she so it was not just a class two even though she did have an airway thing and stuff like that, okay but that’s a gut check when you’re looking at your kids and you’re going okay, am I going to actually practice what I preach? Okay? So it’s the dentist though, it’s the dentist who sees young and old, we see male and female, we see you on a regular basis, we see you when you’re well that is radically different than if you have a strep throat and you got to go to a physician, they can only do put you on antibiotics. And we see you when you’re lying down that is just absolutely critical. Almost all therapies, chiropractor, PT, massage therapy, dentistry, we do it when you’re lying down. And that’s a concept that dentistry hasn’t really quite understood yet. So when you’re lying down in a job drops back a little bit in a closed, they’re in a tighter arc. So we’re actually doing our little crowns in our adjustments and everything is receeding, and we’re seating the condyles without really even knowing it because we’re practicing when they’re lying down. The patient sits up, let’s say you put in the crown first molar patient sits up, and then they go, Oh, Doc, no, I’m hitting it. The dentist, okay, well, fine, lay back down, or they just did some more because you got to retrofit anything. Okay. But you got to ask the question, then, if you were lying down and the bite seemed fine, when the patient was tapping and then the patient sits up and goes, no, no, Doc, it’s too high. And you know, okay, well, I’m not letting them out of the office with this, then with that feeling because you know, you’re getting the phone call tomorrow, okay. All right. So you’ll go back and adjust it. Okay. So why is that? Why is lying down just so absolutely critical? And the reason is simply because your head is supported. And so when you’re supported here, then the neck is going to want to relax. I start every exam, every single exam, hygiene checks, everything like that in the first place I go is here, go right back to the Atlas, they’re lying down, okay. And then I can figure out which is the tighter side. And then pretty much I know that that’s the side that the lateral pole is going to be a little bit tender on, that’s the side that the airway is probably going to be the least. Okay. All right. So think of the maxilla like a V, mandible wants to grow like a U shape, a U doesn’t fit inside of a V. So they pick a side. That’s what you see on the T scan at age 12, 13. You know which side is the side that they’re pushing off, okay? So just for your audience right now, just because there’s everybody has two bites. I mean, all these occlusion Wars came down to this. Everybody has. Okay. You have your skeletal by bones, ligaments, muscles, posture breathing, that’s your skeletal bite, and then you have your teeth bite. Okay. Yeah. So we’re just in dentistry, we know how to retrofit the teeth, a tooth cracks, okay, cracked crown, build it in there, we’ll get it all into it slide. That’s how we do. There’s nothing wrong with it. Okay. All right. But the skeletal bite is the general the skeletal by tells you how stable everything is and how balanced all of the system is. And we still have yet to quite figure this out. The mandible, the shoulders, the hips, the knees and the feet, there’s five planes in the body. And all five of those planes you want to be balanced. But if the mandible is growing off center, like that, then the shoulders like that the hips, the kids that grow, the girls will grow into some scoliosis, all of these sorts of things. So the fact that we can get to these kids young, when they’re healthy as a dentist, and we’re looking down the oral cavity. Dentistry is literally in the mainstream of health care, but healthcare doesn’t know it yet. Okay, we have the power to change health and wellness. But we got to get to the kids and we got to get them widened out and we got to get them to breathe through their nose. And so you were talking about your son. So here just a little thing if you’re just sitting right now, okay, if you’re sitting and slouching, okay, and one shoulders like this, because I do this way in. When I’m in a lecture hall, because everybody’s sitting there, you’re like an hour and they’re all tired. Everybody’s like, okay, yeah, they got their hands on the table like that. And they’re kind of sitting like that they go, okay, so stop right there. Now, tap your teeth. Just tap your teeth in that path. Okay. All right. Then I tell him okay, now. Take a deep breath. All right. Chest up, we’re going to roll our shoulders back, you’re going to take your hands, you’re going to stretch back, you know, you can do this if you want, but stretch all the way back, tilt your head up a little bit better get your posture, exactly all like that. Perfect. Okay? Then you get it. Okay? Now take a couple of deep, deep breaths, just breathe in, breathe out like that, okay? Now, if you take the tip of your tongue and you put it on the roof of your palate, you just put it up on the palate to the back. Okay, now the condyles will sit, the condyles will want to sit. And then you just do like, I get, don’t touch your teeth, fail, let the time relax, just go like that. Okay, they are sitting up like that perfectly straight. Now close. And just lightly close down. And I want to know what to touches first. Okay? [Jaz]For me, it was my upper left premolar, on my left premolars, yeah. [Bobby]So is this going to be one of four primary positions, it’s either going to be a second molar in the back, is going to be a pre molar in the corner. So if you think of it like a V shape and a U shape, well, it’s either going to be way back, or it’s going to be in the corner, okay? All right, and it’s going to be on one side more than the other. Now, that is your skeletal bite. So what you would see on the T scan when you were lying down, if you had the patient, close, swallow, squeeze, and then tap tap tap like three times, then the pressure would push off of your upper left premolar side. Okay, so it’s like, it’s the clue that says, Okay, wait a second, my teeth bite is a little different than my skeletal bite. For you, that’s your anterior control, that’s where you’re going to see some abfractions, that’s where you’re going to see the little pole in the gums. That’s where the lower cheese is going to start to press for it. So then you get a bicuspid drop off, and it all goes like that. Okay. Now in all fairness, if we track this and you cone beam get, then we would find that between your nose, your sinus and your ear on that side is narrower than on the other side. Because growing up your cartilage base, wasn’t perfectly symmetrical, because nobody is. So you’re sitting in first grade, you’re just sitting in first grade, and you can’t breathe perfectly like this. So literally, you tilt your head up like this and turn it in. And that’s how you sit, grow, sleep, swallow, and everything is going to grow into that. So between 6 when your first molars come in, and 12 when you have your full adult dentition then the cranium is grown and the asymmetry is in the mid face. And we call the cranium the criminal. And finally, basically now it’s, you just draw a line between the nasal airway, the cheekbone, the jaw, go back to the ear, go right back into the trigger and the neck and then drop down into the shoulder. And the epicenter is here. So I knew we would do this. [Jaz]Excellent. [Bobby]All right. [Jaz]Trigger points. Lovely [Bobby]Trigger points. [Jaz]Janet Travell and David Simon’s. Yeah [Bobby]Exactly. So I was probably I’m gonna say it was 1995-97, somewhere in there. And I went to California, and I’m listening to Janet Travell. Okay. Janet Travell, she was kind of eclectic. And there were some really wealthy women in New Mexico. A couple of them were my patients and they would actually fly, bring Janet Travell in, and they, she would work on them. Now Janet Travell was John F. Kennedy’s personal physician because he had back pain and so she that’s where she kind of got famous to start. Alright, but I had never heard her lecture until I went to Palm Springs. You know, one January when it’s all sunny and everything like that. You know, I just tell my wife. Hey, you want to go here? Yeah, I’ll go there. Okay. So I’m sitting in the room. Okay. And then they bring Janet Travell so they have to help her onto the podium, sees 90 some years old, she can walk but she’s not in a wheelchair or anything like that. But she can’t make it up the steps to the podium. So she’s up there and my first thought, I mean, it’s like an idiot. My first thought was, oh, I’m too late. I missed her. She’s too old. Okay, literally, she starts talking. And then I’m going okay, wait a second. This is Mother Teresa. And a lot of the audience was surgeons and stuff. They weren’t really interested in Oral Biology conference. And so they weren’t clinical dentists like I was. Okay. And literally, she’s five minutes in. And then this is what she says, she’s pointing to these two. So this trigger here, and this trigger right here. Okay, she goes, [Jaz]So just to describe, you’re pointing to the trapezius and right side of the [Bobby]You go to the Atlas, and then you drop down, and you can find it in a dental chair as soon as the patient lays down. So Monday, you’re going to go right to here, and you’re going to feel the tight side. And then you take your fingers and you go underneath the shoulder blades, and then you’ll find this trigger here. Okay, all right, they’ll just be tight. In the beginning, you’ll kind of think, okay, it takes a little bit of time to practice to feel the difference. But after 10-20 of them, you know, you’ll start to go oh, now I get it. And just like when you palpate here and you’re going you’re putting pressure on a lateral pole or whatever, put some pressure on it. I mean, you can literally take your finger and press into it like that, every once in a while the patient will jump or whatever, okay, but what happens is a child and these become your headache patterns. Okay, well, this is what Travell said right off, she said it two or three times in a row, because she’s talking to a dentist, and she goes, These are your dental triggers. Okay, I took a couple of deep breaths because I’m thinking late 90s. I’m thinking job teeth. I’m thinking this here. And I was all into her these all of these guts. Okay? So all of these clothes squeeze, temporal headache, jaw into the ear, pressure here. So this guy, this guy up and down here, sometimes I could get this one here. But never this one, this one, this one and this one was how totally out of my paradigm at the time. [Jaz]Bobby about some videos in Instagram actually are patients who come in and in pain from a lateral incisor. And then I’m checking the trigger point on the temporalis and I can recreate the familiar pain. So this is when you first do it, it’s like wow, okay, this is there’s something to this. [Bobby]Now, you’re going to take it all the way back. Because the future of dentistry. Yeah, the future of dentistry going forward in a digital world. Okay. Yeah, we know that teeth job, bite relationship because of all the philosophy wars and everything like that. But now it’s what’s below the teeth, your tongue swallow. What’s behind the teeth, the Atlas and the neck posture. What’s above the teeth, your nasal airway, and what’s in front, the face. Because we would always look at the face and then design the teeth to make it look like it all matched up into it and take a look at how pretty we’ve made these smiles. But the patient might be like this, okay? But the future going forward in dentistry is literally tongue swallow reflex. How does that tongue grow? Now we call it myofunctional therapy. I’m going to show you one book here brand new book out of Italy. Okay, so it’s called myofunctional therapy. I’ll set it up into it. You can’t I don’t know that. You can buy this on Amazon. But I might be you just gonna [Jaz]I’ll throw a link. If it’s wherever it’s available from I’ll throw a link on there. So yeah, new trends in myofunctional therapy occlusion muscles and posture. It’s a very similar to the Carlson books? [Bobby]Yeah, exactly. Exactly. It’s just, it’s out of Italy. And during COVID What happened was, there was six or eight weeks when the whole world was shut down. Every single dentist in the world was furlough. Okay. And then dentists just their social so they were going online. Okay, and then they had this occlusion confusions things like that. So, Javier out of Florida was putting in and he was interviewing people about occlusion, but what he literally did is he was zipping around the world. And so every single day, I would have a podcast, it’d be like two o’clock. And I could just dial in, I’ve just go right on the internet and go oh, which podcasts are happening today and they were coming from all over the world. You had Chirodontics, you had you know, orthodontists, you had the airway Doc’s, you had the surgeons, you had the cosmetic dentists and everything like that, but they were after a couple of days on my first thinking was, you know what, we’re all on the same page. I can’t even believe this. Dentistry around the world, we’re like on it. And everybody was coming at it and, and they were all kind of coming around it. And so then this one group out of Italy, Sacred Heart Hospital next to the Vatican in Rome. It was like the pope blessed him, you know, literally across the street from the Vatican in this big hospital and 20 years of research, but they’re looking at Oral oncology, and they’re looking at anything to do with swallowing and breathing with the kids. And then they just developed into it and they going, okay, the tongue swallow reflex, that’s the maxilla and the maxilla is offset by cause of the airway. And then the head has to hold into that. And so the epicenter is that tongue swallow reflex in the kids. And it’s age 7 through 10, that that tongue should break and you should lose the infantile swallow into being an adult chewing swallow. Any person who at age 10, still exhibits an infantile swallow means that the tongue swallow is over protecting the airway. And it’s all because of post nasal drip, and then they swallow it. And then they grew into that pattern. So now, you know, the sockets aren’t symmetrical. The sockets aren’t symmetrical, the atlases aren’t symmetrical, and then you made the comment at the beginning and then I’ll be done. You made the comment. Oh, yeah, we’ll see our doesn’t talk about the disc. That doesn’t end the definition, doesn’t talk about the disc. Well, guess what, you have a lower compartment that has to do with more rotation, you have an upper compartment above the disc that has to do more with translation. And then you have another condyle back here, which is the Atlas, which is all off center, too. So in to have six joints, you’ve got three on each side, like that, and all of them grew into this, have and now you can systematically just pick it apart as a dentist, if you start with the triggers, then you’ll kind of get the idea, then you’ll start looking at your panels, and going oh, one condyle’s up here, the other ones down here, oh, one palate goes this way. And then it stairsteps up and, and you’ll start looking at it, this side and this side skeletally. And then you’ll quickly start going, Oh, the abfractions match this, the forest patterns on the T scan match it, the gum recession, the cracks, the wear facettes, they all start to match up. Because it was one shoe at a time like one leg shorter than another over decades. So it goes into an asymmetry. Everybody has two bites. It’s when the skeletal bite and the airway and then posture bite are overpowering the teeth, that a dentist will have a problem. Those are the ones where you prep a second molar, and then the joint seats. And then they come back and then you put the crown on and the crown’s too high. And you go No, I know I gave myself enough space. Well, what happened? The condyles, you know, and the posture went better. And their headaches are less. And then now you go put the crown in. And now the crown’s too high. Well, guess what? It wasn’t your lap. It was like you have two bites and so dentists are good. We know how to get around problems, because you don’t want the patient complaining or you don’t want the too sensitive so we can retrofit it. And I’m just telling you, there’s nothing wrong with that. Dentists are Awesome. [Jaz]Well, I just want to just say that mean, I like the term retrofit that you used because I think it really makes it tangible who are listening that okay, what we’re essentially doing is we are retrofitting teeth to an ignoring the underlying, and I think what you’ve done is brought lighter fact that, okay, it all starts at a very young age with the swallowing, and how things compensate. And what we’re dealing with here is a much bigger issue. But before I let you just talk about the direction about how in dentistry, we can be more unified in this front, because one of the challenges is A) lack of education on this at Dental school and acceptance amongst perhaps some prosthodontics societies who are very much still focused on the teeth and jaw and not at the bigger picture. So that’s a big challenge. And B) you know, it’d be great if the health care professionals are more allied, you know, as a general, we are almost sometimes dentistry as if the mouth is not part of the body. You know, it’s sometimes we need to have more open conversations with our other healthcare professionals to be able to do a more holistic diagnosis. So those are some of the challenges but I was just pose you this one question could have so many different directions we can go in, if you can go back 10, 15, 20 years to those cases, when you were doing these beautiful Empress restorations. And you had these teeth setup, how you were trained to set them up and for many patients at work, but then you know, it’s obvious, some chipping and cracking, which you now can look back and think, Okay, it’s because at a higher level you are retrofitting. How would you manage that case today? And then if and I’ll let you answer that. And then I might just give you another sort of challenge to what I think you might say. So how would you manage those same cases today? [Bobby]So you mentioned dentistry relationship with health care. So in my community, I have never ever seen this at all. In my community, the chiropractors, the massage therapists, the physical therapists, even the neurologists, they’re all starting to get on board, we’re all starting to talk about the same thing. We’re all in the same camp. So just 10 years ago, now a chiropractor was a quack, a massage therapist, you know, was just likes surface stuff, they weren’t really helping so much. And even anything to do with dry needling and stuff like that, it was just No, it was not in the consciousness of even dentistry or medicine. And then, because medicine so cracked, and there is not a family physician anymore, and things like that, that’s why the dentist is going to become the family physician. And now in my community, a neurologist will say, hey, I can solve this part of the migraine, I want you to go see Bobby, and he can help you with the rest of it. So you’re watching it change. Now every community is going to be a little bit different in that sort of thing. But I have never ever seen everybody on the same page. Because posture and nutrition and things like that are really at the forefront. And post COVID I mean, literally dentistry is going to be pre COVID, post COVID. With everything starts all over, everybody’s got a clean, fresh slate, everything in the past is fine. I’m just going to tell every single dentist young or old, you’re fine. You’re brilliant. You know how to fix teeth, you can get rid of abscesses, the younger dentists know all about pathology, way better than I did in school. They know the legal part of it. So they have to deal with that. So that’s fine, because you got to basically stay out of trouble. Okay, but we’re good. We’re really good at what we do. So going forward, what you were trained to do you keep on doing. So yes, you build in MIP. Okay, because that was always the thing about the philosophies is Oh, MIP is not right, well, it is right, it’s the best that we can do at that time. Okay. Now, if you’re going to go forward, and you’re going to do more comprehensive dentistry, now, you have to start thinking on a little different hat because your teeth bite and your skeletal bite now start to come into play. So now you’re going to have to get better at orthotics and literally center this thing up, and you got to get these condyles. But mostly, you got to get the condyle in the neck in harmony with each other before you’re going to do a full mouth reconstruction. Okay? So you’re going to pick your poison, alright, if you want to go in that direction and do more and more comprehensive. So pretty much what happens to the average dentist is you practice for about 10 years, and you go, you know, I am just good enough to be dangerous. It’s like, I want to do all this sort of stuff. And then there’s more money or there’s more, you know, satisfaction into doing this. And my patients are asking me to do all of this sort of thing. And so it’s like, then the question is, how can I do this? Where can I go? Where can I learn? So now we have people like you podcasts and internet and stuff like that. I mean, you’re not paying attention, then that’s your problem. And the way I look at it right now because it’s everywhere you can think okay, but now you go back Monday morning, your first patient and after you watch like videos all weekend, you’re like, Okay, I see the end result, I can see all these beautiful smiles involved because they show the before then they show the after and all of that. It’s like, how do I get from A to B, you’re gonna have to go back to the basic definitions and the basic definitions is condyles have to go into socket. Literally, they put them in a socket, even if it’s an adaptive position and all that sort of thing. Find your skeletal bite, find that first point where you’re touching. Okay, so I’ll straighten out the neck, stretch them all out, palpate their joint, a lightly lightly do my little bite thing like Dawson taught me not hold it tight. All of that sort of thing, tongue to the roof of the mouth. I’ll let them find that position naturally close down. And then I make sure it matches the T scan. So then I know Okay, a duck is a duck. But we don’t do models anymore. We don’t. I don’t take impressions and go in. I don’t know is about 15 years ago, one of my assistants goes Dr Supple it’s like you make us take these models and we do it all that and we get it all nice and healthy. And then you go to the consultation and you don’t even look at the models. I go well you’re right I’m looking at the photographs. So if you’re going to get into any kind adapt, the number one thing you have to do and you have to get good at is photography. If you’re not taking pictures, if you’re not taking pictures of the palate, and you’re not looking at Tori, or you’re looking at a lower arch and how the teeth are going, you’re never going to get the 3d concept of how the teeth are fitting into the skeleton. Okay, so you got to almost blank out the teeth and look at the bone structure. I’ll leave you with one last little pearl, I don’t know where we are time it but, but if you breathe perfectly neutral through your nose like this, and everything’s nice and wide, your palate should be dead flat, you should have room for all 16 teeth on the top, relatively flat, lips and tongue seal breathe through your nose. Okay? Now if only one in 100 Kids have that. Okay? So instead of the palate growing like that, if this airway grows like this, and then they’re in this pattern like that, then literally the cartilage, what happens is the cartilage is going to grow. So instead of growing flat, the cartilage in a nasal downdrafts. So then it drops like that. So we look at an upper Tori and go, How the hell would that happen? I don’t know, well, what Guess what? It’s because of their nasal airway, it grew like that. So literally, you’re going to look at it differently. And when you see a Tori and you see it downdrafted, and you see it pushed off to the side, or you take your finger, and it’s high vaulted, right here and my friend, can you rub it back, and then you’ll feel the tori line up and stuff like that. And then you look at the picture. So what happened is it got downdrafted, there was so much cartilage compression into here, and the patient’s swallowing, and they’re holding it like that. They’re squeezing their teeth, that’s that sleep disorder breathing, you know, the kids and in their teeth, and all that sort of thing, okay? All it means is the tongue is in the way of their airway. And the back of their tongue is a muscle and it’s not relaxing at nighttime. It’s literally simply every time you swallow, it’s compressing so then you drop into it, then the mandible would love to grow forward the mandible, but it’s being trapped. So you got like, the mandible wants to come forward. And then you start to see the Tori on the lower on the lingual and you’ll see like two bumps on one side and one on the other. Well, literally the mandible is trying to grow forward and in throughout life, it’s trapped. It’s like a shoe that’s on that’s too tight, and you never take the shoe. So every time you go to eat and chew, you’re compressing like that. I’m just, I’m just going to tell you photograph everything you want to see abfractions and you want to see the gum poles, you want to see the wear facets in the teeth. But mostly you want to look at the architectural of the bone. Once you have the digital pictures. Okay, so I just got lucky 1980s were photographing, so I don’t ever do an exam or I mean a records appointment without the photograph. So I have a photograph of every patient from their initial exam full set, just like an orthodontist would do the photograph. So you have to the first digital technology is the cheapest it’s a good it’s a camera. Okay. Number one. All right. So I would then say okay, now scanners are the future. So since we don’t take impressions and I don’t take bottles and I don’t put them articulators to do that console, literally, we just take the scanners and go all the way around in and off the scanner, then I can teach the patient if I need to, but the scanners are the future. Hey, there’s different kinds of prices for scanners, okay, I use an iTero. But iTero I do that because of Invisalign. iTero has the best software, they have the most bells and whistles in the software. They showed the pictures. So I’m addicted to the iTero software. And so that’s why I use that scanner. Okay. The other ones find they’re good. It’s just that they’re not tied to Invisalign. Why probably 15 years into Invisalign, and then you going okay, so most of my practice is TMJ bite issues. I do do some dentistry now, but not so much. I have a partner who’s an implantologist so he can handle all the perio and the implants and then I have Bethany who’s just this brilliant she’s 10 years out of school so she can do the dental work and things like that. I see literally 10 new TM patients a week, [Jaz]You pretty much niche down into TM patients who are suffering with a temporomandibular disorders. [Bobby]I generally the patient, when I see him, they’ve already seen at least three docs, it might be a dentist, but it also might be a neurologist or they’re chasing some kind of other medical issue. For sure they’ve been going to physical therapists, chiropractors, stuff like that. But I have a network in my community where you know, I have 20 chiropractors who know who I am, all the PTs. At the university, I was actually teaching the physical therapy students in school whenever it came up, because the instructors were my patients, you know, so Bobby, come here, can you talk to my class and things like that, we would go into the PT class when they were learning about their jaw, and sit them up, put them on the T scan and show him they’re fitting up by on the T scan, lay them all down, then go back in there, close it. And so then you can put on the screen they’re sitting up bite and they’re lying down bite and then I would just simply go, you guys are the heroes here, you have to understand the PTs because they’re going after all of this and they’re lining up neck and shoulder and they’re helping us a lot. So going forwards if if you’re going to do a comprehensive case, and you have a lot of wear, okay, and you know you got this airway and neck issue and posture, you have to kind of clean this up, and then use the scanner. Now the scanners will then now you can mail your orthotics. So we’re a couple years into that scan, then I just send the study models to the lab. And then we use the lab software now to then articulate it. Because I can pick five different articulators on there, you know, I can do a hand our Sam or whatever, okay? You just pick your articulator and then all adapt, I’ll just take the pan out, and then literally, I can change the condylar thing just a little bit, whether there, it’s just three things, okay? Are they flat? Are they medium or is it curved? Okay, because that’s going to make a little bit of a difference. Okay, so then you can just set it because sometimes you’ll have one eminent saddle flat and the other one that will be much more steeper, because they grew compressed. Okay. All right. So then I can quickly make a little thing, the lab guy does it now I don’t. Ralph and I been together for 20 years, so he knows what I want. Okay, so he just looks at it changes the condylar inclination. And then we just open up the vertical a little bit, just three millimeters to five millimeters on the front, because I know there’s [Jaz]Using the neuromuscular background that you also got so at all the schools that it all tied up at the end, you know, although all these wars and really, you know, occlusal religions arguing each other, ultimately, they tied up in this very comprehensive era. Now, as we’re looking at the bigger picture there, like you told me in the emails, we’re all friends now. They’re all the religions our friends. [Bobby]Yeah. So this book you can still buy, if you kind of want to go back out away. This is the one I’m saving in my archives, but this book is called posture airway and tongue [Jaz]By Jenkinson, right, [Bobby]Jenkinson. So this is the father of neuromuscular dentistry. But before LBI and with before we started doing full mouth reconstructions to match this, though this just right off in the beginning it goes okay, these are the things you’re looking for upper narrow arch, inflamed adenoids and tonsils history of throats and stuff like that. So the dentist now is the oral physician. It’s called integrative dental medicine. So the Dawson Academy this is what’s new book, it’s called The Shift is literally the entire Dawson curriculum is in here with the whole concept of Wait a second, start with the nasal airway, understand how it’s kind of grew that way. Then if you’re gonna do more comprehensive dentistry, you have to make sure the neuromuscular is correct, but you do that within orthotic, okay? And then the whole idea that if you’re just adjusting teeth, and then that’s called mutilation, you have to get that out of your mind. The word equilibration and the word CR, they were so bastardized that everybody just had the bail on, So originally it was the American Equilibration Society. Okay, well, when I was on the board, when with put me on it. 10 years back, then you could see, okay, the word equilibration isn’t fitting. And then society is a fitting, and Americans not fit. Okay? Cuz it’s international. And a equilibration is a bad word. Okay? And so then now we just kept the word A, so we kept this, basically the brand and then dropped all the words. So now it’s just known as the AES. Nobody in the world really notice that it used to be the American Equilibration Society, but we dropped all the words because the world were pathology, in a sense, because if you didn’t understand what true CR or the epigenetics of a equilibration, okay, where all that came from, then it was all fake news. And so then you threw it out. And so then you were well, where do I start? Okay. But in all fairness, the thing that I learned most from Peter Dawson, and all of the early Pankey guys, was that the master teachers, then they definitely stayed on topic to the definitions. They didn’t bastardize the definitions. Okay. So, the biggest one is anterior. Anterior, that word right away, in dental school, you thought it was anterior guidance, canine disclusion, when in fact, anterior means in front of the condyles [Jaz]The anterior determinants of occlusion. [Bobby]Your anterior guidance is your occlusion. And so if you go back to the basic definitions as how the master teachers taught them, how Pete originally talked about center in the sockets, and you didn’t get into all these other philosophies that were brought into it for basically economic reasons, okay, there’s a lot of this was because, oh, I’ll do it this way, because I can make more money or whatever, okay, there was that part of the whole thing. Okay. But in all fairness, it comes down now to a couple of basic definitions, understand what the tongue swallows doing, understand how the postures going, think about the nasal airway, and Invisalign, what it does is literally you take all these old orthodontic cases that have all collapsed, and then I just basically I stand them back up. So in a sense, instead of doing a lot of prepping on the teeth, we’re just we move the teeth back and then the amount of dentistry is less. And so I’m going to finish my career as more of a orthotic orthodontist that deals with medical issues that mostly migraine, things like that. So teeth come from the nerve family. So in embryology, they literally come from the second brachial arch. So teeth are neurotransmitters. So Nick Yana , he’s taught me over and over Kirstine all those guys, we’re into the neuro part of it. Okay, so it’s just called sensory neuro overload. So if the teeth at nighttime, if you’re swallowing, you’re kind of squeezing your teeth a little bit, or you’re squeezing and pressing off and then Apneic and things like that. Okay, so Teeth are together for long periods of time at nighttime, then the sympathetic nervous system stays on. The sympathetic is fight or flight. That’s what apnea is. Squeeze, ah, save your life. Okay. But the teeth are resting, it takes years before the Apneic comes in, where they stop breathing, they just literally close down, swallow and adjust and squeeze a little bit, okay. But through all that time, and especially with young teenagers, females, especially when they’re hormone, so what will happen is their teeth will be together and then they’re squeezing down a little bit in their sympathetics are on, that’s anxiety, that’s depression. That’s this building where they’re not in REM sleep, that’s where they think that they’re waking up, but they’re not. Okay? One last Pearl, because everything’s cartilage base, and cartilage grows by cell division, then the girls get their hormones quicker and sooner. So there’s some times age 10 years old, and that estrogen starts to hit those periods start, and then literally, the girls will turn, they’ll twist. So this gets off center more, and the guys we compress and so we’ll hold more tension and neck and shoulder and snore more Hold on all the way back, but we have bigger round or stronger condyles, the female’s not so much. So if they really get into trouble here, and when they get off center, and this is growing, and their hormones are hitting, and they’re growing into the spurts like that, that’s why you see 7, 8, 9, 10 Girls, for every guy for TM issues, aged 18 and say 25. And those hormones have in and out of pregnancy, messes with them, you know, so we’re getting the concepts better, you just have to start younger than older and understand how all of this stuff grows. But when the teeth are together, because they’re neuro, they’re literally neuro systems. They’re telling the trigeminal cervical nucleus, okay, squeeze and grow, and all of that sort of thing. So the neuro network will become more and more part of dentistry, that’s the migraine anxiety and things like that. But it’s the dentist to pick it out in the kids. And once that takes over across the world, then look out because people love their dentist. [Jaz]And that’s where the prevention comes in. And that’s we can pick up things earlier. And one of my favorite quotes here, Bobby, which I did accompany them, and said here is the mouth is like a window to the health of the body. So the mouth is a window to health of the body. And I think, you know, just like going to be very much allied with the like you are in your community, I wish that upon all dentists listening, that you have this support network of healthcare professionals, who are all singing from the same hymn sheet with airway principles in mind, Bobby, you’ve been absolutely amazing. Thank you so much for giving so much of your time here to really cover what we started off with the teeth and bite and why everyone’s fighting about that. And we evolved into the bigger picture, which I think a lot of them, especially in the UK are going to find very fascinating. I do believe that our colleagues in the US where you are a little bit more switched on in this, I hope and I’d certainly seems that way to me. But please tell us how you can educate more of us dentists. I know obviously, with AES mean, I’ve been wanting to come to AES every year and I’ve got a small child, but 2025 is a really cool date that I can earmark to my wife and and really just build this what is 2021 now I’m gonna keep whispering every few nights, every few weeks, okay, 2025 AES, 2025 AES. So when it comes, there will be no objection to be able to make it a very successful trip when you are president. Please tell us what else, you know, because this knowledge needs to get out there. What else do you teach? How can we learn from you, from the AES and from yourself? [Bobby]Well, I would go back to a book like this now. [Jaz]So that’s new trends in myofunctional therapy for those who are driving or listening to this book. [Bobby]This book is two years old, all comes out in Italy. So and it’s not really tied to philosophies. It’s tied to basically the growth and development of the kid. So any younger dentists, any dentist, if you’ve been practicing for 2030 years, okay, and is thinking okay, now Whoa, I really want to put this oral physician model into my practice and I gotta tell you, it just grows the practice so fast, you know, you have a mom there and then you see how this grew and then you’re going okay, how old are your kids, you know, and then do they have allergies and things like that. The mom’s all over it, that child has an appointment, you know, set up before she leaves [Jaz]Some of the most powerful moments I’ve had in the last few years as I’m learning more about this field as well Bobby is having those conversations about Bedwetting, having those conversations about children who are making sounds when they’re sleeping when they really shouldn’t be, children who are having behavioral issues at school and then just suggesting to have a look at these massive tonsils that these children have and the parents have no idea and to encourage them to get investigated and the kind of engagement and interest you get from the parents and like the the warm do you get for liking, thank you for almost they think that is beyond our remit and thank you for looking after the health of my child and I completely agree with you [Bobby]No, it’s that they leave and they’re going okay, it’s not really about costs. It’s about health and wellness. And once that brand is in your practice once you’re known as a not a dentist but you’re basically a wellness person, then it’s all over. I mean, I say this in a really humble way but it takes three months to get an appointment with me. So if somebody calls the office and they go okay, yeah, and then I’m seeing 10 TM patient Well imagine how many phone calls that is and stuff like that and some of them are like in an acute situation I can’t really get to them [Jaz]Probably from out of state as well who probably heard about you want to travel and come and see usually when you know people with TM niches they do attract patients from all over. [Bobby]No every single day they travel three, four hours, I mean, my community is the state of New Mexico. So we have a big territory. And I’m not going to apologize, I built that. But that wasn’t the intention in the beginning. That’s just what happens when you start to put all these little puzzle parts together. And it started as a dentist who did a lot of prosthodontics. I mean, so you, you’re gonna learn it, and I’m just saying, learn it, but, but we kind of learned it backwards a little bit. And then you’re gonna have failures, it’s like my coaches growing up, every single workout was okay, we’re going to warm you up, we’re going to do a couple sets. And then I’m going to give you a set that you’re going to fail that, though I do that with my staff, when we sit down every single day, it’s not like you’re going to win the Olympics every day, basically, you come in every day. And we’re gonna fail, we’re gonna fail either through a phone call or a communication, or we didn’t do the temporary right or something like that. Just know that every single day you’re going to fail. But the problem there is, if you don’t learn from those mistakes, and then you just keep repeating it, now you’re locked in. And then generally, that’s when your career path is going to seem like it’s a little bit of a dead end. So it starts on Monday morning. And it starts with an attitude of okay, yeah, come in, I’m gonna start off with the best I can, come in, rested, ready to go. And then as things start to fail around you during the day, you can absorb it, you just cannot absorb it, you got to let it be Teflon person bounce off of you. Because patients come at you hard these days. If something doesn’t come, right, the patient’s calling and they’re blaming you. It’s like my tooth didn’t hurt before you prepped it. So now it’s sensitive. Now what are you going to do? And so then or a temporary will pop off I call it the refactor. So anytime you’re redoing something or reappointing or recementing, or anytime you’re backtracking, it feels like pain to the dentist. It feels like Okay, wait a second, where did I fail. And literally once you get everybody in the your group and your team to know Okay, recognize the failure right off the bat, the phone call that’s coming, deal with it as quick as you can. And then just in the future, just try not to make that mistake again. Because we do learn it backwards. You have to learn it by experience, you have to learn, you have to make the mistakes, okay, you literally the only way you learn. But if you want to advance the envelope into wellness and comprehensive and put it all together, then literally you just have to go back to the kids. The only way you’re going to learn it. [Jaz]And it starts with a sound understanding of anatomy physiology, as it’s being presented to us in those textbooks, which I’m going to totally buy so and share it with everyone. Bobby, thank you so much for giving your time and your knowledge and your generosity and all these lovely things. I look forward to hopefully meeting you one day 2025 AES it’s going to happen. Who knows? Maybe someone listen to this in 2025. And think I wonder if Jaz made it I think I really do want to. So let’s see. [Bobby]Let me congratulate you too. Because it’s different now is because of people like you can you imagine it used to be okay, I would jump off and jump on a plane on a Thursday, go to a lecture, you know, lecture the podium. Now I missed the happy hours, I miss all of that sort of thing unto itself like that, but then go, then I’m back on Monday morning and I’m tired. Okay, and fine. On advanced, I taught I did it, you know, my career path, all of that sort of thing. But I gotta tell you, in this hour and a half, I’m probably going to reach 10 times more people because of people like you, because of the way we teach now. Okay. And you got to know that Dentistry has never been in a better place absolutely never been [Jaz]100%. And we need to hear that. I think our young colleagues, we need to hear that there’s so much doom and gloom. But I always emphasize that message. I’m so glad you echo it as well. Thank you. [Bobby]You’re very welcome. Jaz’ Outro: Well, there we have it guys. Thanks so much. Again, as always listening all the way to the end. I really, really appreciate it. It was a little bit more complex than that. I appreciate that. But massive kudos to Bobby Supple for giving his time, giving his knowledge, sharing his experiences, sharing his failures. You know, the whole occlusion was part one. We talked about all these full mouth rehabs, which are breaking down and sharing that information with us and letting us consider that actually is more to it. There’s a skeletal bite. There’s a skeletal difference. And it’s not just about the teeth At the dental level is high level, skeletal bite level. So I hope that gave you some food for thought and I’ll catch you in the next episode. Same time, same place

Only a dental superstar could do episode 100 justice! For this very special episode I have deviated from the usual flow – it’s kind of like a Vlog. We’re going to go through some major takeaways from the BACD conference in Edinburgh, when Pascal Magne came on stage and completely blew the audience away. We have Dr Ricky Bhopal some Protruserati cameo appearances! https://youtu.be/TINNRw1_iUM Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: If ever you wanted to read or just take notes of everything we’ve said on the podcast, just scroll down below the blog post. Every episode has been fully transcribed! Celebrate the 100th episode with us! Join the ‘Hoodie’ giveaway in three steps: 1. Follow @protrusivedental on Instagram 2. Share the promotional video on Instagram story, tag @protrusivedental 3. Tell us your favorite Protrusive Dental Podcast episode when you share the story or in the comments! If you are interested in the RipeGlobal Fellowship in Restorative Dentistry (FRD) click here to learn more. “I think one of the things that really stuck out to me today from the course was that it’s not necessarily what some one person does, it’s what works in your hands.” Dr Ricky Bhopal In this episode, we discussed: The ‘Enamel CADCAM’ case Pascal Magne shared 13:27 Importance of the Ferrule effect 14:30 The fourth generation bonding system 15:47 Silane coupling agent 17:32 Ricky’s takeaway tip from the Pascal Magne 20:17 Managing PTFE for Interproximals 22:07 Click below for full episode transcript: Opening Snippet: Oh my goodness. Welcome to Episode 100, Protruserati. I'm Jaz Gulati, your host and it's so great to have you here. This is a special episode. To celebrate 100, We're doing like a documentary, mockumentary, vlog kind of episode, but I still hopes and give you so much value... Jaz’ Introduction: We’re gonna talk some key lessons that I learned and we learned even I mentioned about Ricky’s involvement in this from the BACD conference in Edinburgh, where Pascal Magne came and just absolutely blew the stage away. So some key lessons from that. But also speaking to other dentists, some of my colleagues, some of the Protruserati that have appeared on the podcast before and hope to make it like a fun and entertaining listen for you. Now before we dive right in, the Protrusive Dental Pearl for you is that you may or may not know this, now, maybe you do. But if ever you’ve listened to any of the previous episodes and thought, You know what I wish, like maybe you take notes, but some I know some of the Protruserati they show me on Instagram, they take notes of the episodes because they find it very valuable, very educational, which is awesome. I love that. I think it’s great to be an active learner. So if you’re taking notes, but sometimes you wish you could just like copy and paste segments of some of the things that the guests say or I say and like a little communication gems, then every episode is actually transcribed fully. They like about 99% accurate, my colleague Krissel, who’s like my scientific adviser, she does all the transcriptions, so you can check them out on the Protrusive website. Under the episode blog if you like, scroll down, and every episode is fully transcribed. So that’s your big pearl that if you ever wanted, like a database of everything that we’ve said on the podcast, it’s all fully transcribed and ready for you. And by the way, also to celebrate episode 100. There’s a little competition or giveaway on Instagram. So if you want to win one of the hoodies that, if you’re watching on YouTube and you can see that I’m wearing, the new hoodies are even better than this. They’re blue and gold. And it’s pretty cool. If you’re in a chance to win a hoodie, no matter where you are in the world, then log onto Instagram, share the promotional video that I’m putting on. You’ll see like the giveaway video, share it to your story. And tell me which was your favorite episode could be like any episode from the archive, which was your favorite episode to be in a chance to win one the hoodies and I will reveal who wins live on the 21st of December. So if you are a massive fan of the podcast, I really appreciate you and if you want to hoodie, I’d love for you to tell me which was your favorite episode by sharing that video to your story. So do check that one out. Main Episode: Okay, so back to the main episode now. So the date is 11th November 2021. And I was on the late shift. So you know I do like a late shift or early shift. So I was doing a late shift in Reading, came to our parents house in London, and all of the last month. Me and Ricky, Ricky Bhopal, who was a prosthodontist. He came on the podcast and we talked about Productivity with the Prosthodontist. So you may remember him from the episode. We’re like total geeks, right? So we were so pumped, we’re like fangirling over Pascal Magne. Like, I’m kind of embarrassed to share this with you. But we made a little rap, or I may I started the rap and Ricky said he was gonna finish it off. I’ll tell you how that went. So we’re, like, so excited and pumped and so quite cringe worthy, but I’m gonna play it for you, just so you get the vibe of what we were thinking. So I’m gonna play that now. What you’re gonna say Pascal Magne, comes to the land, the USA, A, B, C, D, E, F G, he’s going to teach you DME. Okay, so that was totally cringe worthy. I apologize that your ears had to listen to that. But I wanted to show you the vibe. I mean, Ricky is super geeky. And the plan was that on the flight, we’d be working on it together just for jokes. And you know, he’s a brother from another mother. It’s great to have him as geeky and as goofy as I am. But here’s the big problem. So the night before so 11th of November, we’re about to sleep, like, almost midnight, and with the plan was that Ricky was giving me a 4am wake up call. He said Jaz, don’t worry. I’ll call you at 4am. I’ll be at yours at 4:30am We’ll go to Heathrow or fly to Edinburgh. That was the plan. So I’m like, Cool. So 4am comes my alarm goes off. Okay. No call from Ricky 4:02, maybe I call Ricky. It’s ringing. Okay, but he’s not answering. Okay, so now I’m like, wait, what’s going on? He should be on the road. He should be driving, right? Then a few minutes later, I call again and I call again and now it’s going straight to voicemail. So I was absolutely shit scared. Because Ricky is a super organized person, if you listen to the Productivity with a Prosthodontist he’s like the 5am wakeup club. He is like super keen. And he was so excited for this it’s like on par with I’m sure it will be his wedding day right so this is huge. So for him to not pick up was a very scary experience for me. So as I was thinking did he oversleep something but it’s just not like him doesn’t make sense. But then when it start to go straight to voicemail, so it’s calling straight to voicemail and now it was coming up to like 5am And I was thinking okay, I gotta leave for the airport now what do I do? But I was actually genuinely scared right out from the bottom my heart I was scared that he maybe he was in a car accident or the only plausible explanation that Ricky is not here right now with me to go to Pascal Magne is that he’s dead, right? Because he just can’t missed Pascal Magne, can’t miss it. So I was like calling his brother. He wouldn’t answer, obviously, 5am. I was trying to get his dad’s number. I was trying to get his fiance’s number. Like I was literally, I was messaging all his like best friends and stuff. I was really worried sick. So I was ready. I was panicking. I don’t know what to do. So I decided, okay, let me just get to the airport. And then if he, if I don’t hear from Ricky, I’m not gonna fly to Edinburgh, because my friend might have died. And I don’t want to go to Edinburgh if my friend has died. And I mean, being serious, I’m not saying for dramatic effect, I was not to speak to Ricky, holy shit scared. On the taxi on the way to Edinburgh on the way to the airport, and on the way that I get the call from Ricky. So pick up Ricky’s call, I’m like, ‘Dude, where the hell are you?’ And he’s like, ‘Oh, my God, I overslept.’ I’m like, ‘Oh, my God, thank God, you’re alive. I’m just happy you’re alive.’ Okay, so he absolutely bombed it down to Heathrow, he missed the flight unfortunately, I was just grateful that he was alive, I took the early flight, he paid a significant sum to come later. So we never actually got to sit on the flight together and continue the rap. So you can be very pleased to know that that’s the end of that rap. And we didn’t develop it further, because Ricky came late. So that was a very scary start to date. So I reached the convention center. And I know that Ricky’s gonna be on the next flight business class, you know how Ricky rolls, and I know that he will probably miss the first two hours of the lecture. So I’ll be making notes for him. And it was a great vibe, great vibe of the place, the students that give you that sort of delicate badge and the goodie bag and stuff. And it’s great to see students maximizing these opportunities. So if you’re a student, and you had the opportunity to go to a conference to help out, and you get to absorb the knowledge for free, wow, you should totally grab those opportunities by the horns. So I think those students that were there, you did a great job and well done for putting yourself in an uncomfortable situation and going out of your comfort zone and being there. I think it’s absolutely great. So it was great to see some of the students there. Hello, to the future of our profession. So the morning of lecture starting a very inspirational way. It was a Neil Cunningham talking about his expedition to the South Pole and the North Pole to raise money for brain tumor research, which was really inspirational. And then of course, the man himself introduced by Tif Qureshi, Pascal Magne, I mean, what a presence this guy has, the way he comes on, the way he spoke the whole day, the energy was just unreal, like top level speaker, you know, I always admired the speakers that can hold an audience, a large audience for an entire day, these keynote speakers is absolute sensational. [Tif]Okay, thanks very much for asking me to do this. In short, it is fundamentally to introduce some of very special guest speakers all day. And I’ll just say, I’m not going to give a resume from Pascal, you can look that up yourself. It’s long and very glamorous as it should be. But I’d say that, you know, in my long career, there’s been moments where you watch speakers, you meet people, where there are key moments, I think, turn your direction. And usually, I think it’s inspiration that kind of helps you kind of make that turn over one of those years, I’ve probably so many of you have seen hundreds of amazing speakers, and you come to sometimes we’ll watch them and you listen to well, pretty good. But you go back to your practice. And you know, you’ve seen your patients a lot that stuff used to get quite quickly, except for a few people. And Pascal is one of those people who literally every day is my career, something he’s tried, I’ve learned from him some inspiration he’s given me, I apply that to my patients. And I think that’s why my career has gone the way it has because of listening to people like him over that time. So it does take a certain type of person, it takes a person who is highly skilled clearly, but also has the right ethos, has the right passion. And it’s just a good patently, a good person I think that comes through in everything that he does. So I’m going to, enough of me, I’m going to now say please Pascal come to stage and please entertain us all. If you haven’t heard Pascal before, I really do hope that you remember today and I think it will kind of go down with your dental history. So let’s give a round of applause. [Jaz]Obviously, I was not allowed to record any parts of lecture I just record like three or four second snippets just for this podcast, just show you the energy and the style of presentation. Sort of colors and everything was just great atmosphere. So well done Pascal, you absolutely blew the audience away. So many gem shared so from the lessons that you’ve shared. We’ve convened Ricky just geek out and talk about it over 25 minutes, which is coming in the next segment of this podcast, just keep listening. And me and Ricky just have like a debrief. I share with him what he missed in the first two hours of the lecture. And then we continue about some of the key lessons that Pascal shared on biomimetic dentistry at the conference and it was great because in the breakout room, there was a great food, great Pantsers, great to see everyone and catch up with Protruserati was so good to see some of you guys there as lovely to actually see in person. Pascal was doing the book signing you know, he’s like a some kind of superstar who’s doing a book signing. I approached him. I asked him to come on the podcast. So this is my letter to Dr. Magne, inviting him to the podcast. There we are Pascal is gonna come on the podcast, he just said it. The second most famous Dentist ever After GV Black man. Mehy, today you listen to podcast. Rupert’s been a guest before on the Suction Complete Dentures. So I just wanted to check the vibe. Are you been here for the whole few days or just today? [Mehy]No. [Jaz]Okay, just today. [Mehy]Yeah, I missed the last night party. That’s why everyone is hungover today you know, I heard [Jaz]You look fresh. [Mehy]I looked fresh? It’s good. [Jaz]Mehy’s on my naughty list for SplintCourse for signing on and not doing anything. So he needs to move. Rupert. How’s it going, man? [Rupert]Really good. Here yesterday, so I was at the party. So I’m one of those people who’s struggling today. That’s why I don’t sound quite as fresh as always, been a really good, Magne is on fire. So you’re gonna see some more of that I’m sure now. [Jaz]Tell us what the program you’re doing for BACD next time? [Rupert]So I don’t know if it’s been announced yet. [Jaz]Okay, imagine you were doing a program for a famous Cosmetic Institute. What would you do a program on? [Rupert]Well, it might be a [New boy in South well], but it’s digital dentures. So we can do workflows, analog, analog and digital hybrid, digital, compare and contrast and see what works for you guys. [Jaz]Mehy, what’s the vibe like him? [Mehy]Amazing. Amazing like a bit dead but. [Jaz]He’s alive. He’s actually alive. Ricky, how’s it feel? [Ricky]I made it man. I made it. [Jaz]This idiot had me worried sick. And he missed Pascal Magne’s first couple hours. You know some guy he idolizes. This is just you know, you need a slap. [Ricky]You can do it, man. [Jaz]I’m gonna delegate your mom’s slap for you. [Ricky]I slap myself for that one. [Jaz]I’m looking forward for the rest of day, man. I made notes for you. Which I’m gonna share with you guys as well. [Ricky] Thank you very much [Jaz] But this is gonna be epic. [Ricky]I’m going to start making some notes now as well. Okay, number one, make sure you wake up in time and go to Jaz’s house for 3am. And don’t miss the next flight. [Jaz]And don’t have to upgrade to business class on your next flight. [Ricky]Dude you know what they gave for business class? A ham and cheese croissant. And the tomato was so hard. [Jaz]You don’t get anything in economy. So there we are. Ricky, I can’t believe you’re actually alive. So here we are. In a hotel nearby, which was a, we didn’t book this one because of the cheapest, we didn’t do that. We certainly wouldn’t would never do that. We booked it because it’s very close by. It happened to be close by not because the cheap, convenient let say. Where the hell were you, man? [Ricky]Let’s just say my stag is coming up soon. And I just wanted to give you a taste of what it’s going to be like. [Jaz]Man, I was worried sick this morning. Anyway, I’m so glad you’re alive. And you came you only missed the first two hours of Pascal Magne, which was, how good was Pascal Magne? [Ricky]Oh, man, dude, this guy was absolutely phenomenal. Nothing short of excellent. I’ve read his book. The 2002 bonding porcelain restorations, you know that book I read that about four years ago. And I was just like this guy. Just amazing. He knows what he’s talking about. So I was really excited to see him today until I missed my damn flight. [Jaz]We caught the most of it. I’m just going to summarize a little bit about what he said in the first couple of hours when you weren’t there, actually. So basically, he showed this case and he apparently published about this in 2014. So I must have missed it. But he share this case whereby there’s a 14, not 14, there was like a teenage girl and her wisdom tooth was decoronated or coronectomy was taking place. And that crown, the wisdom tooth was milled to then provide her mother’s onlay. So this was, the material of the only was enamel and dentine bonded to enamel and dentine. Had you seen that case before? [Ricky]What the? I’ve never heard of that. [Jaz]So he showed that today. [Ricky]Wait, so from one patient to another patient? [Jaz]Yes. So this was from the daughter who need the wisdom tooth out anyway. And then he actually embedded it into the milling machine, [Ricky] and then actually milled the actual crown [Jaz] And then milled, the enamel shape was the same but inside of it was [Ricky] It’s like internal surface for the prep [Jaz] For the prep. So that was pretty cool. So you missed that. I wanted you to take that. Then he talked about the usual Pascal things I talked about. The ferrule, right? The importance of ferrule, and he’s very anti post. And all the studies show that you know, we all know already, everyone who listens podcast we know that already. Posts do not strengthen the teeth. Okay? The only function of a post is to retain a crown. That’s it. And what he was showing all the data that he has, and all these studies are out there already is that even those cases where you don’t use a post and you allow your composite core go into the canal and come out and essentially you got your block of composite as opposed, that was there was no difference in the failure rate compared to putting a post in so essentially don’t put a post but ferrule is king. Okay? Ferrule is King and I don’t think that was anything crazy they put there just promising data about the everX composite you know the composite with the fiber. Any experience with that? [Ricky]Yeah, I actually use everX flow dentine quite a lot for most of my posterior work and I really like the composite. I don’t really tend to use bulk fill too much, unless it’s for a core and I’m trying to build the tooth up quite quickly or if I’m you know, mid prep and I need to take an old restoration out but I think it’s a really good, really good material, you’re getting the reinforcement of the you know, the short fiber reinforced composites so yeah, I really like that, [Jaz]Definitely watch that space is more data emerges, but it definitely is a promising material. Now one thing that I think you’ll really love is we know that Pascal is a huge fan, not because he’s endorsed by them but because he’s done the research and he knows that the fourth generation bonding system OptiBond FL® is the best is like the you know, the highest gold standard, highest bond strengths, the higher filling particle in the natural bond part of it is the DC part of it is pretty cool. It’s good handling and whatnot. But here’s interesting things which Pascal taught me today which you missed, which I’m gonna fill you in. There’s like their fill Ricky in before we discuss a bit about when Ricky was there as well. The interesting thing is that he actually says don’t use a bottle bond system any so he likened it to like my son, Ishaan, when he was teething he had something called Sophie the giraffe. Have you ever seen these? [Ricky] No [Jaz] So Sophie the giraffe is like this famous French toy, which a baby sort of bite on the face for teething and stuff. And what they did one day is that they cut open a Sophie the giraffe, and you don’t want to see what was inside it, was just like gunk and bacteria. [Ricky] It’s all black? [Jaz] Probably, right? He didn’t show the visuals, but I can imagine it, right? It’s always in a kid’s mouth and all the leakage and whatnot. So essentially what you’re saying is that if you’re using these bond bottle for months and months and months and it’s open and stuff and you know the bacteria in the environment, viruses etc. It’s probably a contaminated surface also the filler particles probably sink to the bottom so he was not only recommending OptiBond FL® but he was had he had a big cross next with OptiBond FL®, the bottles is he’s actually saying Let’s use the uni dose system so that you’ve got the right amount of primer, right amount of a bond and they’re fresh and it’s like easy to shake and stuff [Ricky]Similar to when you’re using silane coupling agent [Jaz]Did he touched on that later for the listeners. [Ricky]we were talking about [Jaz]how that applies to silanation [Ricky]Yes, so you know that it was actually in his first book. He discussed it then as well ideally not using one bottle because you know everything is going to get a stink to the end of that bottle [Jaz]Just for any new listeners, any young, I got some students now listening. What is silane?When would you use a silane typically? [Ricky]Silane is where you’d want to be bonding on porcelain restorations. It just comes down to, if your porcelain contains silica Long story short, you want to basically be able to bond to those silica particles and that’s what the silane agent actually does for you. And then you’ve got your adhesive which bonds to your silane [Jaz]Silanated porcelain surface highly active surface. Brilliant. And so you don’t use the one bottle? [Ricky]Yeah, don’t use the one bottle. It may be cheaper but is it cheaper actually? [Jaz]Imagine it would be because two bottle system I imagine there’s gonna be a costing also the date, the expiry date. Yeah, so that’s a inconvenience factor that they run out of date sometimes but the yeah so by using two bottles is a fresh silane, is that the main point, right? [Ricky]Yes, so it’s all fresh. So same thing applying to the bond, bonding agents. Oh there’s Nickhil now. [Jaz]We’ve got Nikhil now as well. One of the beloved Protruserati. Nikhil come here, man. Show your pretty face. Come here. [Ricky]Show that bow tie. [Nikhil]It’s better not be live [Jaz]This is not live. So we were just recapping about the what I talked about how he loves the OptiBond FL® unidose and that was a pretty cool thing to learn. Yeah, and Ricky just added that you know, even when we’re using silane not to use one bottle, use two bottles. You were there for that bit right? Okay, fine. What was your like, what is that one thing that you learned today that you think wow, that was worth it might you know worth him coming, for me see him that this is the best tip. [Nikhil]He had many tips but I think the best thing about today was the inspiration you get from such eminent speaker, seeing his cases and aspiring to be like that is what you always you know, hope to see at conferences like this and this is probably one of the best I’ve been to for a long time. [Jaz]What about you? The best thing that you because you’re here You know, I told Ricky let’s do this. And Ricky buddy went and got his iPad. And he was making notes the whole time. So it just made me good, buddy. [Ricky]I mean, it depends if I can make sense of my own right? [Jaz]I know but anyway give your best tip before I talk about one more thing. [Ricky]I think I’m touching on what Nikhil said, I mean, very inspirational speaker, amazing to hear, like in the flesh. So many clinical tips, I think one of the things that really struck out to me was the use of ptfe, and the lack of sectional matrices when trying to close diastemas or black triangles. So he was saying that he likes to get ptfe and basically put it against the adjacent tooth and then actually make your composite against this. So I found that was quite interesting, because, you know, we’re kind of ingrained in our minds to always use whether it’s a clear strip, whether it’s, you know, I’ve used the Tor VM, anterior matrices. So I think that was [Jaz]It’s actually on that point, it’s actually a Tor VM is that the posterior matrix used vertically for that scenario same with SB 100 from the Garrison to, I find that good because it gives you so much control to get a nice neat finish but what Pascal was arguing is that when you use a curved matrix in an interproximal area, you get a point contact whereas he wants flat to flat broad but just seeing even the images, like it looks messy, like imagine you got ptfe on the tooth next, and you’re just pressing that composite up against the ptfe. For me, it just my OCD goes out of control, it is very messy, but this is the technique that you use. So before you tell everyone how you get around that and some tips on you doing it the Pascal way let’s call it, it’s called the Pascal and Ricky way. What do you at the moment manage it? [Nikhil]It depends on the situation if I’m placing a diastema then that way I find easiest [Jaz]Like the Pascal, Ricky way with the ptfe? [Nikhil]If it’s a class 4, I either use a strip or matrix depending on the shape I want to get. [Jaz]I quite like the mylar pull when you got some, mylar pull’s good, but you know when you have got the ptfe, how you managing it not being so messy and like the floss tearing afterwards and just just being a total mess? [Ricky]Well, I think first of all, having good quality of ptfe because you don’t definitely don’t want to be using like the cheap stuff that you can get out there. I’ll be honest, I don’t actually know where we order it from. Shout out to our head nurse who’s the one who normally orders everything. She gets some good quality stuff. But yeah, the PTFE quality, you want something that’s quite thick, you want to hold it taut against the tooth next door, you will actually floss the PTFE down. So it’s going into the gingival crevice of that adjacent tooth as well [Jaz]Do you find when you floss that PTFE sometimes just crumples up? [Ricky]So it depends on the floss you’re using. So I use floss tape. And when I’m actually flossing, I’m making sure I’m holding it really tall and holding it. So it’s like, it’s almost like a mini like mylar strip. That makes sense? So you’re kind of like really pushing it down. But I use this technique quite a lot when we’re doing injection molding cases as well, when you’re trying to like really isolate that gingival crevice region. And then to try and keep it less messy. The Applica Twist is an instrument from LM-Arte™ kit. So actually not, It’s not LM-Arte™ kit. [Jaz] Haven’t heard about it. [Ricky] It’s a style italiana so you got the LM-Arte™ kit, which has the five standard instruments, but they bought out like new instruments. So it’s a very thin flat plastic basically. It’s like the IPCL. So you can use that to basically really sculpt your composite. And then I like to finish it off by just taking that floss once I’ve put the composite on. [Jaz]Once it’s cured? [Ricky]No, no before [Jaz]Oh, okay, so uncured composite here. And you’re flossing. Yeah, it just sounds like so much mess and oozing. And [Ricky]I think one of the things that really stuck out to me today from the course was that it’s not necessarily what some one person does, it’s what works in your hands. Because Pascal showed us so many different techniques of how he restores using composite, the direct way, the indirect, semi indirect. And, you know, I think we, at some point during the conference, I think returned to both of you and said, You know, I don’t think I couldn’t do something like that. But you know, he shows that beautifully. So this technique is just something that I’ve abused in the past where I struggled with the mylar strip so I actually figured out by accident, but I’ll take give it a shot. Give it a shot. [Nikhil]I think he said himself, Pascal he said that my job is to give you the armamentarium and then you choose what works for you. [Ricky]I even wrote that down. “My job is not to tell you what to do, but give you options” [Nikhil]There we go. [Jaz]Pascal’s job not telling you what to do but to give you options guys listen, we have to have to the party now that’s why we dressed up with a gala dinner. And thanks for listening to this one. I gave Pascal the invitation as you know, and Pascal gave him Ricky an Indian blessing, which are the whole videos will be on it. So thanks for listening and hopefully Pascal now following on from this come on. And you can blame Ricky for not making a more proactive podcast today because of him missing his flight. Thank you. [Ricky]It was, in my defense. Many things happen. It was a series of unfortunate events that cascaded sequentially, progressively getting worse [Jaz]When airplanes fall, it’s never just one thing. It’s like a multiple, it’s not because the pilot was drunk. It’s because the pilot was drunk and the copilot like is not having a great day. And there’s like a scratch on the engine and someone forgot to like twist a knob or something somewhere. And that’s how airplanes fall everyone. So shout out to Nikhil Kanani there was a great to catch up always great. I always see him at conferences. He’s such a great guy, and he was part of that as well. So Nikhil, Ricky thanks so much for making Protrusive what it is with this episode and sharing some of the nuggets and your vibes from Pascal Magne lecture. And it was great to have the party at the National Museum which was absolutely beautiful. What a great venue that was. And then the funny thing is when we got the flight back in the morning. You know Ricky being Ricky completely liking I used to hold him in such high regard. I still do brother, don’t worry, like high regard like what an organized guy, right? But anyway. We get to Heathrow and because he’s parked at short stay carpark, he had a very interesting parking ticket, let’s say, which I may or may not reveal what it is. And then while he was going to drive me home because I live quite close to Heathrow and my parents live quite close to Heathrow Airport. The next curveball was that Ricky had no fuel. So we were on reserved fuel, trying to get to the nearest fuel station, which was again a super stressful experience for me. And I’m still playing little segment from the end of the trip me and Ricky just having like reflections of the day of our interesting and fun day, educational day at the BACD. [Jaz]All right, we’re back. Back in London, got a flight back now. End of BACD which involves Ricky driving us on reserve fuel to nearest petrol station. [Ricky] This looks so bad. [Jaz] Paying 147 pound parking fee not even a like a fine. This is how much the short stay car parking for two days. If you just look like it was like two days and like five minutes in it. You come 147 pounds on parking, guys. That’s crazy. Anyway, Ricky, i just want to ask your reflection on BACD conference 2021- Seeing is believing. [Ricky]Seeing literally is believing because the first BACD I went to a whole deck, the organization’s pretty phenomenal, venue was amazing. Obviously Pascal is absolutely brilliant. And then a lot, met a lot of cool people. [Jaz]And you found out that next year it’s in Wales and a certain Frank freaking Spear. Frank freaking Spear from Arizona will be coming next year. So you better believe I’ll be booking my ticket to see Frank. Probably go to the whole three days. You’ll be there, right? [Ricky]Yeah, that guy’s amazing. I actually signed up to his online course back in 2006. [Jaz]I’ve learned so much from Spear Online, really great educational resource. So I’ve got a lot of time for Speae Academy and whatnot. Love to go to Arizona one day, but Arizona is coming to us. So next year, Wales, November BACD. I’m looking forward to it. I’ll see you guys there. Hopefully me and Ricky will not be on the same flight because I can’t deal with like a couple of hours with him and I’m gonna get hardtack so also he was snoring the whole night and he’s got sleep apnea like moderate to severe so I officially did his sleep test before him [Ricky]I’ve got a mandibular ?? for tonight. [Jaz]He wasn’t wearing it last night. So peace everyone. Jaz’ Outro: So there we have it guys I hope you enjoyed this slightly different episode if you enjoyed it let me know. If you don’t like this kind of thing let me know as well. I’ll try and do less of these. Hope some of the lessons we shared Pascal Magne which by the way has been in touch with Pascal he’s keens to come on, but he’s such a busy guy. So we’ll see when that happens, but it’ll be great. Pascal, it will be great to have you. So if you’re one of my listeners in USC, University of Southern California and you see Pascal all the time, just give them a little you know, elbow in the ribbon say yeah, when are you going to go on the Protrusive Dental Podcast, okay? Just get him to warm up a little bit. Okay, so I appreciate you guys so much for listening to this 100th episode. I look forward to so many more. The Christmas break is coming up now. I’m still going to be getting a few more episodes but the big thing, the big thing I’m focusing on now is the app like the app is coming. And this is so that all the listeners who want to can get CPD ie CE verified certificate, you can answer some multiple choice questions, give some feedback. And that way you can get a verified certificate, you can get a few other extra perks. And it’s a bit like a membership. It’s a bit like a membership thing. But for those people who listen to Protrusive all time, I think you’ll gain so much value for it. So that’s the main thing I’m working on, as well as the 21 day photography challenge, which I’ve told you about as well. So lots of big things coming at the moment. I’ll keep you posted. But thanks again for listening all the way to the end. I always really appreciate it. Thank you so much. And if this is the last time you listen to protrusive this year, I hope you have a very happy Christmas. I wish you and your family all the best of health and a very happy 2022.

It’s the ultimate question: Which is the best Occlusal Camp/Training? Is there really a difference between Occlusal religions? Is Kois better than Spear and Dawson? Do you really need to study each one of them? Hear what Dr Bobby Supple says about the ‘Occlusion Wars’! https://youtu.be/tlhrBcodzbA Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Check the Video on How to successfully give lower first molar anesthesia using buccal articaine (without an inferior alveolar nerve block) https://youtu.be/cCXacw5DE4M “So, as it kind of turned out, they were all the same, except for neuromuscular. Neuromuscular was the odd one out.” Dr Bobby Supple In  this episode, we discuss about History of Occlusion 14:35 True Meaning of Anterior Guidance 17:04 Bio-Aesthetics Group 22:015 Different Occlusal Religions 27:31 Equilibration 41:19 Airway and TMD 51:12 Differences between Occlusal Camps 52:09 If you enjoyed this episode, you will love Myth Busting Occlusion and TMJ Click below for full episode transcript: Opening Snippet: (Jaz) I think you said that when it comes to the Spear group, Kois and Dawson, what I think what you're trying to say is really they're not too different. They're just arguing a little bit about slightly different ways to fix the problem. Would you say there's any more nuances or differences that perhaps we didn't go into that is well worth mentioning between those religions? (Bobby) So, as it kind of turned out, then they were all the same, except for neuromuscular. Neuromuscular was the odd one out... Jaz’ Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome to Occlusion Wars episode 99 with Dr. Bobby Supple. This episode was inspired by a blog post I saw Dr. Bobby Supple right in his website. And it was about the differences between the different occlusal camps or these occlusal religions. Hencewhy the name occlusion wars because the most common questions I get is Jaz, What should I do? Should I study with Dawson? Or should I study with Pankey or Should I study with Kois or Spear and neuromuscular? So there’s a lot of these occlusal religions and that’s what we call them throughout this episode, you know, tongue in cheek kind of thing. And which one is the best one, which is the correct religion. That’s what we’re hoping to answer in this episode. And the main question I asked Dr. Bobby Supple was exactly that. And really, I don’t want to give too much away from this episode. But one thing to consider is that the end goal of no matter who you train with, whether it is Spear or Pankey, Kois whoever. You will do wonderful dentistry, you will do it for the benefit of the patient, you will have more fun as a comprehensive dentist. So whoever you train with, just do everything they say and do it properly and follow that system. But don’t be afraid to expose yourself to other ways of thinking because essentially, what these religions, these occlusal religions argue about is the processes. How do you get from A to B, the B is the same, A is the same. A is your patient. B is a stable position, whereas a better smile, a nice comfortable bite, all those things, right? So A and B are the same. What we’re fighting about is everything in the middle. And that really doesn’t matter. We should be outcome based ie a longevity in our restorations, happy patients. And I think all those whose religions deliver exactly that. That’s one of the sentiments that Dr. Bobby Supple passed on. I just want to echo that. Now if you want to really skip to that bit. It’s probably somewhere in the middle to the end of the episode where we really get to nitty gritty. We start off in this episode, discussing the origin story. I mean, origin stories always really powerful of these clinicians that we speak to Dr. Bobby Supple has so much experience to share. So we learn about his origin story, but also the origin story of how it goes from gnathology to then Pankey to then Dawson, Spear and how they came about in the east coast and west coast, the bio aesthetic group, how that played into it. And eventually, in part two, we’ll cover something really deep I mean, the direction this podcast goes in is really thought provoking, essentially, that the message is that we find these patients who have destroyed their dentition. And we’re arguing about how we’re going to restore this destroyed situation. So we’re all arguing about how to restore the patient. Whereas what Dr. Bobby Supple says that we need to think preventatively, we need to screen our children for airway issues, and consider the correct assessment at the right age and nasal breathing so that we can avoid those bigger issues in the future. So it’s amazing how much of a tangent we go into in terms of posture, airway, which really is the biggest growth area in dentistry in the next 20 years and I’m sure of that. Now, if you’re new to the podcast, Welcome. Thanks so much for listening on episode 99. Almost 100. Wow. Okay, so if you’re new to the podcast, and a lot of the episodes are occlusion based, if you are new to occlusion and your knowledge of occlusion is quite basic, and you haven’t started with big schools or big occlusal religions, then maybe want to go back to Episode 90 basics of occlusion. This is again for the season occlusal practitioner, who has been to maybe a few of these occlusal school thoughts and this loves to learn about what the different camps have to say. So this is really made for the ultra geek when it comes to occlusion, but you can still listen and follow along I think I’m sure you’ll gain so much from it as well. The Protrusive Dental Pearl I want to share with you for this episode is something that you guys have requested, the community, the protrusive dental community have request this for me, and I’ve now finally delivered, okay? It’s about how to give a buccal infiltration for a lower first molar. So a lot of people still doing ID blocks which is fine. I still do ID blocks but I’m doing them way less now compared to five, six years ago when I wasn’t using buccal articaine for lower first molar. So pretty much the only time I’ll be giving a ID block or an inferior alveolar nerve block is if I’m doing an extraction of a lower second molar or a wisdom tooth. And most other scenarios, I’m doing infiltrations with articaine. So I have a video that I’ve posted to YouTube. I toyed with the idea of putting it in this video, but I think for my audio listeners, it just won’t make sense, you want to see exactly where I insert the needle and how we do it. And again, everything that I’m sharing with you guys is stuff that has been taught to me over time. This is nothing new. I’m just passing it on. I’m trying to make it tangible for some young dentists who haven’t done buccal infiltration successfully or you’ve done it before and you found that the anesthesia hasn’t been sufficient. I’m going to share the secrets with you through a clinical video which my patient kindly let me record and that’s going to go on YouTube. So it’s going to be the Protrusive Dental Pearl is how to successfully give lower first molar anesthesia using articaine Without an inferior alveolar nerve block. Anyway, hope you enjoy that. And I’ll catch you in the outro. Here’s quite a long and meaty and geeky episode with Dr. Bobby Supple. Hope you enjoy. Main Interview:[Jaz] Dr. Bobby Supple, Welcome to the Protrusive Dental podcast. How are you? [Bobby]I’m well today, thank you from the US. [Jaz]Thank you so much for coming on. It was a Thanksgiving yesterday and you had some lovely family time, we just catching up before I hit the record button. I had been super excited. I mean, for the listeners that I know and everyone kind of has got the feel for the podcasts now, Protrusive Dental podcast, the cornerstone of this podcast is furthering ourselves in the field of occlusion and learning from lots of different educators. Amazing to have you on today, someone who’s done so much recently. I’ve seen a lot of stuff on digital. But I initially found out about you through a Google search. I was at one stage looking for the differences between what we’ll call the different occlusal religions if you can use that term, you know, what’s the difference between Dawson and Kois and Panky and Spear and neuromuscular? And I came across one of the articles. And I thought okay, I’ve got to get this guy on. I’ve got to get Dr. Bobby on to share with my listeners, because this is something that confused a lot of people, like many things do outside dental school, and I’m just looking for some clarity to pass on. I personally, Bobby, I want to learn about you in terms of which religions you have prayed with. But I have prayed with Dawson. You know Ian Buckle I’ve done you know the Dawson Academy UK. I’ve done lots with Spear Academy online. I’ve done where my mentors and my principles in the past have been Pankey trained. Michael Melkers, Hap Gil. So I’ve got a bit of a background. The only people I haven’t really had training with is neuromuscular. So how about yourself, Bobby, tell us about yourself, where you are? And what is your pathway in terms of the schools of thoughts when it comes to occlusion? [Bobby]Okay, and that’s a long story. But I’ll try and make it as quick as short as possible. I was at Tufts, I went to dental school at Tufts. And I’m now, I got started in [pre clan] on my first day by a lab partner. His name was John Sumaha, his dad was actually head of prosthetics at Harvard. And John did all of his dad’s lab work growing up. And so I was that Thanksgiving. So that was I don’t know, but 40 years ago, almost did the day. And then John invited me to New Hampshire because I couldn’t. I’m from New Mexico. So I didn’t go home for Thanksgiving. But anyway, I’m sitting literally after three months of dental school, with the chairman of prosthetics at Harvard at his Thanksgiving table. So John learned it all from the lab. So I learned it from the lab perspective. And so then out of a no free claim partner that knew all about occlusion and everything like that, and I got off to a awesome start. I had a tremendous dental school experience. There was a another prosthodontist at Harbor, Tufts, his name was Lloyd Miller. Lloyd Miller had a laboratory in Boston. And you had to be somebody just to send your stuff to this lab. Everything had to be fully mounted. And Lloyd Miller was a good friend of Peter Dawson’s. When I finished dental school, I was broken. I wasn’t gonna really hang around in Boston too much because it was gray and cloudy. I’m from New Mexico. So back to the sunshine in the southwest. But Lloyd Miller, he told me Look at your why I need you to just start at Pankey when you’re ready, go to Pankey. So then it was like two years later. So there’s 1982 then I started at Pankey Institute, and then that just got me just often run. And I have to understand growing up as a kid as a swimmer, I hit my jaw on the diving board. I broke my jaw here and here. So I had a condylar fracture was the surgeon in the orthodontist who put me back together, who got me interested in dentistry, so I had no family connections or anything with dentistry. My dad was an engineer. So it was more was the artist person in the family, the odd person out but What happened is simply I was just always always interested in TM. So I’m at dental school, didn’t learn much about my job, that sort of thing. But we didn’t know, we didn’t even have imaging. We didn’t have panels. We didn’t even have anything that could just like image the joints and anything like that. And so when I first went to Pankey, there was a guy named [??] and he had written the radiology textbook that I have studied for my boards I walked in, he’s like seven years old, one of those pure, pure master teachers. And I go, I know you, because I had to study you. And I told him my little story, he sat me down, he did a transcranial and just kind of talking about the lateral Pole in and I’ve literally going, Wait a second, I’m in a world that I know absolutely nothing about. So I kind of made it my life’s work. And then that started me on the journey. Now quickly in Pankey, you just, you go through these curriculums in continuums and things like that. So I was through Pankey pretty much by the through the 80s. There was a gentleman there named Parker Mahon. Parker Mahon was Peter Dawson’s roommate and confidant in dental school. He ran the Florida occlusal pain management from the University of Florida, but he was this Master master teacher. So I did all of my job, dissections with him. And then the real breakthrough started way in 1989. I went to with my fiancee at the time, and we went to St. Thomas Virgin Islands. And there was a week. And the week was Peter Dawson, Parker Mahon and Mark Piper. So they called it the Peter Parker Piper show. [Jaz]That is fantastic. [Bobby]It was a week where you were just literally on the beach at times back and forth. And so I got to be tremendous brands with all three of them. And then I just Mark Piper, he was my TM coach and Pete was my occlusion coach and Parker was medical and TM and dental and all that sort of thing. And so that’s where I got the whole big start. So basically, I’m Pankey born bred Dawson prototype. So I understood CR or the concept of centric very, very well. And then now I’m in New Mexico starting in the 90s. And then now the occlusion war sort of started. Honestly, he called it blood on the walls. He actually liked that, he wanted the fight. He was always up for the fight. So he actually was a proctor. And so when anytime another philosophy kind of came into the scenario, then he wanted the debate. Okay? [Jaz] Excellent. [Bobby] In New Mexico, I’m in a different scenario because I’m in the middle of the country. Pankey, Dawson Academy had not started yet. So the east coast was definitely all centric, oriented. Just put condyles back in the sockets go from there. Okay? And then what happened is the gnathology group was the very first one that I was with, No, they were actually pre Pankey, the nathologists were the ones who invented the Charlie Stewart was fully functional articulators they were into gold, and they would do the points and back and lines in the Front and all of the when you would put it on the articulator, but they were the ones who actually invented the articulator, so they were working through it. The problem with gnathology is that you did all your adjustments on the articulator and everything was done in gold. So you would do gold and you’d have these buttons. And then you would seek the whole case, a Peter K Thomas and some of these brains in the, you know, the history of dentistry, but then they would take off the little buttons, put it back on it, remounted, do all the adjustments on the articulator and come back because they actually believe the articulator was better than now. So that’s kind of how, that part of it started, the natholology guys, they sort of went out of the way because it was way too hard, way too much work. You’re always remounting. And then the whole idea is that we weren’t allowed to adjust in the mouth which turned out to be their downfall. [Jaz]So Bobby, you can argue that the gnathology to practice, like an gnathological dentist, it was not practical and not universal and the point of entry was perhaps too high for someone who wanted to be pragmatic dentist. [Bobby]Absolutely. But the concepts is what we learned in dental school. We like point groove mesial buccal cusp and mesial buccal groove, slide, all of those sorts of things. So, we actually learned all of the gnathology concepts when we first picked up our very first articulator in dental school. Alright, so the next group that kind of came around was a group called Bio aesthetic dentist. Bio aesthetic came out of Southern California, Bob Lee was the general behind all of that. And then, so that they put condyles in centric, they totally believe put them in CR this, they come back and CR but then, then you had to add, not subtract, okay? So they would add composite and a new build up in and everything was all pointed cause so if you were wearing down a canine on one side, and oh my gosh, you have to stop now you got pathology going on. So you got to build back the canine and get all the points back. And so their concept was build up all the anatomy in the front, don’t let it all wear down. Okay, now then, we got into a problem with terms and words because the word ‘Equilibration’, at that time was under attack. So this is in the 90s when Equilibration first started getting attacked. The biosynthetic endace would do what you would call negative coronaplasty. So it was okay for them to adjust the tooth but if you called an Equilibration, then that was nicknamed mutilation. And so Equilibration became mutilation. And then what you were doing is you were just subtracting and everything you were just cutting down the backs in order to get to the trends when they’re thinking was No you have negative coronaplasty but you also have positive coronaplasty. So then by doing composite and adding so, it was sort of the add and subtract. And to this day, I still use those concepts. I’m still use composites and I’ll build some things up in the front and that sort of thing. Okay? [Jaz]Just to make the bio esthetics, tangible, I mean, it’s essentially re-gain anterior guidance and then fill in the spaces at the back to the new vertical dimension. Is that a philosophy that the sums it up well? [Bobby]Yeah, exactly. So you can still use that. So in a sense, what they do is they put him in, they wind up lay close all the way down till you get the first point of contact. Okay, so now you have your first point of contact. So Dawson calls that your anterior control. Now you have to know that the word anterior has been bastardized in dentistry because to the master dentist anterior means anterior to the condyle. We think of anterior as anterior guidance. Anterior guidance is the entire occlusion. We think of it and fond of it as canine disclusion. So all of dentistry thinks, Okay, well the anterior guidance is from canine to canine, when in reality, anterior guidance is from second molar to second molar. So if you close down and the condyles are seated, say young, okay, when there really isn’t any kind of damage or anything adaptations, things like that, you can put them back pretty much every 14, 15 year olds condyles are fine and you stick them back in the condyle socket, goes down, and then that’s your first point of contact. No, that’s called your anterior control, though anterior means in front of the condyle. So you may have a posterior teeth controlling the whole entire occlusion. That’s how I got started with the T scan. So back in Tufts, so T scan came out of Tufts, I go back for my five year reunion. I’m with all of my, you know, dental school teacher friends, but they were into the T scan at that time, because there was a guy named Dr. Magnus who taught so T scan came out of Tufts. So then they’re one of my other professors. He just goes, No, you got to look at this, Bobby, you’re going to love this, you’re just going to absolutely love this. And so anyway, then I became an early adopter to the T scan. So I had a T scan back in the 1990s. So now you’re looking at 30 years, and gone [Jaz]30 years before me, Bobby, because as some of my listeners now know I’ve only recently just got my T scan. I’m about four weeks away from it being delivered at the time of recording. So I’m super excited. And I’ve also recorded with the [Rob Kurstin]. It’s not been published yet. Maybe by the time this comes out. And maybe so we’ve discussed a little bit about the T scanner. So my listeners know a little bit about the T scan research and the applications. [Bobby]Perfect. So I’ve gone through now six, seven generations. So now we’re at T scan 10 Sorry, four, five years, it’s like your cell phone, it comes back out and things like that. And so each generation had a you know when upgrade and that sort of thing. Okay, so we’ll talk a little bit about that later. But the T scan, what I would do is I would literally look for my anterior control. So I wanted to know what was the first tooth that touch, which teeth touch, how hard they touch it and what sequence that they touch into so then, Dr. Dawson, he loved the T scan. Christensen, Gordon Christensen loved it. So I’m in his office in Utah, and there’s his T scan in it, and Dawson had it in his operatories. And so, you know, one time I just asked Pete about it and, and he goes, Yeah, well, we use it in the laboratory all the time. So Dr. Dawson’s dad was a dentist, he grew up in the lab, so he would been doing his dad’s work since he was six years old. So anyway, in the lab, then what they would do is they would take the T scan out the models, and then check it on the models and then go to the mouth. And so then they were using the T scan to check the validity of their mountings to see if they all match that well. Lo and behold, things match up pretty damn good. But you kind of started to realize no, the problem is that the mouth is a little bit more perfect than the articulator because you have flaws where you would take the impression, pour the models and then mount it and all of that sort of thing. So we were close with mountings. But guess what? We never really ever did hit a homerun when we mounted it in, send it into the lab, because you always knew that as a dentist, it would come back but you will always have to do some kind of adjusting in the mouth. Even as close as nice as the dentistry in the lab technician might be. But anyway, that so that’s the whole sort of T scan story. So the bio aesthetic guys, they actually were a bit of a problem in my community because there was a number of bio aesthetic, and they were anti equilibration. So for a little while, it was sort of like I was under attack. But my MO was the T scan and I would sit down in my study clubs, we were in RB Tucker gold study clubs. These are my friends. I mean, I grew up with them in dentistry, we just had a different philosophy of where we were coming from, from an occlusion standpoint. [Jaz]Can I just ask on that regard? You mentioned that bio aesthetics, they had this term called Negative Coronaplasty. Just to make it extremely obvious, for those listening and watching. Do you mean that essentially they were equilibrating, but they didn’t want to admit they were equilibrating, Is that what you’re alluding to? [Bobby]Like Kois, Spear you know, yeah. So yeah, they waited, adjust a cusp tip. But then their concept was, well, we’re never adjusting vertical, we’re just adjusting like left and right lateral slides and things like that, which is fine. But they were adjusting nonetheless. [Jaz]But they’re very much prescriptive in terms of I believe it’s one of the measurements they prescribe is that between the gingival zenith of the upper canine to lower canine it must be 19 millimeters and whatnot. Were they quite prescriptive in those sorts of parameters? [Bobby]Exactly, exactly. They would have it all mounted up in CR, okay? Because CR hadn’t really been totally attacked back then. It really wasn’t adapted centric and things that, that was coming next, that was the next fire storm with because you have imaging in the joints. And then now you were starting to see changes in the joint so that all fired up with the neuromuscular guys that came if the year at the turn of the century. But what happened later in the 90s is occlusion in the US switch from what we would think of as East Coast and West Coast. So you had said Southern California, the gnathology and in east coast was all the centric type guys. Okay. Yeah, bio aesthetics was in there. But it all moved to the northwest part of the country. It all moved to Seattle. So at the Pankey Institute, you would have Dawson masters week. So Pete Dawson every year would have a week and then so I would go, but he always brought in that guest. Okay, so his guests were Kois and Spear, you know, they were the best in the world of dentistry Piper. So I went to two of those, but you’re sitting in an entire week, and then you have Dawson and Spear in the same room for a week. Okay? But this was before Frank was famous and had gotten into it, but the thinking was coming all out of Seattle, Kois, Spear says ortho how you bring ortho into it. And then they formed what was called the Seattle Study Club. So the Seattle Study Club, we had a branch of it in New Mexico and then every quarter you would get a magazine and the magazine would have people’s pictures on it and things like that I should running show you real quick and then a whole stack of all these beautiful beautiful Seattle Study Club pictures and things like that. And so then every single quarter then these magazines would come out but then what they would do is case, So hang on for just a second. You can talk to your audience. I’m gonna go grab those [Jaz]Yes, please. Yeah, that sounds good. So, while Dr. Bobby gets those magazines were very amazing to have him do that. So those who remember, you can watch these episodes on YouTube. And on Facebook, I post snippets on the Instagram @protrusivedental. And a lot of people they like listening to the episodes as they’re driving, commuting. Some people may chop onions, while it’s in the podcast, we know that already. And then of course, for those who want to watch the full experience, they catch it on YouTube. There is the app coming out soon as well. But I’ll keep you updated on that. [Bobby]Okay, so every quarter, you would get a magazine. So four times a year. So we got Kois, you got Spear on the cover. You got everybody. I mean, [Jaz]These are amazing. I love it. [Bobby]Yeah, there’s Peter Dawson. So each one of these would have a case and then there was perio probate and then they would have it and it was, then the case was done, start to finish. Oh, my gosh, it was a textbook every single quarter coming in. [Jaz]These are essentially like for these full protocol cases that are coming. And what we see now Bobby is on the way that learning has become a social experience now with social media, we see these full protocol cases, so much, and then I do believe it’s never been a better time to be a dentist than now, if you’re hungry for knowledge. These cases are great dentists are sharing their full cases, full six point pocket chartings to mountings. Everything the young dentists can learn so much, it’s almost accelerates your learning pathway, compared to when you had to wait a quarter to get that magazine without one case in it. Now you can literally binge case after case after case and you can reach out to any mentor in the world. [Bobby]Oh, no, you’re exactly right is never ever been a better time. And honestly, these occlusion work, they’re all over. We’ll talk about that the second half of this whole thing because we’re now, so for myself, we’re decade almost two decades out in front of all of this, but you’ve got the idea. So that was pre internet. The Seattle Study Club, like you said, it’s every quarter, but I couldn’t wait I’d salivate the next time the magazine, who’s going to be on the cover. You know, [Jaz]I love you. I love you. I’m so glad [Bobby]You know, it always coming from the Northeast, is all coming from Seattle. And then that’s where then the Spear Institute employees. They started there. You had Colin one of the greatest orthodontists in the country. And so these guys were all in the think tank. And if you ever heard any of them lecture like Frank lecture, you just knew that you were in the presence of some kind of Saint that because the way that they would talk about vertical and then it just all made sense. So anyway, they were all centric guys. They were literally they all grew up with the whole concept of CR and putting it back when and they knew the imaging and they would address the joints with the perio with everything else. Now the puzzle part that they actually did not have that came in real quickly at the turn of the century was the neuromuscular guy. So Jake Wilson, he’s out of Seattle, so he’s into posture, airway, tongue, swallowing, breathing, okay? Now this is where I kind of really ended up in a situation where I was one of the few people in the country who was seeing it from all sides. So at the turn of the century, I switched my practice to instead of prosthetics, I mean, we were into empress and gold and everything like that, but I knew that every acute problem had a chronic condition, a crack and abscess and everything like that. So I’m going okay, well, when does this start? Where does it start? How would a dentist then learn about occlusion from beginning to end because what happened is, we would wait till it all broke down, and then argue about how to fix it. In just absolutely, it was like politics, you would just blast anybody that didn’t have your kind of philosophy on how to fix it. One of the philosophies, religions, as Christensen called them, he called them religions. Every one of them was if you did it perfectly worked. So you can’t not say that they don’t work and we learned stuff from all of them. Seriously, I learned a lot of things from the biosynthetic doc. So it was it’s not like any of these things were bad. Okay. It’s just that we couldn’t agree. So at the turn of the century, I joined two I joined the American Equilibration society, of which I’m going to be president in 2025. So be careful when You [Jaz]Amazing. I will come to Chicago to go to a conference. I look forward to it. Amazing. [Bobby]And it’s going to be international. That’s going to be the whole [Jaz]Amazing. Yeah. [Bobby]So it’ll be incredible. Anyway. Then I also joined at the time what was called the American Academy of head, neck and facial pain. So two groups, both of them said, we’re the best in the world at TMD. And then I would go to each of them, each of the academies and it was you were on two different planets, you were literally not even talking the same. And a lot of the head neck and facial pain guys. It was started by an orthodontist, a Brendan Stack, and Stack was the airway guy. Stack was the orthodontist who went okay, the cranium is a criminal. It’s all up in the here. It’s all about how the face grows in the mid face, cranium grows and things like that. And they were the docks that were the first ones into the airway. At these docks, were not really dentist per se, they weren’t clinical dentist. And just down the street was somebody who was on the board. His name was Dan Clifford. So he kind of mentored me, he was the one who got me into this group. But they did not practice clinical dentistry. They literally practice plants, TM, posture and things like that. Okay. They were the ones that jumped in there. And then they said, okay, the condyles do not rotate right out of the starting blocks symmetrically. So they are for CR sucks. So you knew, anytime a neuromuscular dentist was on a podium, they would start off, and the first thing that they would say is, you know, there are seven definitions of centric. So therefore, we don’t know what centric means. And they were the ones who literally machine gun down. They just wanted to destroy it. And they said, like, Dawson is wrong. He’s like, these condyles don’t rotate outside, but one always will translate before the other finishes rotation and back and forth. So therefore, the concept of CR is no good. Blow it away. Jay Levy, today actually wants an eighth definition of CR. He wants to add the Atlas into it, because we’ll call out okay. We’ll do this quick little demo. And Neil kinda understand how posture fits into this real quickly. [Jaz]And while we’re on that, Bobby, if you don’t mind, it’s just going down with a small mini tangent, the definitions obviously, keep changing. And nothing’s created more interferences than the changing definitions, the old recurring joke, obviously, but with the latest definition, it’s funny how there’s no mention of the disc. There’s no mention of the disc or being in a stable position on the condyle, which a lot of people were like, well, what’s the point of having definition if you don’t mention a healthy disc to condyle relationship, so? [Bobby]No, no, you’re right. It’s a theoretical position. So centric means center. And relationship means the relationship of the condyle to the fossa. So you kind of wanted to get it up into the fossa, like Dawson was start with a ball and take a pencil and put a pencil on the ball and then and hold the pencil like that. And then with the ball didn’t tilt, and that was called CR. So it was a theoretical relationship. Now the problem turned out to be it wasn’t the condyles in the disc itself, it turned out to be the sockets, it was the socket center of the problem. So if you have an airway, like a little deviates up into one sider, we’ll get into what’s called Epigenetics, when you have allergies, postnasal drips, why the tongue creates this asymmetry in the cranium. So all of the asymmetry is across the mid face. So if the airway is off, and then one cheekbone is off center, and one year is off a little bit to the difference, and you’re looking at it, or you’ll see one eye tilt down a little bit. Anyway, what simply happens is, you have cartilage base growth. So in an infant growing, so when you’re born, then you have two types of growth patterns in the cranium. So you have what’s called the Cartilage Paste. I’m going to show you a little like picture here if you can see [Jaz] Yeah, sure. [Bobby] Okay, so this is an article that we wrote, it’s called Epigenetics, okay, because this is why we’re in trouble. And this is why dentistry is going to be at the forefront of healthcare for the next couple of decades is like so unbelievable. Okay, but look at, there’s two types of growth patterns in the skull. Okay, so this is cartilage based. So when you’re born, okay? Anything to do with airway, anything to do with your nasal airway, including the sphenoid bone, okay, because that’s the rod in the middle, it’s cartilage based. The mandible is cartilage based. The hyoid bone is cartilage, okay? So they grow by cell division, but that’s your basic architecture inside the cranium. Alright, so all that grows for your ability to breathe and swallow because the brain wants oxygen every few seconds. And so literally as a child, if you’re born premature your tongue swallow reflex isn’t really mature. So in the last month in utero, that’s when the swallow reflex is set. So literally, the infant is just re circulating embryonic fluid, like oil in a car. And then when you’re born, you gasp. Okay, so that reflex is started. Now, that is the exact same reflex that you have in apnea, close, swallow, squeeze, stop breathing gasp. So you start your very first breath off of a reflex and in breathe, okay? Any child then who can actually breathe through their nose correctly as they’re growing all the way through age six. So what you have is what’s called an infantile swallow and infantile swallow is where you swallow, breathe, can breastfeed. And so between zero and six years old before the first molar come in, your tongue is your bite splint. Your tongue is your splint, it’s suckling and swallowing and everything is set. But as that child swallows in the tongue, so anything from a tongue tie to swallow back, but if that child has allergies, then you have a post nasal drip, and in the back of the tongue is not going to let anything drip into your lungs because that’s an ammonia and you die. So you’re basically your brain says, okay, adapt your swallow in order to facilitate your airway. And now the child isn’t really breathing like this. So they’re tilting like this. So that’s how they sit, sleep. Okay? They’re literally growing into this little bit of an asymmetry. So it’s, you know, a bonus twisting a little bit. So now the two sides, so the temporal bones that housed the eminence, they literally slap right on to the sphenoid bone. Okay, so there’s a little wing of the sphenoid bone, but the temporal bones attached to a clip, the two temporal bones aren’t symmetrical. The two maxillas are not symmetrical, they bone based growth, they’re not cartilage based growth, and they’re just growing to the ability for the child to breathe. So it’s all about nasal airway. Well, that, when Stack started in on that I’m like, so confused because I was so into jaw bite for 20 years. The whole idea that actually the cranial architecture was the source of the problem. And then the sockets didn’t grow symmetrical. They didn’t grow symmetrical in shape, height, everything they’re off center. So you can ball, the condyle had to go to the socket, but the sockets aren’t right, so the ball never did fit into the socket. And in the condyle heads are cartilage, but the temporal bones are not, they’re hard bone. So they’ve got a cartilage base growing into it, so it changes shape. So right away the two condyles, they don’t really they’re not symmetrical. No human has really a left side and a right side that are exactly it’s kind of like throwing a ball left handed and right handed. And it’s all tied to how you close, swallow, breathe. And so then now the curve od spee, curve of Wilson, all that it’s going to grow a little bit asymmetric. Alright, so now, the neuromuscular guys, they were into the airway, they had the basic problem with neuromuscular as a philosophy is you had Dickerson. Dickerson and Hornbrook and Rosenthal were the best cosmetics Doc’s at the time of the turn of the century. So we had a study club in New Mexico where we had a cosmetic Study Club, so we wanted to learn all the cosmetics when Empress came out. But what we decided as a group is, Hey, instead of us flying out to California all the time, why don’t we just get a mentor and we’ll bring them to Mexico. So our mentor was David Hornbrook. So we get David before David was famous, and then he would fly out because he loved New Mexico and Santa Fe, and there was a dozen of us, and then he would come in, and then you had to do the whole case photograph and everything like that. And then you would sit down clinically and he would be right behind you when you’re doing prepping, you’re prepping. So back then they called it Pack Live in California. So Pack Live was in Montgomery and Hornbrook and they would bring people in and then you were literally in the 90s learning how to prep veneers, okay? Back then. So anyway, David was our cosmetic coach. We’re still good friends today. Oh my gosh, I love the guy. And But anyway, he and Dickerson, they were together, but they actually got into an argument they had different philosophy. So hornbrook was more Dawson, Panky, Spear, put the condyles back into that close down. But then some of the empresss was breaking. So then that’s when it all started, Oh, you better get everything lined up where you’re going to crack your cosmetics. And so you needed the rear end to match the front end, or you were going to get into trouble. Today, we kind of get around some of that with the materials, we just make the material strong. We don’t have things as much. But back in the day, it was all literally glass. But the materials were changing, and they were beautiful. And yet, there’s no turning back. Once you get a couple of Emperess crowns on the front, you are never doing a PVC. So all that sort of started stopped with me at the turn of the century. We didn’t, we were often running with the new materials, but they were breaking no question in my practice, they were breaking. So it’s like, okay, how do we get around all of this sort of thing? [Jaz]So at that time, when you were using these, what were the time novel restorations, and you were falling in love with the beauty of them and applying them based on what you learned from the courses. But they were coming back and they are breaking. This was despite you putting your knowledge and experience and expertise into putting it setting it up mounting it in what you felt was the most appropriate occlusion, most appropriate force management for that patient. [Bobby]Exactly. And I would have the back somewhat a equilibrated and taken care of. So literally, I have the rear end, I have the condyles and the rear teeth and I knew on the T scan, I had them balanced, okay? And then you would do it across the front. And sometimes then you would have the gingival. So you would use a little lasers and line it all up and everything. But basically what we were doing is we were manufacturing this front to look better for the cosmetics so that when you smile, your lip posture and everything like that, so then you have these just flat out gorgeous smiles, okay, but it would only be a year or two somewhere down the road. And then a lateral would crack right on a corner. And there’s almost always a lateral coming around. Sometimes it can, sometimes it was a central in the middle and stuff like that. But some of them were catastrophic in that it cracked the whole veneer and then you had to go back in and then you went to a crown instead of a veneer. But you would literally spent a number of years with these what we thought were beautiful, perfect cases everything lined up. And I’m kind of doing it like the Spear guys and stuff, or the Seattle City Club guys, you know. And sometimes you finish a case and you’re just like, Oh man, I’m hot stuff, look at this. And then the reality check and they come back but I put every single patient on the T scan when they come in for their cleanings and prophys and things like that. So again, at the turn of the century, it was about 2003 or 2004, I get a call from the CEO of X scan in Boston, he goes, Hey, you order more sensors than anybody in the world. What are you doing? So they started sending software engineers to the practice and then chiropractors and then these neurologist guys who were interested in the neuro network back in the day, they all would just come through my office, they were literally shadowing and stuff like that. Now, it was a little bit of a hassle for me, but I loved it because I was learning stuff that I’m going like whoa. But I was starting to get this concept around 2005 that it’s not really jaw teeth, what we do in dentistry, the way we do dentistry, the way we were taught MIP all that sort of stuff. It’s awesome. It’s what we do, it’s what 90% of all the dentists around the world do it works. It’s how dentistry should be done, okay? The only thing with the philosophies is okay, if it’s breaking down and you want to restore it all the way back to a perfect system, then that’s when the philosophies jumped in and started arguing with each other and, okay, so you could still even after the cases, even if they broke, you could still do a little bit of adjusting. So a lot of it was like in protrusive, that person would slide forward but a canine would hit the lateral on this side, but a canine would hit a canine on the other side. So you always had these little asymmetries and then it was pretty obvious that Okay, wait a sec. The architecture of the bones is where the issue is. And the argument always in occlusion with the orthodontist, the orthodontist would go, it’s a class one occlusion. Well, Class One to them man, the mesial buccal cusp of the first molar hit the mesial buccal groove in the lower and if those lined up, it was all good and everything else didn’t matter even if you’re taking out teeth and all of that. But no, it’s has to do with the bones. So we take a class one like a teeth and orthodontic started, and they were just ramming it down dentistry through, No class one means that you have the teeth in the right position, when in reality, it’s the bones were never ever in the right position coming out. So you have class one, so we think of it as class one, class two, class three skeletal relationships. That’s how we’re taught, okay? But you could retrofit a tooth in the class one in a basically a class two skeletal thing. And now what happens is you had all this power here, so the teeth were just in the way of the bones, and then cracks and all of that sort of thing. And then it really wasn’t until about 2010, where orthodontics now got the memo. So the younger orthodontists coming out of school, they’re brilliant. They’re like they get it, they grew up digital, they understand digital, they’re not in the old concepts. They’re not doing retrofit extraction or those anything. [Jaz]And obviously imaging has helped so greatly with our understanding. [Bobby]Yeah, it’s all over now. I still in my community have a couple old time orthodontists. But they were a pain in my ass for decades, because they were literally like, No, this is it. This is the highway, you’re just a general dentist, I’m a God. And so they wouldn’t, they couldn’t switch and change. But they never ever learned it correctly from a joint situation, they never put in, these ortho cases would come back and they’d be 15, 16 years old, I would put them on the T scan, have them close down and go, Oh my gosh, this thing’s not even we’re close to being in some kind of harmony, where the envelope of function on one side is equal to the envelope of function on the other. So then we started putting all the kids on the T scan, I put them when they were six years old, 10 years old, 12, pre-orth, post-ortho and quickly figured out it takes about age eight 910 Somewhere in that girl’s a little sooner than the guy so when the girls hit their hormones and they’re starting to grow so so what happens is age six, the first molars come in and seven and eight, the anterior start to come in, the lip posture should start to seal and then about age 12. When the bites and the canine are set, then you have your what I call your ‘adult envelope of function’. So your adult T scan pattern is set at age 12. Pretty much routine, okay? So it’s kind of like if think of it, like if you had one leg shorter than another, you can step fine, but it’s the push up where the problem so everything is fine, symmetrical you go to step. Okay, so think of closing everybody can close, you can close fine, that’s MIP, right? You’re like, okay, but the push off is where the problem is. And that’s where the T scan is just invaluable. Now, the scanners, the scanners will show the force map before and then you do like Invisalign or something like that. And then it shows you the force mapping afterwards. So the scanners are gonna teach dentistry, about balance force, because the computer is doing it. It’s just that the dentist don’t know exactly what it’s doing because they don’t understand the dynamics of the trays moving and why TIF lined up and then why things are better balance but that’s the future of ortho, you’re gonna have a lot of trays and things like that into it. Kids, it’s all about the airway. You if they’re jammed up and they have that what’s called their infantile swallow should actually break at age seven and eight. So it’s seven years old. Okay, anterior teeth start to come in. Lips should seal, tongue should seal, child’s could breathe through their nose. Okay? If that doesn’t happen, and they don’t breathe through their nose, close, swallow, squeeze gasp, lips roll size up like that. They’ll have a little dark eye right here because bloods trying to get into the nasal lacrimal duct and the veins fill up and then the child has a dark eye, and you’ll quickly see where they’re starting to grow off center. Now think of this as literally it wasn’t just five generations ago. Pretty much everybody in the world had room for all 32 teeth, okay? How in our country and our culture, when anytime you came in industrialized, then literally you’re looking at maybe one or two out of 100 skulls, where the child has root for all 32 teeth. So now that’s just in five generations. Okay, so now all of that sort of evolution, what’s happening is, were insulting the system so much with inflammation and nutrition and inside and being. So kind of life expectancy is about 80%, where you’re born and who you’re born to. The other 20% has to do with your environment that you’re living in and working into and stuff like that. But what happens in epigenetics is your grandparents could have been heavy smokers. And so you have a recessive gene, it’s not your genetic gene. It’s your epigenetic gene, where now you are totally prone to inflammation. And so inflammation is now the problem in the future. Okay. I’ll stop there, you catch up, Catch me up in where we want to go. Cuz I can see [Jaz]All the things you’re saying about airway are so important in my own journey in airway and TMD. I think I’ve spoken about this in the podcast before where in the UK, we are a little bit behind, I look at US, I look at Australia as doing a lot of good work, groundbreaking work in terms of furthering our knowledge in dentistry, about this. So only in the UK was we’re starting to catch up. We’re about 15, 20 years behind. And even in my own son, when I look at him, I’m like, Is he nasal breathing? Was he mouth breathing, I’m like, very picky. And now then I’m applying that to my patients. And I’m having those daily conversations with children, mothers, and then on adult patients screening for airway. So that’s huge. And I love your explanations of epigenetics. I think that’s so needed. And and I like how you evolved from Okay, these were schools of thoughts, we’re all fighting about teeth and jaws. But really, the problem is a higher level up, it’s a basal issue, skeletal issue, which therefore affects the entire chewing system, just so that I can give those answers I promised the community. I think you said that when it comes to the Spear group, Kois and Dawson, what I think what you’re trying to say is really, they’re not too different. They’re just arguing a little bit about slightly different ways to fix the problem. Would you say there’s any more nuances or differences that perhaps we didn’t go into that is that worth mentioning between those religions? [Bobby]So, as it kind of turned out, then they were all the same, except for neuromuscular. Neuromuscular was the odd one out, okay? So it’s kind of getting into that because of a Dickerson and Hornbrook. So they broke apart and so, and they differed over basically condyle position, okay? Now, if you’re neuromuscular, so if you tense the jaw, so you literally put 10 units on it, okay, and then you turn it on for, like, 10, 15 minutes. We used to do a mile monitor, I used to do that do a mile monitor in the 80s. And then that’s how I would set my bites. Literally I just like Paul said, okay, and then [Jaz]like Jenkinson Orthotic appliance, right? [Bobby]The jaw would just kind of hang open, okay, and then I go, Alright, so then just took that relationship. And then when I went to adjust the splint, I have less adjustments to do and it’s like, okay, and then the patient’s their headaches went away and things like that I didn’t really understand. I always thought it was these muscles that were doing the issue I didn’t understand it was a head and neck posture, which will just get into an adjuster the next step here, okay? But what happened is, is the neuromuscular they would tense it and then the jaw would hang open. Okay, so it opens literally, after you turns it, you vertical opens about three millimeters on the average and forward about a millimeter and to the side left or right about a millimeter. Okay, so it’s a pretty standard, you pull some all out pretty predictable, falls into position. Why? Because you pulled the condyles out of the socket, so they just dropped down and now they’re kind of hanging open. So now what they go is now the neuromuscular says, Okay, well now we can rotate out of the starting block, you’re not jammed up so one isn’t turning to rotate and to get to the other level. Well, as it turns out, there was a temporal bones that were up so once I’d have to drop like one leg shorter than the other in order to get to that position but open three millimeters forward, one off to the side, one and now that’s pretty much a neuromuscular bite left side or right side, okay? And so then what they would do is then they saw Okay, well then putty so you’re hanging open you tense for 20, 30 minutes, your jaw sits in rest position hanging open, and then hurry up get some goop Go in there, take that registration. And then they would build a lower orthotic, awesome thinking, okay, lower orthotic, they would actually the neuromuscular guys use the T scan way more than anybody else. Oh, it was crazy, they were using the T scan, but to balance their orthotics. So they would make the lower splint and then they would hold it in the vertical and let the patient chew but then the thinking was okay, that’s where the teeth need to go. So now everything’s a full mouth reconstruction. [Jaz]Everything needs to crowns, which is the what the computer says. [Bobby]Okay, so you do the full mouth reconstruction, alright? But then a year or two later, okay, they’re not cracking the front. So the CR guys, we would line it all up, we would set it and then on protrusive and sliding was always a little bit like this away or that away or a little bit stressed. Okay? Nueromuscularly you line up everything in the back, okay? And then the condyles are literally out of the socket. So now they’re coming down, okay? All right, front teeth are fine, but you open the vertical. Okay, so now what happens in a neuromuscular case is the condyle, one of them wants to seek, so one of them wants to go back. Well, now you start cracking back teeth. So the neuromuscular, which is crack in the backwards, in the backwards, in the backwards and they would just go like dominoes, you know. And then that got into a bunch of lawsuits. Because these were $50,000 cases, at a minimum to start with gorgeous, beautiful, beautiful smiles. I mean, everything was just like, Absolutely, but they couldn’t function correctly. You actually have that same problem now with all on four cases when you’re doing these implant cases and we’re building them in zirconium. And then the zirconium, the teeth are so hard but you you retrofit it all in sort of a quick, fast time and you really haven’t planned out everything and so now the teeth are so hard that there is no give anywhere else. So a lot of these cases they’re going into neurologic overload and then they’re literally in pain. So there’s percentage of these all zirconium cases that are thrown into patients into these neurological overloads that are landing in the [Jaz]Something has to give in the system and that sometimes is the patient’s chewing system. [Bobby]Exactly. Sometimes you want to teach the crack. I mean, if you think about it, before we ever started doing crown and bridge, all you would do is chew out all the uppers and all the lower posteriors and so I when I was first starting it , I teach patients I make a denture and all they had was lower 60s. That was it. Because everything else they broke apart, trying to find neutral just by retrofitting and we just took out all the teeth but honestly it’s only been 50 years that we’re actually saving the teeth. Okay? So dentistry is still young in that scenario. Jaz’ Outro: Well there we have it guys Dr. Bobby Supple part one. Okay, now the next episode we’re gonna go a little bit different. It’s going to be the Pascal Magne at BCD. Episode 100 is a homage to Pascal Magne. It is my experience of flying to Edinburgh and everything that happened. It’s like a slightly different quirky, fun episode slightly different what we usually do, like I’m there, I’ve got my sort of camera and microphone. I’m speaking to other dentists at the conference. And me and Ricky have a little like chat at the conference itself to share some of the lessons that we learned from Pascal Magne and we pass them on to you. So do check out episode 100. And then we’ll rejoin Dr. Bobby supple for part two. And we really go deeper into posture, airway, assessment, the role of what we call myofunction therapy and all those things in comprehensive dentistry. So it does take a couple of tangents but I think it’s important because what he, what Bobby Supple argues and he’s suggesting really convinced me as well as that there’s so much more to it, than the occlusion at a tooth level, we need to look higher up, we need to look at the skeletal and airway. And that really is the future about how dental and medical will talk to each other so much more. And the future is looking bright, you know the innovations looking great. So that’s exactly what the next episodes about. It’s a bigger picture stuff. So hope you join me for that as well. Anyway, I’ll let you have a fantastic day wherever you’re doing. Thanks so much for listening. As always, if you enjoy these episodes, do consider leaving a review on Apple, if you listen on Apple, please do consider leaving a review. It’s how the podcast grows. Thanks so much and I’ll catch you in episode 100!