Protrusive Dental Podcast

There is WAY too much plastic in our profession – it’s insane. How can we do our part in Dentistry to make better choices for our environment? NOW is the time to spread positive messages for the environment to make a better world for our children and our children’s children. In this interference cast, we are joined by Dr. Mike Gow and Marcus McLeod who basically have started the journey to Net Zero Dentistry https://youtu.be/n8rSYpf0ld0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “So even if you can do a small thing…..get involved, get active and we will make a difference. This is going to happen. So be part of it!” Dr Mike Gow In this episode, we talked about Implementation of Managing Net Zero Dentistry 6:42 Mental Health element of Dentistry 13:59 Similar Advocates Internationally 16:50 Aligner recycling Companies 17:49 Quick wins Practices that aren’t doing Net Zero Dentistry 20:46 Being green in dentistry 24:55 Check out the Net Zero Dentistry and Let’s all contribute on becoming a greener world  If you enjoyed this episode, you may also like What Every Dentist Should Know About Managing Dental Anxiety Click below for full episode transcript: Opening Snippet: You're going to save money. Okay? And we look at the bottom line in Dentistry, we look at our profits at the end of year, you will have more bottom line profits if you follow Net Zero dentistry and follow the stuff that we're going to be talking about and that is a simple fact that will be true. You will also motivate your team. Okay? This is something that everybody in the clinic can get involved with... Jaz’ Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome this really, really important interference cast on how we as a profession can be greener? The time is now. It’s right now, we take some massive action in our profession throughout the world, so we can have a better future for our children and our children’s children. Guys, I hope this episode makes Greta Thunberg proud. I’m joined today by Dr. Mike Gow and Marcus McLeod, who basically have started this initiative, this free initiative for us all called Net Zero dentistry. I think it’s a great idea. I’m fully in support of it, I want you to listen to this episode so badly. So you can implement something like for example, when I recorded with these gents, I made a promise to walk to work every day. So it doesn’t have to be just like purely dental reducing plastic, which obviously we’re gonna cover all that in this episode, what we can do at the workplace to be greener, even thinking outside the box. But what can we do in our lives having a meat free day, walking, being mindful of our energy consumption? All these things are so important. So yes, this is dentistry, it’s very relevant to dentistry, and how we can be as a profession greener but just you personally as well. Hope you find value in this episode if you do share it with someone. Okay? Now is the time to spread positive messages for the environment like this one. Anyway, I catch you in the outro. Main Interview: [Jaz] Marcus and Mike, Welcome to Protrusive Dental podcast. How are you gents? [Marcus]Thank you very much. Excellent. [Mike] Very well. Thank you. [Jaz]Amazing to have you both. Recently I was at the BACD conference in Edinburgh, Mike I was able to reconnect with you. And on that same evening we were discussing about Net Zero dentistry. I thought this is amazing. I want to give this a voice. I want to get people to start talking about how we can be more green obviously recently with COP26. Everything’s very topical. We shouldn’t have to wait for two Taco to have these kinds of discussions. But here we are. It’s a start. And also on the same evening, just a slight little tangent on the same evening. I also met Jeremy Cooper and he was talking about confidential and the mental health aspects of dentistry and the sad areas, the dark areas of suicide and all these horrible things, depression and I decided that night that okay, I’m gonna leave Edinburgh with a reconnection with Mike and a new connection with Jeremy and I definitely want to support that charity. And of course we talked about Net Zero dentistry. Mike we know you already a little bit or get you to do instruction shortly but Marcus, I know less about you, Marcus, tell us about yourself. How long have you practicing for? What your niche is? What are your areas of dentistry? [Marcus]And well I haven’t been practicing anything. I’ve been practicing life for the past 60 years. I’m not a dentist. [Jaz]Amazing. Even better. [Marcus]Perhaps no, I come from a banking background and changed direction about 20 years ago. So in the past year, in the past six years, we’ve been building up a portfolio of dental websites. And we’ve got the leading listing clinic websites in the UK defacto dentists. We’ve got about 8000 clinics on there I think it is at the moment. And we have an E-commerce platform for dentists whereby we do the fulfillment transaction, the delivery as patients order from the dentist. We also have foster markets, video interviewing on a recruitment website. So we’re embedded in the dental profession and work provides really meaty, juicy, write on solutions for them. [Jaz]Fantastic. Will be great to borrow both of your expertise today. Mike, great to have you back on the podcast. So we obviously talked about anxiety management before when you taught us so many amazing things and how you were involved in that experience of placing an implant without local anesthetic so if anyone hasn’t heard that episode, please go back, listen to it. There’s some great communication gems in there. Just remind us for those maybe who are listening to you for the first time, haven’t listened to that episode, whereabouts you are? What you do? And then both of you together what makes I mean Marcus is talking earlier about there’s no true expert in this but what makes you guys passionate to be able to talk about Net Zero dentistry? So Yeah, Mike go first, my friend. [Mike]Sure. Yes. So my name is Mike Gow. I am a dentist, I own a private practice in the centre of Glasgow. Really ever since qualifying, my main passion and interests were helping anxious and phobic patients. So I’ve studied all the years a variety of techniques including sedation, and interestingly hypnosis. So I have a master’s in hypnosis, applied to dentistry. And you know, so no working in private practice, I see lots of anxious patients to help patients with bruxism using the psychological aspects of that. So I’m excited to be joining you in your SplintCourse that’s going to be another string to my boy as far as that’s concerned. And just yeah, just enjoying the work that they do. No, Marcus actually is my cousin, as well believe it or not. So we are friends, we are cousins, and we work together. So every morning we have phone calls, and every night on the way home from work, we have phone calls, as well. And really we talk about the hot topics of the day, what sort of things, you know, could we be looking at? How can we help the profession? What can we do for the businesses that we have? And recently, we started talking about the amount of plastics, the amount of clinical waste, the amount of pollution that’s caused by dentistry, I think it was the end of a particularly long session, I’ve looked at my clinical waste at the end of the day. And I just felt really disheartened by how much I was throwing away. And the conversation started from there, really. But you’re right we are, you know, I’m certainly no expert in green, or net zero. But that’s kind of what I like about it, because I don’t think this should be an exclusive club where you have to be an eco warrior to be able to make your difference. So we’re pretty good at coming up with strategies and plans. And over the last month or two, that’s what we’ve done. And Marcus is the brain behind it. And he’ll tell you more about that come up with some of the ideas and then Marcus makes them happen. So works [Jaz]Well, tell us about the implementation, Marcus and what ideas you have generated so far before we then talk a little bit about in daily practice, the challenges you face all the single use staff or the packaging that we use, and that these are the real frustrations that we have. But tell us any ideas and directions that you find could be fruitful in managing this, Marcus? [Marcus]Okay. And well, when we decided to approach this initiative, we wanted it to be free to use. So we didn’t want to charge dentists to get involved in something. So it’s a not for profit entity. And we set out four pillars of understanding, the first pillar being awareness. COP26 been brilliant, and actually making people aware of all the issues that will go on and the planet just now. And we’ve had feedback people saying, well, it’s China, it’s India, they’re polluting the world. And it’s their fault. The fact that I use a single use tepe brush, that’s not going to make a difference. But we do, we know that one small step makes a difference. You’re taking one small step towards this better world that we’re trying to create. That’s all it is. It’s very simple, very basic. So the awareness site is getting people engaged with net zero dentistry. The second side is an assessment. And now we’ve gone to great trouble, time costs, whatever else putting together an assessment, whereby clinic principles are those engaged with the work in the clinic, and can assess where they’re at at the moment. And it’s not a judgment document to make somebody bad, somebody good. That’s not the purpose of it. The purpose is to set a mark in the sandbox so that 12 months down line, practices can actually see, well, I’ve actually made a difference during this 12 months. [Mike]Yeah, kind of like an audit process. That’s our idea was it’s almost like a net zero audit. How are we know? [Jaz]This is something that should be really, this should be like made part of the CQC. Like everyone, every practice should be made to do this. Wouldn’t it be wonderful in terms of enforcement of policy to assess how green you are? I mean, that’s the kind of future we should be looking at. Just while we’re on this topic, how can a dentist who’s maybe listening already think okay, yeah, I mean, the only dentist who listen to this is someone who cares about the environment and for this title come up how to be greener, net zero. And so we have the attention of dentists who have at least some care and some dedication. So how can they download or access this audit tool so they can get started straightaway with their team Monday morning. [Marcus]And if you make it Tuesday morning [Jaz]By the time this episode comes out [Marcus]The painter still waits on the websites. So [Jaz]By the time this comes out, I’ll make sure I time it in a way that the resource ready because I want people to strike while the iron’s hot. They’ll be enthused hopefully, after getting some ideas from you guys, and I want them to log in download it, get into practice, start doing the audit. This is going to be the thing that’s going to start the engine. Get things going [Marcus]Great. And the website is ready? No. But as I say that the pain says whereas we’re still going revising and tweaking, [Jaz]No, well done to both of you for setting up this not for profit organization to help such a huge topic. So amazing. Awareness, we’ve got this audit tool, what else? [Marcus]And the third pillar is the education platform. And this is what’s taking all the time and efforts put together. And we have an educational platform with 26 modules in it. Now, these modules are being generated by experts and not one field. So we’ll have 26 authors, if you like, and the education module. And those are perhaps dentist practicing, dentists who have gone through a process, they understand how to better that process, they’ll write up the 500 words, and that’s done education module. And so it’s really to match up with your witnesses from your assessments. You see, yeah, I’ve got a gap there, faster learning [backdoor] slot into the gap. Yeah. And the fourth bit is an offset program. And we’re not quite there yet with an offset program. But collectively, the dental profession has much greater power than me or you as an individual saying, I feel guilty, I want to buy my way to heaven, I want to buy some carbon offsets. Yeah. And we’re making sure that the three steps prior to that are followed through before they even consider offset. So unless, through the assessment, unless, as a result of the assessments, they put the sustainability section into the operations manual, when must have that in the ops manual. That must Yeah. So beyond that, the education modules, when they read through all the education modules, then they consider offsets. And the way we’ve approached offsets is that, if we’re gathering money, I pause on behalf of the profession. We’ve got a bit really, really careful what we do with that money, if we make a mistake. And it’s so easy to make a mistake in that field, that area, Mike and I had the discussion with someone and it ended tirade plausible, like a blue chip company, it was absolutely spot on. And we were engaging. And so we were setting up the terms and everything else. And we were asked repeatedly, and where does this money, how is it used? And it turned out that that money was going to be used to pay people and the Amazon forest, not to chop down trees. Yeah, all of a sudden the alarm bells. So what we have put together so far, is gold certified, through the Forestry Commission, Gold Certified carbon offset, whereby every single tree, and that we, we don’t purchase trees, we only buy offset. So every single tree has an offset. And it has varying different offsets. And so we buy a patch of trees, if you like, that has the offset, we buy the offset, that money is then used to replant trees. And that’s what the gold certification kind of basically as all of those [Jaz]But like you said that that’s very much not last resort, but like something that is a hierarchy. And that’s the very small part, the foundations are very much the awareness, the education, like you said [Marcus]And the offset is, it’s an involvement as well. So we decided that, for example, organising two days and next year, to do beach combing, as a profession, we go out there into the countryside, into country parks, onto beaches, and we gather plastic and dispose of it properly. [Jaz] Amazing. [Marcus] That’s something that doesn’t cost money to in terms of contribution or anything. But it’s something that we want to be involved in and build. [Mike]You talk about the mental health element of dentistry just now. And you know, team building, I had to do this with my daughter as part of our school project recently. And we went to a local park and I thought there’s not really a huge amount of litter here, but we’ve got to fulfill the project and we got our bend bags, and we started going around with our litter pickers. And at the end of it, we had about three or four full bags of plastic, of cans, of everything, of glass bottles. And we stood there feeling proud as bunch that with made a difference to this play park, you know, so it’ll be a great motivational tool. It’ll make a difference. And it’ll be a great team building exercise. [Jaz]I think, yeah, team building, everyone should bring their whole team, the nurses, associates, neighbor practices, make a social occasion of it. Let that be in the sun and the daily. You know that the Times and The Daily Mail, that kind of stuff, you know, forget the other non sense. This is the kind of stuff that we should be promoting and should be at the forefront to show that we care because we generally do, we see on the Facebook groups all the time, as dentists moaning about how much plastic there is, let’s now take action. That’s a great initiative and wouldn’t have thought that. It sounds wonderful. [Marcus]Well, we’re trying to think outside the box is easy for any company to set up and say, right, do the assessments, therefore pay this every month, and actually clear. But that doesn’t actually, it doesn’t create anything, there’s zero impact with that other than someone’s wallet being less real than it was. Really what we’re after, is the effect of what we’re doing. And by reducing single use plastic, by looking at how we can do treatments, using some gases, and removing amalgam fillings, the whole gambit. And that’s not necessarily going to change the world tomorrow, but it’ll have that small step towards it. [Mike]Yeah. It’s a change of attitude as well, of course, you know, and somebody has to, as you say, draw the line in the sand and say, right, we need to change. And that’s what audit is all about. It’s about recognizing this is an issue. If we don’t change this, the coming generations are just going to keep doing the same thing. And we look at you know, greenness and big environmental, and somehow we look at it outside of our practice, because we justify it by its single use, it’s a clinical area, we can do anything about it. We can, you know, we can lobby manufacturers, and see the little like plastic micro brushes, can we get a made of bamboo or something else? I looked at my tree the other day, and it was like somebody had lost a game of kerplunk or something, there was this pile of plastic sticks, you know, and I’m like, There’s 40,000 dentists in the UK, I’ve just used 10 of them in the [??]. That’s almost half a million plastic brushes. We’re all using 10 a day. [Jaz] Wow [Mike] That’s a lot of plastic. [Jaz]The scale is huge. We’ve known for a long time. And so it’s great where we’re having these conversations. How can we obviously this is spreading awareness through mediums like this and getting people involved. It’s about making it international as well. Do you know if any other countries are or have any similar initiatives? And if we can learn something from them? [Marcus]And we looked, so that we could copy. There are experts out there, where we discovered there aren’t any experts? [Jaz]Please reach out if you’re listening, because you clicked on. And you know, you saw the title green and it spoke to you and you’re working in the community in dentistry. And you have some ideas reach out to Marcus and Mike because they’re on something here and they want to promote it. So I’m sure you’d welcome that gents. [Mike]I was just gonna say we launched them, we have a steering group. So part of what we need to do is draw in people that we know we’re not in competition with anyone. If anyone is doing something, we want to embrace that because this is knowledge and ethos that has to be shared. This can be owned by anyone. We don’t own that zero dentistry we are we are just helping provide the platform, they’ll hopefully bring all of it together. So we want people you know, if you’ve got projects, you’ve got things you’re doing, come onboard, let’s hold this together. That’s the idea. [Jaz]Have you both seen this a company that does aligner recycling? I don’t know if there’s multiple of these companies, or there’s just one. There’s one that I recently saw. And I think my practice inquired, and my practice had to say that you know what, there is a bit out of budget in terms of doing it. So I don’t know how much it costs. But my principal sort of side, okay, yeah, we don’t do enough in this line. And we did the cost too hard to justify, although we’d like to do it because part of the values of practice is to be greener, any ideas of how we can reduce the costs of practices getting involved in that. So we can recycle aligners. [Marcus]That would be the lobby group that would go to the Aligner group, and to fill up so I’ve engaged quite considerably and saying, we know that we’re pumping plastic and through the profession, into the patient base, but that can be averted, will have a refund system almost. Gather back in the replacement heads. So yeah, there are firms note setting up and taking attention, and doing something about it. But collectively, as supposed to individually, if you individually, go to that aligner company and see. So we went too heavy the price. But if the 8000 dentist going towards them and saying, Look, this is the price we want to deal at, then it makes sense. [Jaz]Mike, you can say something sorry. [Mike]I know. Sure. It was probably something really important. You’re true but again, I think I mean, this is where it gets complicated. You need the experts, because there’s one thing to have a green ethos and to want to be doing green things, but it’s also then looking at, you know, what is the thing that I’m doing and what impact does that have? So you know, recycling aligners, you know, how much of a carbon footprint is there actually getting the plastic back to wherever it’s been recycled? All those kind of questions have to be asked and looked at as well. And then all because that’s a general issue and everyday household plastic recycling as well. So, you know, again, we’re looking at creating the forum to have all of these discussions, you know, and hopefully come up with solutions and growing engagement with people that have said, Look I’m passionate about this, I want to be actively involved. In fact, one of the great little things we’ve got here was trying to reduce meat. And we came up with one of these smart and we know each little ideas not going to cure the problem. But they all have their impact. And, you know, we had this idea of meat free Mondays, calling them dental dinners where everybody in the professional agrees to have one or maybe two meat free days a week. And we put a thing saying, you know, if anyone’s got any meat free recipes or ideas, that would be great to have them. And that’s one of the things that we’ve been swamped with, I’ve had loads and loads of people, contacting us with those, you know, and again, that’s going to engage people and be fun, and it’s going to be good. [Jaz]Is any low hanging fruit? That you’ve had to think about that you think, you know what, actually, we’re already doing this. And you recently found out that actually, other practices aren’t doing this. Is there any quick wins that you could share with us today that people can go away listening and think that oh, yeah, I can easily make that change on Monday morning, to make my practice more green. [Mike]I think probably one of the things that I hadn’t, I guess thought about massively until Marcus started talking about it was just the energy bill at the practice. You know, you even as a practice owner, you know, things are on timers, you know, there’s an energy bill that comes in, but it’s not something I just consider that as unnecessary cost to the practice, but it didn’t really, I didn’t really have the full impact of the environmental costs of that. So I think there are ways that I can be more clever with regards to the use of energy within the practice, the heating bills, the, you know, the energy usage, that type of thing. So, you know, Marcus said to me, he asked the question said Mike what’s your energy bill every month? And I said, I’ve got no idea. I don’t know if someone else deals with that. I don’t know. I don’t know what my energy bills are and I should know, because I should be aware of how much we’re using and how much that could come down. And that would be massive, you know, some simple changes in how and when the heatings coming on, could instantly make a massive difference to your net zero goals. [Jaz]If all the practices reviewed that just one thing again, it makes a little ripple, doesn’t it? In the ocean. Marcus anything to add to terms of any ideas you’ve had so far in terms of quick wins that we can do not necessarily as dentists but as humans, but anything in the dental setting that we could look at as well? [Marcus]Yeah, if I could align briefly, and one of the groups that we were talking to try to implement a sustainability module in their ops manual. They wrote a document about this size, and funked it down on every clinic’s desk. Six months later, absolutely nothing had been implemented. So they approach this with the 1% gains. What can we do just now just to make a small difference? So they started planting an wild flowers outside the clinics. So the bees commend those cross pollination happening, and the food chain started to dry but unprovable, but that in theory is what would happen. They then extended that and started to put beehives on top of the clinics. So the bees were feeding off their own wildflowers. [Jaz] Is this in the UK? [Marcus] This is in the UK. Yeah. And so by taking these small steps, and people who opposed the green thing, the Eco thing, because everyone that’s green or eco are strange. And they said, Well, that’s really nice having flowers outside. It’s really cool. Having bees up on the roof is really cool. I was looking at that paper and recycling that paper, I guess it No. So all of a sudden three steps have been taken towards this net zero dentistry. And it might take five years, it might take 10 years, it might never happen. But the net zero dentistry thing is a case of very small steps. So by bringing in a plant to put in the waiting room, and have that plant, give us oxygen. Yeah, that’s one small step towards this net zero, you’re offsetting by doing that. So there’s one small step for Monday morning. [Jaz]Great. Well, in dentistry, we’re so used to having instant gratification, that when it comes to this, we have to really think the bigger picture, we have to think infinite game. So I think really beyond generations. And so that, that needs to be a very important part of our mindset. As we approach that. Gents, that’s the main sort of core I wanted to cover. Are there any message that you wanted to share to leave dentist with, so that they can now act on it? Obviously, I’m gonna share the website, they can hopefully then download the audit process, get involved, sign up to a newsletter that you guys provide. That’d be wonderful. Any other important messages regarding being green in dentistry? [Mike]I think so. I think You know, obviously, yes, we should all be greener for the sake of the planet and the environment. But if you engage, and you do this, you’re gonna save money. Okay, and we look at the bottom line in dentistry, we look at our profits at the end of year, you will have more bottom line profits, if you follow Net Zero dentistry and follow the stuff that we’re going to be talking about is, that is a simple fact, that will be true, you will also motivate your team, okay? This is something that everybody in the clinic can get involved with, no matter what the position and the business is. And I think it will be a real morale booster for a lot of clinics to be able to proudly have the badge on their website. We’re at net zero dentistry clinic, and it’s something we’re passionate about. As a follow on from that patients are gonna see that you know, and as you mentioned, we’re no longer the bad guys, we’re actively making a difference. We cared about our community, we care about our patients, we care about our planet. So other than, you know, just the pure and simple, yes, we want to make a difference for the planet. I think the knock on effect for this and the mental health elements of this are huge. And it’s exciting, the people, we’ve been speaking with a wonderful group of people who are all passionate and wanting to share and wanting to actively get involved. And some of them are saying, I’ve got loads of commitments, I can only do a little bit. And other people are given us loads of stuff. And that’s how it’s going to build. So even if you can do a small thing, as we’ve said, you know, get involved, get active and we will make a difference. This is going to happen. So be part of it. [Jaz]Be part of it, and including the trade as well as huge part of the trade complaints in being involved in this and an encouraging and passing it on and paying it forward to their family members, their spouses, everyone, it can definitely have a ripple effect. Marcus anything to share my friend? [Marcus]Yeah, we’ve talked through the business aspects of net zero dentistry and a clinic, Mike touched on the dental dinners, we actually have a full program, and I can touching on the mental health issues and the pressures on everyone in the clinic just in that we have an active session in there. So people that have cycled to work, people that run to work. And people simply walk to work because they’re not able to run a safer door. So doing those small things is another big important step. So we’ve gone into the personal side, the dental demos is going to be a big life really is that’s gonna be a lot of fun. And then we’ve got a gardening section, to grow your own vegetables, to grow your own flowers, to grow your own whatever, and then the exercise, the getting yourself back to fitness, both mentally and physically. And so I think the result of engaging as a very positive one [Jaz]Well, I would like to publicly commit to something as part of my thank you for sharing this, I’m gonna publicly commit to walking to work, I don’t live very far away from work but I still drive. So here now, I’m going to commit to walking to work after our discussion today. So thank you, and that’s me doing one thing, small thing and hopefully will lead to having those conversations to practice. So please do hold me accountable. My wife will love that I actually could use the exercise as well. So you guys have it, they’ve done it, you’ve inspired me to walk to work. And if you’re someone who can do that, or just like I said, run or bike, I think you should. And these are, it’s not just reducing the stereo pouches. It’s far bigger than that, you know, you immediately think all the plastic and micro brushes, but there’s so much more we can do as humans, not just dentists. [Mike]Yeah, and even if you can, if you don’t live close enough to your work, that you can walk all the way, you know, Park half a mile, you know, park a mile away from the clinic, shave that off the journey and you’re reducing, you know, 10 miles a week of your journeys and getting the exercise so there’s lots of little ways around this as well. But that’s excellent. We want some photographic proof otherwise, it didn’t happen. [Jaz]It’s gonna happen. It’s gonna happen. And I love that and it will happen accountability is everything. Gents, thank you so much for sharing your time in this initiative. I want to plaster this everywhere. I’d love to put it on the website. Let’s put a blog. I want to email everyone. I want to get people talking about this. And if you’re listening been inspired by Marcus and Mike, please do reach out to them, reached out with them with love, with ideas, which is just as with criticism, it’s okay. If you think there’s a different angle you need to take, tell them. I know Mike and he’s a very open man. He’s gonna listen to you and together you seem like you guys have got the heart for it. So gents, thanks so much for starting net zero dentistry. And I’m excited to see where this goes. And maybe let’s do a follow on maybe a year, year and a half time to see what changes on what you’ve done, what we’ve accomplished. That’d be wonderful, I think. [Mike]Excellent. That sounds perfect. And please, please do follow us on social media. We’re on Instagram, Facebook, and the website. We’ve not mentioned the website name. It’s www.netzerodentistry.com. Jaz’ Outro: Amazing. I’ll get that on the blog post as well. So yes, have a lovely rest of your weekend. And thank you so much for coming on the podcast. So there we have it guys. What are you going to do? What are you going to do? What are you gonna commit to today? Let me know. Share it on your Facebook or Instagram story, tag protrusive dental, tag net zero dentistry. Let us know what are you going to do to make sure that we can be greener as a profession and greener personally. Thank you so much for listening to is really, really important episode. I really appreciate it

How do you manage cracks? The ‘Direct Composite Splint Technique’ is kind of controversial. Whilst it may seem intuitive to take cracked teeth OUT of the occlusion, this technique builds composite on top of the cracked tooth in to SUPRA-Occlusion. So what’s the crack? (Sorry) – I brought on the pioneers of DCS, Professor Shamir Mehta and Dr. Subir Banerji who enlighten us about this minimally invasive technique. https://www.youtube.com/watch?v=SpkrUBIJji4 Have you subscribed on Youtube yet?! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Get the largest magnification loupes you can afford and you can think you can sustain. I personally use 7.5x for EVERYTHING! A sharp probe has a resolution of 40 microns, at 8x magnification the resolution is 25 microns. We need high magnification to treat cracks! In this episode we discussed: What is the Direct Composite Splint Technique? 9:23 Decision making and Sequencing of Direct Composite Splint Technique 11:05 DCS Technique protocol in term of of thickness and bonding 16:54 Aiding disclusion with canine risers 19:55  DCS Technique Protocol 22:20 How does DCS Technique work in terms of the relative actual movement? 27:15 Patient Communication for Cracked Teeth 33:22 Re-established occlusion after DCS? 42:53 Are you sure we can leave it in Supra-Occlusion? 50:55 Should you chase cracks? 54:33 Favourite Sectional Matrix Bands 56:56 Tips and Tricks in making patients comfortable 58:25 Check out this paper by Professor Shamir Mehta and Dr. Subir Banerji about DCS Technique Cracked-tooth-syndrome-Part-1Download Cracked-tooth-syndrome-Part-2-1Download Check out the PG Dip / Master’s in Advanced Aesthetic and Restorative Dentistry: Aesthetic-Dentistry-PGDipDownload If you enjoyed this episode, you will love I Hate Cracked Teeth with Kreena Patel Click below for full episode transcript: Opening Snippet: I would encourage you to read more about it before you actually do it. And it may even save you from a tricky situation. Even if you just use it diagnostically, ie, you suspect there's a cracked tooth, you then place the composite on top, and now the pain goes away. That is a diagnostic event. So even if you don't think you're gonna go the full hog and use this technique because it's too controversial for you, I think you can still use it as a diagnostic aid... Jaz’ Introduction: Hello, Protruserati. I’m Jaz Gulati. And welcome back to another episode of The Protrusive Dental podcast. On this episode, today, we’re talking about something called The Direct Composite Splint Technique for managing cracked teeth. Now, if this is the first time that you’re coming across this, it is a completely alien, weird, crazy concept like the first time I came across this, like, you know, our natural instinct when managing crack teeth is to take it out of occlusion, right? You see a crack, ah, let me remove it out of occlusion. But what this technique actually does is the opposite, it actually puts that same cracks tooth in Supra occlusion, right? And by doing that, you will by wrapping some composite over the crack molar, let’s say, basically prevents the cusps from flexing and therefore maintaining the crack rather than allowing it to propagate. So that’s how it works. And then to even add the controversies of this technique, what happens over time is that, that composite is left in the patient’s mouth over the offending tooth, the cracked tooth, right? And then what happens over time is what we call relative actual movement. So that tooth, which is proud in the bite, eventually, over time is no longer proud in the bite. And suddenly, it’s almost pretty much in the patient’s maximum intercuspal position. So that when you remove that composite, you now have restorative space. Now, if I’ve gone too fast then don’t worry, we’ve got a whole hour or something with two leading experts on this technique. So if you’re listening, if your buddies listening from the USA, from across the pond in Canada, maybe you need to sit down for this one, okay? Maybe grab a stiff drink, because there’s going to really challenge some paradigms that you have. But I think that’s the beauty of dentistry. There’s so many different ways of doing it. And this is a very minimally invasive way of managing cracked teeth. So I’m not going to blab on too much about this technique. Because we got a whole episode on that. I will give you the Protrusive Dental pearl for today, though, it is, you know, it’s an obvious one, okay, we’re dealing with cracked teeth, we need magnification. So the reason I’m putting this pearl in now for Episode 98, is one of the top five most common questions young dentist asked me is about magnification. And specifically, it’s like, hey, Jaz, do I go for three times? Or do I go for five times? Or do I go five times? Or do I go for seven times? The answer is super simple, okay? You need to go for as much as you can. And as much as you can afford. Magnification is like a drug I say it again, it’s like a drug you want more and more and more. I’m on 7.5 now, and I do everything with I even do children’s checkups with my 7.5 magnification. It does not leave my face. And I love it. And if there was like tomorrow, if the same company I bought my loupes from release a 10 times I probably get it, right? Yes, there’s a whole thing about you know, maybe the next step is a scope. And I’ve tried the scope and I and enjoyed using the scope. But in my surgery at the moment, it’s just not feasible, it’s not possible. And also the whole thing about being associated with a scope and that kind of stuff, which I totally respect. I know some associates have their own scopes, which is awesome. But talking, generally speaking, most of us all have a good pair of loupes. So the pearl is get the largest magnification you can afford and you think you can sustain. So if you are deciding between three and five, go for five, if you decide between five and eight, go for eight, you know, go for as much as you can. One tip that Pascal Magne shared at the BACD Conference recently is and he shared it based on the findings of a paper is the probe itself, the sharp probe has got like the ability to feel a resolution of like 40 microns, okay, that’s like the resolution of a sharp probe. Whereas our human eye is at 200 microns. Eight times magnification is at 25 microns. So when we’re dealing with cracked teeth, you want to use something with a resolution, ideally, superior to your sharp probe. So that’s just another reason to go for as much magnification as possible. And you will adapt. Don’t worry, I know many dentists are concerned or worried about not being able to adapt. But I think you will, I think everyone almost everyone does. And usually most people say, most people regret the fact that they didn’t go for higher magnification. So in a nutshell, go for the highest magnification so, so important, especially when we’re looking for cracks. Anyway, let’s join our guests Dr. Subir Banerji and Dr. Shamir Mehta, who are absolutely brilliant pioneers in this field of managing cracked teeth. With this technique they’ve done. They’ve contributed to research in this as well. So the papers of course will be on the blog and on the Protrusive Dental community Facebook group. I’ll catch you in the outro. Main Interview:[Jaz] Welcome everybody to this very rare live Protrusive Dental Podcast. Today, I’m joined by Professor Shamir Mehta. So congratulations professorship we’ll talk about in a second and Dr. Subir Banerji. Two absolutely great people in restorative dentist and I’m really excited to share what they have today about the Direct Composite Splint Technique for managing cracked teeth. Let’s start by welcoming our guests and give them a warm welcome, Professor Shamir Mehta. Tell us about yourself. Where you’re working at the moment? Tell us about the PhD that you told me that you recently did. What was that on? [Shamir]Thank you, Jaz. It’s a pleasure to be involved with this podcast. So yeah, my name is Shamir. So I do a number of things. Sort of I’m a practice owner in northwest London and do a little bit of practice. I’m the senior clinical advisor to the GDC largely with fitness to practice. I am Subir’s deputy with the MSc in Aesthetic Dentistry at Kings which we’ve been working together on for since around 2009. And more recently, I’ve been appointed a professor in Aesthetic Dentistry at the College of Medicine and Dentistry, which is with the Ulster University. So it’s a bit of a varied week. And yeah, I’ve recently done my PhD in toothwear in Nijmegen as part of the Radboud Tooth Wear Project in the Netherlands. And so that’s me. [Jaz]Yeah, well, I’ve seen so many of your publications, including dental update, and a few papers are very, very practical, very helpful things that you share all the time. So very, very excited to share those nitty gritty little details with you. Subir, I was just telling you before we hit the record button that either I seen you lecture, to in a small room in a pub in Twickenham in about 2013, 2014. You inspired me that evening, show me what’s possible with composite resin. I’ve seen you in even bigger stages, the BDA, on a massive big screen showing your beautiful work. Tell us about where you work at the moment? How much teaching do you do? And a little about yourself in general? [Subir]Oh, thank you very much for a very kind introduction, Jaz, and I’m admiring your mastery of technology, I have to say, and yeah, my actually bread and butter is in general practice, I’m not in Ealing. I’ve actually been in the same practice ever since I qualified so I kind of been there ever since. So that’s where my bread and butter is. As far as my academic areas concerned, I’ve been teaching at Kings for about just over 20 years or so. I teach on the prosthodontic program and as a director of the MSC esthetics program that Shamir mentioned to you. And I’ve also got my own private teaching academy, the Academy of Dental Excellence on which we run some diploma and masters courses for restorative dentistry. I’m an associate professor in the Department of Prosthodontics at the University of Melbourne in Sydney. So I’ve been kind of very varied background academic. I’ve always been partly an academic, but I have to say my bread and butter is in practice, in general practice. And that’s where my passion is mostly. And yes, I do remember meeting you in the pub, which is kind of likely location to find me mostly, but not all the time. I hasten to add, but yes, I do. Remember. [Jaz]Subir, are you a cricket fan? [Subir]I’m a bit Cricket fan. Indeed. Yes. [Jaz]Because I remember you were running this occlusion course, together with the IPL. And I just love that concept, which really caught my eye at the time, but it did that ever go ahead? or did COVID get in the away? [Subir]COVID got in the way of that when the idea was to actually hold an occlusion course and a restorative course in Mumbai. And at the same time to actually combine with some the Mumbai Indians fixture but then COVID got in the way. So we might relate that at some stage later [Jaz]Please, please Subir do that. I will support you fully with that. I will come and I will get as many of the Protruserati to come with me as possible. I’m a huge fan of cricket. It was good to see India win today. I’m sure you will watch it as well. But yeah, we could easily spend a whole podcast on my cricket. But we won’t because today we’re talking about the direct composite splint technique for managing cracked teeth. So many people listening watching right now will never have heard of it. Some people will have seen it and heard of it and thought what the hell is this? That was my initial reaction. No offense, when I first saw this like this, it just seemed very counterintuitive, right? But then when I actually did it myself in practice, and I saw that, hey, actually, this is pretty clever. And then some people may be well versed in it. In fact, Zain sent a question in which I’ll ask later, so he’s been using it, and he’s found a few challenges with it. So we’ve got three or four different groups of listeners and watchers. So let’s start with the very basics. Either of you wants to go first. What is the direct composite splint technique? [Subir]Well, I’ll let Shamir answer that one actually [Shamir]Well, it’s a technique that actually evolved. We were just discussing before the session. I see a lot of, I used to see a lot of cracked tooth syndrome in my own practice. And this caused me a lot of difficulty in that, you know, diagnosing was a challenge. Treating it was an even bigger challenge. And, you know, many, many years ago Subir and I both used to teach on in primary dental care at King’s in Denmark Hill. And I remember one Friday, lunchtime, I was sat with him and you know, thought that, you know, asked him, How do you go about managing this? It’s really, really difficult. And then, you know, we got chatting and you know, how about this. And essentially what this technique is, it’s a minimally invasive way of managing cracked tooth syndrome. And this technique involves placing composite resin over a tooth like an onlay, if you like, in supra occlusion, and it can be used before it’s bonded to help diagnose the condition. And then it can be used to help manage the condition as well. And the beauty of it is that where it’s successful through the process of the intrusion, and extrusive movements that take place, it creates the room to put a definitive restoration without having to do very much by the way of any reduction to the effect of tooth. So it’s a way of diagnosing cracked tooth syndrome and treating it. [Jaz]Let’s explore that, because what you’ve covered is in a beautiful way, very short way you’ve covered the whole technique, let’s break it down into individual components. Diagnosis of cracked tooth syndrome is a challenging thing in daily practice, sometimes a pain is difficult to localize, we often rely on biting on cotton roll or biting on a tooth sleuth or something like that. Do you still do that as part of your protocol? And then you maybe would then use the direct composite splint? Or would you nowadays go straight for the direct composite splint on the tooth that you suspect maybe exhibiting the signs of cracked tooth syndrome? How would you go about your like decision making and sequencing? [Subir]Sorry, I was just gonna say, Jaz, you raised a very important point there in that, you know, in practically, that’s the challenge, isn’t it? To diagnose it. And then pretty much when you want to manage it, you want to do something that is not intrusive, or not invasive, so that if for any reason you got your diagnosis wrong, you haven’t done anything to the tooth. And primarily, when you look at ways in which you actually manage it, there do involve a little bit of reduction and therefore putting, for example, band around it and something like that. So there is that aspect of it. And from a general practice point of view, of course, when you’ve made that decision to actually do that is kind of you’ve made an irreversible change in the tooth. The other thing I think it’s important to emphasize is that unlike osseous tissue bone, for example, when you put two bits of bone together and hold it still enough for long enough, then they fuse back together, the fracture mends but a fracture, a tooth does not fuse back together again, it is there and there forever, and it will only increase never decrease. And so you always manage the situation and to get the result from it. So when it comes to the diagnosis, one of the things you have to remember is that you do have to have a technique whereby you want to minimize increasing the crack that you already may have in a tooth. And all that is difficult to locate, you need to be very careful in the history taking, try and locate it as best you can. And try and arrive at a diagnosis by minimally putting a pressure on the tooth. And so when you have a tooth for example, that you’re suspecting that is kind of giving a little sharp pain on recall, for example, on cotton roll or tooth, my presser preference is cotton wool rather than the tooth sleuth because I find a little bit harder, because you don’t want to put too much pressure on it, is that when you use it at the diagnostic stages, Shamir pointed out where it’s unbonded, the response that you’re looking for is that you put the composite over the occlusal, the lingual or the palatal and the buccal, and then you ask the patient to bite and release. And what you’re really looking for is a complete elimination of the symptom. Okay? So basically, you know, before on release that on that tooth, the patient might have reported a sharp response. And now that when you put it on a diagnostic level, it is completely gone. Because if it hasn’t, then it is usually indicative that the crack is a little bit further or deeper than this technique that perhaps would old allow you to control it with. But that’s one of the things that I will sort of emphasize on it. And then of course, this also helps a diagnostic process because if you actually completely disappears, then you kind of know that by providing some sort of cuspal protection and prevention of lecture, you’re able to get the management starting. Sorry, Shamir I interupt you at the very beginning. So [Shamir]I would have pretty much said the same thing in that I still would start off with a history and look for you know, the classic sort of pain on biting or release and the sort of acute thermal sensitivity to cold. Of course, there may be other things as well. And I still do use a tooth sleuth. I know that there are you know, sort of issues with the risk of breaking things with it. And I think that has happened to me once so that there is that risk, but then I would then apply that trial splint as Subir described and then repeat the same test with the tooth sleuth to see if there has been resolution, obviously, you’re looking at the patient’s feedback. And I think the beauty of it is that there are so many conditions, which could be quite easily confused with cracked tooth syndrome, that this kind of does help in that, if the pain still persists with this splint in place, it just gives a further sort of level with helping to ensure that you’ve got the right diagnosis, because I think it is quite easy to get it wrong with there being so many other things which could manifest in a very similar way. [Subir]And of course, the other thing to add to that I was going to say is that the evidence shows that when you have a fracture, as soon as you put a bur to it, or you take any reduction of tooth, there is a high probability around about I think 26% of teeth, then going into the sort of endodontic exposure in endodontic requirement, you know, pulpal intervention. So when you have a technique whereby you don’t actually to have to open the tooth up, there is that advantage and with it. So that was essentially a conservative way of managing something in the process, which could be applicable in general practice. [Jaz]Very much so applicable in general practice. I think the way you’ve designed it, and there’s studies that you’ve done, and the protocols that you’ve written about, which I read are very much a quick and easy to apply once you know and that’s what this podcast episode is about is that disseminate that information, making it easy for general practitioners, practitioners tomorrow to be able to utilize the DCS technique in diagnosis. So, you know, is this a cracked tooth. And if you make that blob of concept, we want to a better word over the tooth, compressing the cusps and containing it. And then when they get a negative response, you can then confirm with some relative accuracy. Okay, this is a crack toothache and it was that tooth in question. But that same composite, how many millimeters are you aiming for in terms of thickness? And is it that same composite that you’re bonding onto a tooth? And if so, how? [Subir]Well, here you might find a difference of opinion between myself and Shamir. Because the but saying, in my personal experience, what I tend to do is use a sort of roundabout a millimeter on the occlusal, or thickness that I’m using now. Do I use the same one? Often not because sometimes I’m trying to do this very quickly on the diagnosis front, so it’s not very neat. And when I’ve completed the diagnosis, and the symptom has completely disappeared, then I would look for approximately about a millimeter occlusally, and then go around the sides. Now, one of the aspects that I feel is important, although there has been evidence to the contrary that I have read, whereby to keep this supra occluded tooth out of lateral excursions, my preference at the moment is still to have it out of lateral excursions contact. So essentially, if a canine if I can add a canine rise to actually lift that out of lateral excursions or any excursive movements, that would be my preference, rather than having any lateral load. So it’s essentially a axial load on the tooth as far as possible. And I use sometimes a million and sometimes even less than that, for this phase. I don’t Shamir what you feel, but I think you wanted a bit more than that on the occlusal it show [Shamir]Yes, for the trial one, I will probably use a you know approximately a millimeter. As you describe sort of flat on the occlusal surface, wrap sort of, you know, 1/3 of the way down the axial walls, buccally and lingually, or palatally. I’ve never reused the same, never rebonded the same thing back. So I would always make a fresh one. My skills with composite artistry are not to the same level of Subir, so it would have to be remade. But I would normally be looking for about a millimeter and half in thickness. Just to sort of, I think that we know from studies that we’ve done with tooth wear, etc, that you know that the actual height you build into the resin restoration has a substantial impact on its survival. So I would normally be aiming for about a millimeter in half. But you know, once I’ve satisfied with the diagnosis, then I would would remake the thing. Pretty much how Subir is described, keeping it flat on the occlusal surface and out of contact during lateral and protrusive movements. [Jaz]That the thing that initially confused me when I first heard about the technique because in my mind, only a few years qualify the way how is that possible to build something in Supra occlusion, but then also have it out of excursions. But then when I actually did it, I found that okay, when the patient does excurse and you mark it up and you mark up the centric stop, where if you just get rid of the lines and keep that one dot sometimes it just works out but you’re also raise a good point Subir that sometimes you may need to add a canine riser. How often does it just work? And how often would you actually have to add further anteriorly to aid that disclusion [Subir]It depend on the occlusion that is at the moment, you know, depending on the existing canine slope and the existing slopes, cuspal slopes that you have. So it’s very much dependent, but it’s something I feel that needs to be checked. And one thing about canine risers which I think our experience, what my experience has been is that sometimes when you add a canine raise, if you added inappropriate, in other words, it’s too much, or it’s beyond that, if you like threshold of tolerance, then the composite tends to wear off very, very quickly. Whereas when it’s within tolerance, it tends to last for a long time. So if there is some canine wear, then it works best, you know, then it can kind of almost dictate the fact that it’s going to be alright. And if there isn’t, then you might just be a little bit prepared for the fact that they’re composite that you’ve added to give that disclusion, might actually chip away or wear away really, really quickly. And if we have to come back to this mean, in other words, you don’t put the splint and forget about it is you have to monitor the response. So I couldn’t tell you sort of a number on this. But you know, and but it’s quite surprising that you know, the number of times that you have to raise an canine rise, or not that many, but it really must depend upon what is a class one, class two, what sort of whether it’s lateral guidance is shared by a group of teeth or not. And whether or not you know, there is the slopes of the cuspid that involved. So it’s been a combination of those factors. [Shamir]So if I just pick up on that, in the actual study that we did, there was a sample of about 150 patients, and Subir is quite right that the number that was only 12 and a half percent or so off the sample where we applied a canine rise. So it’s sort of my experience, anecdotally as well, you don’t end up placing it that frequently. And that’s got it kind of benchmarked in the study data as well. [Jaz]And that’s good. That’s what we want as GDPs, we want something quick and easy in that emergency appointment when they got cracked tooth, and to not have to add another additional thing and explain to the patient that, that would be quite helpful actually to have to do that. So when I’ve done it, it has worked out that on excursion, because of the cuspal slopes were in my favor, I was able to avoid it and lateral excursions. Now can either of you or both of you just describe the exact protocol for because a lot of times crack teeth involve amalgam restorations. So do you, are you air abrading the amalgam? And then you’re using a universal bonding agent? And then you’re just building it and molding it using a flat plastic? Or is this under rubberdam? Or is it not? Just describe the workflow and the protocols, if that’s okay? [Subir]Well, for me, if I’m kind of facing an amalgam restoration, then yes, you can air abrade the amalgam and then you put it over the top of it in the first instance. And then that would be to give you the emergency scenario the control because then you would actually want that patient back. And then once it is kind of settled down, and you confirm the diagnosis and the response to what the therapeutic measure that you’ve applied, is working, that’s when I would take the amalgam out and then proceed to do the restoration and hopefully, because I’ve got the occlusal height be able to restore that. So that would be my protocol if there was an amalgam in the tooth, initially, because usually when you’re seeing this, you’re seeing it at a time of day when you want to get the patient comfortable and relieved. So you kind of, I would air abrade the amalgam and then go over the top and if it’s an MOD amalgam, I would leave the of course, because it’s just going over the occlusal and the outer surfaces that the amalgam stays, but then on the return visit when we’re confirming that I would remove the amalgam and restored accordingly. So that would be my protocol of doing it. Otherwise, if it was a tooth that was completely unrestored and there is no restoration in it. Then of course, it’s a question of air abrading the enamel making sure it’s sort of nice and clean, isolation is good. And then of course, place the composite bonding agent and then place the bond, the composite on top. My personal preference for bonding still is the three step technique or you can use a two step technique rather than the self etching once that’s that works better in my hands. And then of course enamel bond is very predictable as we know and the more enamel we have, the better and that will be my protocol for restored or an unrestored tooth. Shamir, I don’t know if you want to add something to that as well. [Shamir]Yeah, I think mine’s pretty much the same. I tried to put a matrix band around the tooth when sort of doing the adhesive conditioning to try and help make sure that the material doesn’t stick to the adjacent teeth. In terms of the contouring, just a flat plastic or, you know, composite instruments. There’s no merit, there’s no yeah, the old finger, spade, there’s, it’s kept fairly basic, there’s this, there’s no real attempt to sort of, you know, make it look anything fancy. And as long as it’s splints, the fracture is in the right location, and obviously has to be kept flat, to try and help sort of putting those lateral loads on the tooth. [Subir]I think it’s an important aspect here to also draw attention is when you do go to, it’s quite interesting that in both my practice, I’ll find as well as I think we found in our study is that, of course, when patients get very, very comfortable with this and the occlusion equilibrates, after a period of time, patients are very reluctant to have this off again, you know, particularly if this very, very comfortable, so you kind of have this sort of a flattish molar at the back. But if you were to restore and replace it with something like indirect restoration, once you have that space, then it’s important to stress that the cuspal angles that you want to put in after on your restore on the indirect restoration have to be fairly free in excursive contacts, because you really don’t want to recreate a scenario where there’s any chance of this sort of forces that split the tooth, or create courses like that, again, developing in your sort of range. So looking at it from an aesthetic point of view, you may be compromising a little bit on the lovely cuspal angles and fissure bands for the sake of limiting the load on that tooth. Because you really, because it like I mentioned before the crack actually never heals, it’s always there. You’re just managing the problem. [Jaz]I’m just gonna acknowledge that Vimal has been asking some questions on the live and I will get those very shortly. But just so in the interest of the of the workflow. So thanks for describing the step by step. Now, if you’ve played this, according to the research you’ve done, how long do you typically need to wait before you are happy about the pulpal diagnosis and the diagnosis that okay, that the pain is now gone and you can proceed. And also, just describe the what you mentioned before, Subir, about the relative axial movement, it’s almost as though in my mind is as though the supra occluded restoration and the tooth itself is intruding? And then that gives you the space to add your cuspal coverage. So you can be very minimal. Is that all that’s happening? Or is the opposing tooth intruding a bit as well? Do we know exactly the mechanics of this a bit like, how does a dahl work, right? How does this technique work in terms of the relative actual movement? [Subir]In my view, I think this is sort of a combination of several things. And it’s very difficult to determine how much of what happens in the other. In my opinion, I think there is an element of intrusion extrusion that takes place posteriorly. But the very first thing that happens is a condyle repositioning element. So essentially, it’s like putting a little jig in if you like, and the first thing that happens is a condylar repositioning at the back. And then that immediately creates a bit of room as you know, there’s a little bit of room co CEO and CEO and a lot of patients. And that’s the first thing that happens following that it’s a kind of a sort of axial movement, both intrusion extrusion, eruption, overeruption of the surrounding teeth. My thinking on this, and this actually, when I used to lecture about it, almost 20 years ago, in places like America, where this concept is quite can be challenging to explain them except the issue is really, that when you have something like this, that the teeth are coming, drifting back into what I would term as the neutral zone, you know, and kind of reestablishing the contact, according to that. And the fact that there is a few like an obstruction in the way that teeth that are moved back into the. Now sometimes we find that we may have pushed this technique, so in other words too high, and so it comes almost back, but not quite. And of course, if you’ve done it in something reversible material, then you can adjust slightly in order to fine tune the equilibration in that way. But in a lot of cases, particularly if there’s tooth wear, the amount of adaptation that takes place is quite surprising and quite consistent in my experience, it’s very rare that it doesn’t. So that would be the kind of criteria there for it. So it’s a combination of movements. I think initially it’s a condyle repositioning, and then it’s a combination of the intrusion extrusion of certain teeth. And of course, there is no permanent increase in the vertical of the patient at all because it’s sort of reestablishes back into work actually kind of showed and then you’re going to establish that but then the professor is that sometimes if you’ve just overshot the threshold and the tooth and some of the teeth do not restore back And the timeframe you’re looking at is around about a three month period when these sorts of things happen, then you may have to adjust the occlusal of the composite. To answer your question as to when you would replace this composite. Like I was saying to him, practically pragmatically, what happens, a lot of patients resist this change. And sometimes if they do, if you’re using nanohybrid, composite, which is flat, and they’re not worried about the aesthetics, I have instances left behind and then carefully monitored, and made sure there’s is no wear and to be honest, it’s a sort of a safe default position to be in if you kind of control the situation like that, if not round about the sort of the, I would say the month to month limit is where you would look to sort of replace it if you wanted to. But I have a lot of cases whereby, once managed, very few patients do not take it to the next level. [Jaz]It’s a bit like some patients, when you place the ortho in, you used to place the ortho band and as some practice will do, and then they like it, and they don’t want you to then place the crown or the indirect restoration, because they’re happy to have this ugly ortho band on but it’s not really a symptom, so very much in that way. Shamir, did you want to add anything to that in terms of how long to wait in your experience? [Shamir]Yeah. So in terms of our study, which is obviously based on our own experience, my sort of thinking is, normally would say to patients that look, if you’re not happy with anything with the symptoms, let me know, straightaway. Usual review period initially would be two weeks. And what we found in our study is actually all the wear, all the problems were, that kind of happened within those first two weeks. So we had about 20 patients of which 16 they developed irreversible pulpitis or the fractured progress to a complete fracture. And those patients, those were identified fairly quickly, we had four patients who sort of expressed intolerance. And that all happened within the first two weeks, the rest of the sample pretty much progressed to the end of the three month period. And we did a review at four weeks, and at three months. And again, what we kind of found is that all this sort of niggles, and the adaptation, that all took place within the first two weeks, yes, at four weeks, these patients were quite happy. And I suspect that may well have something to do with the you know, the adaptation, the condylar repositioning that Subir was talking about, together with some central adaptation with a patient sort of brain starts to accept that I’ve got something that’s foreign, which is proud. Many,, it was quite interesting to see that the change in, you know, the sort of things that people were complaining about going from the two week to the four week. So usually, in my experience, if you’re going to see things wrong, you see pretty quickly. [Subir]Yes, and I think Shamir hit upon something quite important that is patient management, because the patient has to be carefully managed to see what to expect here, you know, because to them, of course, you’ve just explained to them that this tooth is cracked, and you’re making it high. And the first thought that going through their mind is well you know, this is a little bit contra productive, isn’t it? Contra-intuitive, rather. And it’s just basically the management scenario because of course, when you make that tooth high, the forces on it, the general bite force is actually a reduced on it, because of the fact that it’s sort of a if you like an interference on that in the thing in occlusal system. So there is that aspect. [Jaz]Could you describe, Subir what you actually say to patients if you don’t mind? Because you touched on it, I’d love for you to just give me like your one minute spiel on what you warn the patient. I mean, I know Shamir said, even, you know, if any symptoms raise any issues, you know, let me know. But is there anything else you say in terms of fine tuning movements may be affected? Take some painkillers, I don’t know. What is your spiel? [Subir]My most feed in practice is once I’ve identified the tooth and kind of confirmed a diagnosis with the patient, as if this is what has happened. I think the analogy that I used about bone fracture, which a lot of patients can identify with is quite useful in the sense that bone fuses to back together if you hold it still enough, but a tooth is not going to do that. It is a splint and it’s splint there for Life is nothing you can do about it. And there’s nothing, even if I make it short and you bite on it, there’s nothing that will happily come back and erupt and the same forces will apply. You’re never going to stop chewing on this tooth. And that’s the reality of the situation that this is the problem that we have. And the next step of that is that to going through the all the alternatives. And it’s very important to point out to the patient that all the alternatives that are available, including the if you like the bands, etc, etc. And then of course, for then when you look at this particular option, and you look into the advantages and disadvantage of it, the reason why it kind of appeals to patient that you kind of say, well, I’m going to put it on right now I’m not going to cut your tooth, and all I’m going to do is probably not even a local that’s required for me to do it. And hey, if it doesn’t work, I can always reduce it and there’s that added factor and this of course you have to throw into that factor of the disadvantages is that if I use some of the other techniques and there is a higher proportion according to the evidence of the going necrotic, or reading root canal treatment. And then of course, when they get, when you get them on board on that is to just be absolutely plain, you know, honest with themselves, you’re not going to like me for this, and this is the exact words I use it in, I’m going to do this and you’re not going to like me for this. And but there is a reason I’ve just explained to you the reason I’m doing it, you’re going to find it very difficult to eat, and swallow and find satisfaction to eating with this. But usually in about the two week time, you will start to tolerate it better. And you’re tending not to get pain from it, but more of an annoyance, it’s not going to. If it hurts, you let me know, okay, give me a call and let me know straight away. If it’s annoyance, and it’s just bugging, you can’t chew properly and you can’t get the satisfaction of chewiing, then please tolerate it, we’ll see you in two weeks to see how you’re getting on. So that’s the sort of the spiel I kind of used. Because I do paint a picture of that we are in a situation which is very difficult to manage something that is not going to heal. And, of course, it’s important to also point out to the patient that the situation can escalate. Because it’s a crack, it’s we’re trying our best to hold it together. But nature is what it is. And the forces are what they are, this is going to be an issue. So that’s my usual, the build up to it and preparing them for uncomfortable time. But for a good cause. And that, it’s also the fact that it is got a reversible element to it. And I haven’t cut the tooth, which is if you like the seller of it and his tooth colors in there is not, you know, there’s the knob looking at something that’s metal. I don’t know, Shamir, if you have any other added tricks with that? [Shamir]No, not really, I think it’s the same thing, same sort of spiel that I would normally give in, of course, where we’ve used the trial version to assist with the diagnosis, they’ve already had that experience of what it feels like with having something proud. And I know with some of my patients, you know, you put it No, no, I’m not having that, you know, I’ll come back or go for Plan B, but I’m not having that. So that I think having the trial thing, there’s also you know, help with the process of obtaining the consent, but the spiel is pretty much it, this is how you described it. [Subir]Can I ask you Jaz? I mean, I know you have done this yourself. What we have said, is there some something else you would say to this? Or how do you or when you do it for your patients, what sort of do you say? [Jaz]Very much the same as what you guys done, you know, undersell overdeliver, explain that, you know you’re gonna hate me initially, I love saying that as well. They’re gonna hate me but it’s for a better cause. The bone, the thing that you said, my old principal Amit Mohindra in Oxford, he used to use the same thing. So I also use. So it was cool to see that you also communicate in the same way to patients. So very much the same. So I don’t have anything to add to that except whenever I’m explaining the different things that can happen. I do like to quote study. So for example, Shamir, you mentioned that in that study that you did, I think you said 16% went on to experience irreversible pulpitis or the crack, becoming, making the deem the tooth unrestorable. And I would say, you know, in some studies, this could happen. So let’s say one out of five times your tooth, because the crack is already quite bad is not going to make it. And I like to just give those figures to a patient. Obviously, we can’t apply studies to that individual. But when it’s more average case, I like to just give them a few numbers about Okay, well, we’re aiming for about this percentage of success rate. Is that a fair thing to do Shamir with your position in the GDC? Is that a fair thing? Or is that? Is that incorrectly applying study to an individual? [Shamir]Well, I was gonna say that whatever I say, is my own opinion, and not the GDC. Let’s just make that clear, but I think it’s fair that to, you know, when you’re looking at trying to attain consent, you know, you’ve got to be done in a logical balance, accurate. And of course, we’re trying to do it in a scientific way. So I think it’s fair to use studies, and is you said that there was 16 patients out of the 150. So not quite 16%. So yeah, it was a lot less than 16%. But if we look at the number of the overall sort of 20 patients, whether there were problems, effectively, that’s in line with what you see with most of the other protocols, which were just sort of mainstream. So, in terms of the success of the procedure, it is in line with what you may expect with you know, a direct composite onlay or an indirect composite onlay, or even a crown. However, as severe said in the beginning with crowns, we know roughly a fifth of these teeth are non vital within the first six months. And we also know that the prognosis of root field crack tooth is also poor that you don’t certainly that’s not what we found within our study. So look, what we would say to patients, what I would say is that whatever of these techniques that you use, there is a chance it is not going to work because we don’t know how deep this crack is. And it’s very possible, it’s hovering right near the pulp chamber or right near the sort of the periodontal ligament. And it won’t matter which technique we use there about, you’re still going to get the same outcome. But I think I kind of do like the idea of quoting studies how you do, as long as it’s articulated in a way that the patient understands, and sort of can make an informed decision from that. [Subir]I think this is important point, as you raise Shamir as you build more talk about discussing, everything should be fairly comfortable discussing evidence, of course, the numbers might not be in there, but you generally are quoting, you know, quoting evidence. And I think that’s important. And I think in level of consent, I would go more towards Montgomery on this one, rather than Bolam, where you can actually go to every little bit that and it’s easy to describe because it is a situation that is non healing. And it’s kind of, if you kind of stress that with the patient, that is, this ain’t going to get any better, I’m just managing the problem, and make sure that they’re aware of the risks. And that is the best way. And I think I offer not just in this particular instance of cracked teeth, but in a lot of treatments I do, I’m always looking at reference, quoting references in a way that the patient understands. You know, in fact, I hope just to go through one particular patient for tooth wear he came in, and then he’d read all the papers that were written. And so he was quoting the stuff that I’ve written several years back, which I actually didn’t remember at the time, which is a bit embarrassing. So, you know, our patients are very knowledgeable nowadays. So you have to be aware of that. [Jaz]I mean, I have an episode out with Kreena Patel all about I hate cracked teeth. And we talked about, she talks as an endodontist, about management cracked teeth, and it was very generic cracked teeth episode. But it’s one of those things where I can’t emphasize enough now you guys, I know you guys have done it as well, where we as a group cannot emphasize enough the importance of really over egging the communication part in someone’s got a cracked tooth, because it’s something that can be a source of stress for a dentist that you know, they intervene. And then a condition that was always inevitably going to get worse, because of the nature of root crack get does get worse, and then the dentist ends up owning the problem rather than the patient. So those you know, younger clinicians watching, listening, you know, when it comes to communication and cracked teeth, you have to do your due diligence and have to spend the, even when you run a couple minutes late, just in a calm tone. Explain that, okay, there is a crack, it may get worse. And that’s the reality of it, we’re trying our best. But there’s a you know, this, this could very much lead tooth loss as at worst case scenario. Just in the interest of time, you know, we’ve covered so much ground, which is fantastic. I’ve got some questions in as well. Before we do that I’m gonna just finalize the sort of the clinical protocol element, which is, imagine you’ve put your direct composite splint on, it’s been on a lower molar, on a lower first molar, let’s say, it’s been there for it’s got past the two weeks point it hasn’t dropped off, patients tolerating fine, you haven’t needed to do any adjustment or anything. You see the patient again in three months. And now, would you find that in your experience that the bite or all the other contexts have fully established? Or would you find that they’re almost established, but not quite? And then the second part of that question is, when you flick off, or drill off back end composite, how much space do you usually get? So all that 1.5 millimeters, do you find that you have got 1.5 millimeters or around about a millimeter to play with [Subir]In my experience, the various between patients by round about three months, I’m kind of finding all the other contacts reestablished, in my experience, is that three months in probably about six months is probably the longest I’ve seen it personally. But I do believe in the literature that it varies, you know, in that, but I think after the three months, if I haven’t established all the contact, I’m maybe looking at adjusting the splint a little bit until I do that kind of level. So we were looking at that, of course, you know, we make a note of what the occlusal contacts were before we started, which, essentially all shim stock, if I was to be pragmatic about it. As to model space that’s left behind for the ones that we’ve taken away. It’s about that, I think it’s you kind of, if you had placed a sort of a millimeter, millimeter half of composite on it, But then by the time if you are doing something in the sort of within the six months to a year limit, then you’re probably not seeing a lot of wear on that composite you will get, a lot of that space that will never ever fall off because you’re born into enamel, so that I’ve never had a case scenario where they actually fallen off tall because you’re bonding very well to enamel and that’s fine. And that’s what you get. And of course, if you are also managed the patient, I tend to sort of prepare them for a crown which is also rather than onlay not a crown, which is going to be a little bit sort of bulky on the palatal and the buccal aspect because of that control, because I really don’t want to cut tooth after all of this is I’m just going to sort of polish the composite off of that. Now, the difficulty comes in how you provisionalize this in that interim that it takes you to make the indirect one. And sometimes I find I add to the opposing tooth, you know, or, you know, you can actually if you book it with the laboratory as soon enough, then you can actually get the onlay back as soon as you can with it. Or if you’ve got a CAD CAM, I guess that there’s a bit although I don’t have an experience in CAD CAM-ing it, but that’s another way of doing it, if you want to do. The difficulty comes in that interim stage as to managing it for that period of time. But that’s my experience on it. But like I say a lot of patients are kind of what I’ve done, a lot of the times, it’s actually just contoured the composite into making it look prettier, or closer rather than having it flat. And that’s a lot of the time that I do. But that would be my observations on it. And my ingot of choice is gold alloy, but a lot of patients don’t want that, the lithium disilicate, you’re really looking to bond onto the tooth again, in order to really restore the integrity of the tooth. And Electromatic over know that that is? [Shamir]Yeah, I mean, my experience is fairly similar. If we go back to the study, in 97% of the sample, the contacts are established. And this is checked with shim stock within that three months. So we know that it is with good case selection, it’s fairly predictable based on this, it’s quicker than what we find with anterior teeth probably to do with the loading. And that comes back to the point that you made with the amount of space, I sometimes find that it’s very difficult to judge whether you’ve actually got that 1.5 or 1 or whatever, I sometimes find the space isn’t quite as much as I would have hoped. And I suspect and this is when I’ve spoken to colleagues of uses, I suspect there may well be some element of wear of that composite, which may also mean that, you know, the contacts are establishing a lot quicker posteriorly than what we see anteriorly where you’re looking at a longer time, certainly with the dowel studies, they’re sort of a nine month period, whereas this is a lot quicker. So I think that there may well be some wear and tear of that composite that takes place. But again, as Subir’s sort of alluded to, more often than not, I will just replace it with a new direct composite, which will look a little bit nicer than what’s already gone on there. Rather than I’ve found that the provisionalization. And what happens in the interim, leads to more headaches. And it’s a case of you sometimes learn from getting it wrong and getting your fingers done. [Jaz]So essentially a direct composite overlay? [Subir]Yes, essentially. So you kind of just basically refine what you have there, because a lot of it is still bonded, especially if you bonded correctly in the first place. And if you’re not really involved in replacing an amalgam and stuff like that, then of course, you can just modify the one you have placed. And that’s the one with the least risk because then you don’t have to worry about provisionalization not worry about going back to our cutting. And that’s the easiest way to manage it. And if need be if you want to strengthen and weaken add a bit more composite to it on the size if you need to. So that I have to say that is my first preference to manage it with it. And to resist the temptation to actually remove is something that’s working. Because remember, as we said before, we’re managing the problem, it’s kind of thing. The other thing to add to this whole management scenarios, and then just sharing a little bit of my experience here is that with this scenario, and then the thing that I specified to my patients is that I’ve taken the least step possible to get the result that I want, you know, and so when you’re managing a cracked tooth is important to take it in steps like that, rather than go straight for the endodontics as well as you know, start following the crack endodontics. And doing it sometimes as this allows that to happen in a more controlled way. [Jaz]Great. And it’s great that you mentioned that in your experiences, they very rarely come away because they’re well bonded. I think that’s partly probably to do with the fact that it’s usually in compressive loading sort of hugs the tooth and probably even cures towards the tooth and just thinking out loud. And the other thing is because you’ve managed the lateral excursions on it, there’s going to be less tensile shear forces on it and we’ll be dipping into the sort of the cuspal incline so very much isn’t compressive. Have you ever seen any cracks split in three or four? Get cracks and come lost in that way? [Subir]Not on these? Not on the one’s we bonded well, that’s not been my experience. [Jaz]And in the study? [Shamir]Yeah, I mean, I have an in the study as well that probably my ones ?? work but not cracks as such, but sort of odd, you know, bit of marginal chipping or something that that which is easily repaired rather than having to go in and redo the whole thing. I think the key is making sure there’s enough height to this, that the height is critical, but there will be some, you know, areas where, you know, maybe towards a marginal ridge area where they you know that the height isn’t quite what it should be. And you see a little bit of chipping or whatever, something that that can be readily repaired, but not a case of, you know, a complete sort of fracture where it needs to be re done, No. [Jaz]Okay, great. Well, we reached that point. Now, in the last 30 minutes, we’ll just take some questions. So if anyone’s watching the moment either on YouTube or Facebook, and you got any questions, If you’re on YouTube, please come on Facebook, because I am not reading the YouTube comments at the moment. I’m just reading the Facebook ones. But I’ve got some questions from beforehand on our Facebook, on the Protrusive Dental Community Facebook group. So question one, we’ll go with [Schweter], woudn’t, keeping a painful suspected, fractured tooth high, add occlusal load on the single tooth and make the periodontium sore and worsening the pain? So this is like the very classic, instinctive response of a dentist who comes across your study and your technique for the first time. Right? And it’s those sorts definitely went through my head. But I mean, Subir, you’re a man, you already mentioned before, it’s a bit like those studies where they’ve introduced interference, they found that patients were bruxing less, and they were actually chewing with reduced EMG forces. Is that what you do? Is that what you think’s going on here? [Subir]In my view, yes. In fact, it’s not just [Schweter] that sort of had this heartache. Reviews of the article, I know, on hindsight, had the same sort of when it was published in the general dentist, you had the same sort of anxiety. And do just to reassure that though I did receive the written communication from later on quite later after the article and research was published as to how this phenomenon it does kind of doesn’t have that effect that you mentioned, two things that it tends not to happen because of the rationale that reasons you mentioned. And that’s what the color of the study is showing. Of course, this is also a technique whereby you can actually reduce it as well. So in other words, you can reduce that composite doubt, the main issue, the reason why it works is because you’ve kind of eliminated the primary reason why the symptoms of there’s with a tooth flexing. So by doing that, but yes, it was, it is kind of sounds counterintuitive, but interestingly how the actual your own body actually protects against that lower, Shamir, anything to add to that? [Shamir]No, not really, I don’t really want to go into the sort of physiology of it, because it probably don’t understand it that well. But I think when you’ve got something that with the simulation of the you know, Periodontal proprioceptors, it probably triggers some kind of a reflex bit like what Jaz was alluding to, which therefore means that it actually isn’t something that gets blasted away. It’s odd, isn’t it? When we put our restorations, which at times a proud by a whisker, patients will come back. Whereas with this, it’s funny that you go through the consent, and you go through the spiel. And you know, you’ve been through it. And on the odd occasion, when you may have not done it as well, that person will call that I think that the psychology has a big role to play as well in that, you know, the patient knows what to expect, and therefore they’re able to adapt it. But yeah, I mean, the concept, when you look at it in the way that, you know, [Schweter] kind of described it, it sounds ridiculous, that why would you do that? But well, the proof is in the paper, or the pudding or whatever you want to call it. [Subir]But saying that going back to the, sorry Jaz, as I mentioned, one other study that is actually the it’s not particularly new, this concept in the Senate is reported in the 60s, but in a paper directly forget to pop my head, but essentially, isn’t simply because you wear a particular tooth was put in Supra occlusion, and how essentially that the equilibration took place. So it’s not really something that’s absolutely news being done there as well as other studies. Now, of course, the bit that’s new is this effect that it’s a cracked tooth. You know, that’s the main challenging bit with this bit. But for to answer this question about the periodontium response. That is not unusual. It actually has been done previously. And without these effects. So it’s not, it’s the putting on a cracked tooth doesn’t seem to affect that aspect of it at all. Anyway. [Jaz]Great. Next question I’m asked is by Vimal. Let’s see, I think essentially, is once you come to the three month mark, and you’re let’s say, you’ve removed the composite and it’s got an amalgam inside and you can remove the amalgam this is just general crack management, because everyone actually has got a different opinion. Everyone’s got different threshold. So both of you, gentlemen, how far do you chase the crack is the question from Vimal. [Shamir]So okay, I’ll go first and this is where we may differ slightly? I don’t know, I tend not to chase cracks, I tend not to chase them. Try to splint conservatively where possible. It’s a question that I get asked all the time, especially from students and colleagues in Australia for some reason about chasing cracks, including on teeth, which are asymptomatic. I tend not to chase cracks. You know, once I know the diagnosis, take the amalgam out if that’s required, and you know, seal that intracoronally and then put the extra coronal overlay on top, I tend not to chase the crack. [Subir]I actually, Shamir, I agree with you. I don’t either. And I think that kind of, you know, we could we come across as when I was lecturing in the States, it was a similar sort of phenomena as in Australia, funnily enough, it’s half of Australia. I don’t know what is this little half of it kind of agreed and the other half doesn’t, or something, but it’s quite controversial in the Middle Eastern and Asian countries about this. But no, I don’t chase cracks either. Providing we have kind of established the symptoms are controlled. And I think that don’t chase the crack. [Jaz]With me, gentlemen, I went through a phase of at the beginning very early on my career thinking that was the right thing to do, chasing cracks just because that’s what I was taught by the certain mentors I had or clinicians that were teaching me, then a chap called Pasquale Venuti, who I’m recording with on Saturday, he gave a lecture, he said that, the most dangerous part of the crack is the part that you can’t see. So all this bit that you’re chasing, you’re still never gonna get to that bit where you can’t see, which is the leading part of the crack, you know, and you won’t even see that. So why are we weakening the tooth by chasing it? So that really was playing on my mind. And then I was with a group of dentist, very good dentist, and they sort of ostracized me for not chasing crack. So now I’ve gone back to chasing cracks. So I’m glad I met you two. And you two, don’t chase cracks. But there we are. We don’t know really, what is the best way to go. But there we are. Now we know what Subir and Shamir do. Let’s see, I’m just reading some more questions, just for contact points. So what bands do you like to use for to get good contact points? So let’s say Shamir, you’re using your direct composite overlay technique. Any preference of bands to get good contacts? I think it’s a question really. [Shamir]Yeah. I like using the the garrison sectional matrices, which are Teflon coated, dead soft matrices. I’ve been using them for quite some time now. And that’s my personal preference. Certainly, for doing standard, you know, regular composite work. I’ve used those as well. I stopped using circumferential bands, which are not good for crack teeth as it is anyway. A while back. [Subir]Yes, my preference is the same as a sectional matrix band, Garrison’s the ones I use as well, are the only thing I would add to that I use a lot of customized wedging, I don’t rake very much customize the interproximal wedging of my band, whether it be with different types of wedges, whether it be PTFE tapes, or most similar, sometimes even Greenstick, just to actually really customize that band. [Jaz]Wow, I’ve never had a green stick being used in that way. Pretty cool. [Subir] Yes, I’m showing my age here. [Jaz] Excellent, fine. And it’s got one last question. There are a few more from Vimal by an interest of time. Can I ask one more before we wrap up? This is from Zain Rizvi, really talented young dentist. I found patients just don’t like how it feels. What’s the best way to get around it? Is there anything more than just patient management and communication and underselling and overdelivering? Or Have you got any little tricks up your sleeve to make it feel more comfortable for patients? [Subir]I think the explanation is to the non invasive nature of what works with me in the sense that, you know, the all the other things I’ve got to offer are invasive, you know, and the fact that the most likely that I have to put a local in usually swings it my way as well as say, Well, I don’t have to give you a local for this one. What do you think? And the reversibility of it. And I think the combination of the reversibility and the uncertainty of the diagnosis and the manager prognosis of it kind of swings it in my favor. But yeah, I mean it mainly is this fact that I have to say that the all the other ones are very invasive. And but at the end of the day is about informed consent, and the patient will have to consent to the treatment. So that’s important. And they may if they’ve been misled as some of you for some patients don’t like the idea of being high on that. So we have to do something else. [Shamir]Yeah, I guess from my perspective, it pretty much the same other than what I can do with this is treatment there and then, whereas, before it would be usually be there’s sort of an amalgam or something I used to splint it with direct composite as an interim measure. Can’t use orthodontic bands or copper rings, or it would be a provisional crown. And again, I used to really struggle with getting these those teeth numbed up. I remember when you know 20 years ago, putting temporary crowns, provisional crowns on these teeth. Trying to get these teeth numbed was a, it was really difficult. And I think patients liked the idea of, well, if I get it treated now, and also that you know that the fact is, if I can’t see them straightaway, it may take a week or two, the crack, make progress, things could get worse. And I think that the selling point being that well, something can be done now and look, hey, if you’ve got problems, come back tomorrow, and we can take it off and we can look at Plan B, that seems to be the thing that sort of flips, it doesn’t always work. But that seems to flip it. It’s patients sort of saying okay, fine, we’ll let’s give it a go. [Subir]The other thing that also is supportive is the fact that the diagnostic element, you know, if you put the diagnosing the patient in themselves experience, the completion symptoms being gone, which they did experience a second ago, that’s often sways them as well, because it kind of worked that work, the pain is gone. And yes, it feels awkward, but it’s not hard as I bite, it doesn’t actually hurt anymore, as they were doing because I don’t know if you’ve ever suffered from a cracked tooth, but it’s the pain is quite can be quite unnerving. Excuse, unnerving sometimes actually shoots into the jaw. And so the almost worried about biting and they suddenly think, oh, wow, I can actually really put pressure, and then sometime that convinces them. And so the diagnostic element is quite an important element, both from clinical as well as patient acceptability point of view. [Shamir]I suppose the other thing that we have is that we’ve probably been seeing the same patients for a long time, which is a common theme. And I think that trust element probably has a role. And that may well be I think, Zain, you said you know, with a younger practitioner who may have not had that same level of history with that patient and I think that trust thing certainly even when using dahl with the tooth wear cases or whatever, I think it does, I think its got a role to play. [Jaz]Very fair point. Gentlemen, The time has really flown by it’s been really great to have you guys on. I really enjoy this chat that our went really quickly just like when I asked you in February to come onto the show. And we booked for November and how quick November came by you two are the busiest people I know. So it’s really great to finally have you guys on. At the end of the show, I usually like to find out where we can learn more from you, if you have any courses or website because a lot of people listen and they you know what I like this person if they got any educational work and I read the papers, etc, etc. So Shamir, tell us where can we learn more from you? Are you running courses? I know you’re really big on tooth wear that kind of stuff? [Shamir]Yeah, I mean, but both of us teach at Kings on the MSc in Aesthetic Dentistry. I teach at the College of Medicine and Dentistry on their MSc in restorative. I tend not to do too many courses and stuff outside of that. Yeah, we do write, do a fair bit of writing. We’ve written textbooks, as well. Subir is probably more, does a lot more hands on stuff than what I do. [Subir]Yeah, I mean, yeah, apart from Kings, I’ve just launched my own diploma and Master’s program with the University of Portsmouth. So recruiting for March of next year. So if anybody’s interested do let me know. This is a master’s in advanced aesthetic and restorative dentistry program, which you can actually do a diploma in with us, where I teach along with my faculty, and then you can take it to a master’s with University of Portsmouth. If you want to masters from an aesthetic dentistry from Kings, of course I manage that program as well. I’ve stopped doing shorter courses, I do two lectures, the others you have you’ve mentioned Jaz, but I prefer structured learning I always, I’ve always a big advocate of that. I think the shorter courses fit very well after you’ve got the sort of the second sort of foundation of the postgraduate structured learning I think so you have a structured learning and undergraduate level, then you have a structured learning at postgraduate level whether it be towards specialist or a general practice. And then from there on, you can really then add to your skills by adding short courses going around the world and listening to people speak. So I’m a big proponent of structured learning at the postgraduate level, I think that has to get the whole picture whenever I run short courses is very difficult to give the full picture so we’ve always kind of done that and I think that’s definitely my big thing on it. Do it structured and you know, just invest time, it’s worth it. It’s worth pays off in the end. [Jaz]I still really want you to think of IPL 2022 And if you can do it in Punjab and not in Mumbai, that will be even better. So I can be there to watch the Kings 11 Punjab play. Gentlemen, it’s an absolute pleasure to have you on. You’ve been absolutely fantastic. Really great to learn from you both just gonna end the live video on Facebook. Goodbye Facebook people. Amazing So yeah, that was absolutely fantastic. I really enjoyed myself. Thanks so much for coming on gents. Jaz’ Outro: So there we have it. This crazy weird technique called The Direct Composite Splint Technique for managing cracked teeth. Check out the papers. It’s too controversial for you. I think you can still use it as a diagnostic aid. Anyway, hope you enjoy that and I’ll catch you in episode 99. Oh my goodness, we’re approaching 100. I’ve got something special planned for 100. You knew I would, right? You knew I would. Okay. Anyway, I’ll catch you soon Same time. Same place. Take care.

The best articulator is the patient’s TMJ, but you knew that already, right? As a dental student I was always confused by Facebows in Dentistry and their role. Lots of clinicians I respect used facebows….but many others do not! What role do Facebows play in relation to Articulators? How can we make sure that articulators mimic the human articulation as accurately as possible? I am joined by Dr Salman Pirmohamed to end our confusion with Facebows! https://youtu.be/l3MrLVTYsz8 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: If you’re planning to increase the occluso-vertical dimension (perhaps for multiple restorations or an occlusal appliance) and you know the final vertical dimension, try recording your Centric relation record (or whichever bite religion you follow) AT that desired vertical dimension and NOT at the ‘first point of contact’. This is because traditionally when we send the technician a first point of contact bite, they will open up the pin to give you the space that you need for the restorations and optimal aesthetics. The problem with this is that it introduces an error because the arc closure/opening of the patient is likely going to be different (even with the best Facebow in the world) to the arc on the articulator. Therefore, reduce that error by doing your bite registration, not at the first point of contact, but doing it at where you want to finish. Read that again! In this episode we discussed: Implant cases in MClindent in prosthodontics at Eastman 8:32 Microbrush Technique (Stickbite) 12:24 The ‘Putty Bite’ technique 16:05 When to use the ‘Putty Bite’ technique? 18:29  What is the role of a Facebow? 20:52 Benefits of a Facebow registration 23:41 Communicating to the technician in terms of using an average Value Articulator 25:23 Making Facebows a part of your Clinical Practice 31:02 Kois DentoFacial Analyzer 36:40  Guidelines for using a Facebow 38:34 Check out this papers as mentioned by Dr Salaman on the Podcast! Face-bow-transfer-in-prosthodonticsDownload Dogmas-in-prosthodonticsDownload If you liked this episode, you might enjoy A Story of Digital Occlusion with Dr Ian Buckle Click below for full episode transcript: Opening Snippet: So that makes the best type of articulator, which is the patient, the patient is the best articulator. Like when you have temporaries or mock up so you can try something, you know, you've got complex restorations, just putting temporaries in the mouth, but lab provisionals checking the patient, if it will make sense, cement them in temporaries, see how it goes and when you're happy, just take a copy and use that because that's actually the best articulator you'll get... Jaz’ Introduction: Let’s say you have a patient in front of you and you’re observing their movements, you’re observing their left lateral excursion, their right lateral excursion, and this just a bite in general with their delicate, wear facets and now you’re planning some restorations. Let’s say you can do some crowns and veneers on this patient. Now, you send the case to a technician, a technician that you’d like to work with and what they will do is they will design some restorations. And what they hope is that as they are planning the excursions on the restorations, when they send you back that work and you try-in in the mouth, the movements that the lab was making is the same as what you’re finding in the mouth. So essentially, going from patient to the technician and back to the patient. Okay? So how can we make sure that this is as reliable and as predictable as possible? Well, that’s why we use articulators, right? So we use articulators to mimic the TMJ and mimic the upper jaw and the lower jaw and all the movement. So that’s essentially why we use articulators, but we know that the best articulator is the TMJ. So now we have tools. Tools that help to sort of supposedly help to improve the reliability or predictability of those movements on the articulator being the same as the patient. So essentially, the articulator is the best articulate in the world should it be ever be designed would have the exact same movements as the patient, so it’s like recreating the patient’s jaw movements but outside the mouth. So One such tool is a Facebow, and that is exactly what this episode is about. The Facebow is a tool which confused me so much for so many years, I had to go in so many different occlusion courses to get my head around the facebow and the different types. So I’m hoping this episode is going to give you some closure on Facebows, some idea and some understanding, some theories and philosophies and also how you can get away without using a Facebow where necessary. Welcome, Protruserati, I’m Jaz Gulati, to this episode with Salman Pirmohamed was a specialist trainee at the Eastman doing prosthodontics. Sorry for the short break in episodes. I was at the BACD conference with Pascal Magne, who’s agreed to come on the podcast and here’s a little clip and a sound clip of what he said. Or I said to him at the time of handing him this handwritten note inviting him very dearly, inviting my hero to podcast. So fingers crossed this is gonna happen soon but here’s a little soundbite of the magic of Pascal Magne. There we are. Pascal’s gonna come on the podcast, he just said it. The second most famous Dentist Ever After GV Black. Man, I’m such a fanboy there. The other reason I’ve been a little bit delayed is my son is a not great sleeper. He’s you know, he’s only two. And we go through good patches. And one stage I thought, Wow, I’m absolutely an amazing parent and I’ve got this whole parenthood thing. And this whole parenthood thing is easy. And I managed to sleep train my son and I felt like I was on cloud nine. And then you have a bad week of illness and suddenly your son becomes a nightmare at nighttime. So it’s a real struggle. You know, the parenthood struggle is real, but it’s a beautiful struggle. And so we persevere and we do the best we can. Before we jump to the main episode The Protrusive Dental Pearl I have for you is probably something I’ve shared with you before and I have no shame in sharing it again, if that’s the case, because I think it’s such a huge pearl. If you are going to be using Facebow or if not, okay? This is a bite registration tip. If you’re planning some restorations, or if you are planning a splint of any type, if you know the final vertical dimension that you’ll be working to, for example, you know that you’ve got a generalized wear case, so you know that you want to lengthen the incisors and you want to open up the bite and you know the final Overbite you’re finishing with, you have a pretty good idea of how much you’re raising the bite. So what the traditional concepts teach us is that when you’re recording your centric relation bite or whichever position your religion believes in, you want to do it at the first point of contact, okay? And traditionally what would happen is that the first point of contact recorded and then the technician will open up the pin to give you the space that you need for the restorations. Now, the problem is that and you’ll suss this out in the episode as well and we talk about this is, is something I’ve already touched on in the very beginning of this intro, which is the articulator is not the person is not the articulator, so if you change anything vertically on the articulator, then there is no guarantee, in fact it’s definitely not happening at all that the patient does also opens in the same arc, okay? The arc of the patient is likely going to be different even with the best Facebow in the world to the arc on the articulator. Therefore, why don’t we reduce that error by doing your bite registration, not at the first point of contact, but doing it at where you want to finish. So if you decided, okay, I want to go from here, and I want to open them up three millimeters, why don’t you take your bite record at that three millimeters, or if you know that your splint is going to be, you know, 1.5 to 2 millimeters at the thinnest portion, maybe in the molar region, that you get your bite record at that position. And you can use something like a leaf gauge, for example. Now, these are all foreign terms. This is the first time you’ve tuned into Protrusive Dental podcast, you’re a student something and you’re thinking What the hell’s going on? Don’t worry, okay? Deep breaths, okay? Occlusion is a journey. Okay? And for those of you who understood what I said, I hope you implement it. I hope you get some good success out of that tip, and I hope you probably philosophize early, think about it. Think about what we’re trying to achieve here. So just to summarize, when you’re taking your bite record, consider taking it at your desired vertical dimension and not at an arbitrary position, because your technician will not have to raise the pin or open the pin on the articulator, and therefore you reduce another layer of error. Anyway, I’ll stop babbling. Hope you enjoyed that pearl. And I’ll catch you in the outro after this stonker with Salman. Main Interview: [Jaz] Salman Pirmohamed, Welcome to the Protrusive Dental podcast, my friend, how are you? [Salman] Yeah, thanks for inviting me. [Jaz] No, it’s great to have you on. And the story when you and me is we’ve been following each other on social media we’ve never actually physically met, I look forward to one day as we get more and more face to face, but my buddy Harjot, he spoke very highly of you. He said, You’re doing the pros program at Eastman, which I want to probe you a bit further about, but I’ve been seeing some really cool tips you’ve been sharing on Instagram. And one really caught my eye recently, which was a putty and you know, we’ll expand on in a moment because it was a putty and then you drew on the putty with, I can only assume with a sharpie pen to give the technician some more information about the sort of horizontal plane of the anterior teeth. And that, for me was genius, from an evolution of sometimes using micro brushes as a stick bite and again, if someone’s listening to this, and you have no idea what I’m talking about, we’re going to go through in this little impromptu episode on exactly that. So that was really, why why you’re here because you inspired me a lot with that. So with that, Salman, tell us, tell everyone where you are at the moment. What are you studying? What are your interests? And how you’ve been finding your program at the moment? [Salman] So hi, everyone, my name is Salman, very happy to join you guys on this podcast. Essentially, I qualified from King’s College in 2016. Spent a bit of time doing PT in Northwest London. And I’ve still been on my VT practice for the last five, six years. So I’ve never really left, asked my VT I did a hospital job for one year, I was lucky enough to be at decent dental hospital. So [?] job a bit similar to I think what Jaz has done in the past also, after that went back to practice because I thought I’d had enough of hospital and after a few more years in practice, I realized I need to learn a little bit more. So I’m now halfway through my pros specialty training program at EastMan Dental Hospital, which I’m really enjoying. It’s while I go through a bit more detail later, but it’s pretty intense. It’s very hard for me [?] Google of dentistry, it’s amazing. I love every day I go in [Jaz] That really shines through on your social media that you’re really passionate and you love it and you live and breathe this stuff which is great to see Salman, honestly it’s amazing. Now, just the first question that springs to my mind about anyone doing a specialty program is a lot of dentists listening there may be considering at one point in to do something like what you’re doing you’re especially MClindent in prosthodontics for example, how much implant training do you get? So for example, do all the trainees get to a certain level of competency with an implant? Or do you make what you want? Do you get what you put in that if you want to do more of implants in that you can be pushed in that direction. So how can you answer that one for us? [Salman] So in terms of implant experience issued implants is there’s no specific specialty on implants, everyone gets involved in it, we’ve got prostho, we’ve got Perio, and then we’ve got people in the restorative training program within us oral surgeons and everyone’s a bit of a taste of implants. And for me, when I first went for my interview, the supervisor told me that this is not an implant training program, it’s a prosth training program. And in pros teaches you the treatment planning that you need to know to give the patient the appropriate option. So I think I speak a lot of Implantologists and the kind of thing everyone says before you’ve got as a hammer, everything becomes a nail and everything that comes in implants and I think the one one question to ask first is when should we be placing these implants? What’s the right situation for them? In terms of my experience in implants, so the pros training program in the Eastman, the first day we had a few weeks dedicated to implant training from a theoretical perspective, and then a very much depends on your case mix. By the second or third year if you’re lacking in a certain specialty and you want to get more involved in it, then patients get this ?? accordingly. The difference with implant planning is the planning for these implant patients in the Eastman Dental hospital because they’re either cancer patients, or hypodontia patients who met the treatment planning, the kind of NHS funding criteria, they’re really complex cases. So the planning can take three to six months before getting to implant placement, the way I went along my journey, so I’m five, five and a half years qualified. I’ve done quite a few implants, but I did all my implant training before during the prosthodontic program. So I wanted to kind of short foundation courses together to kind of figure stuck in there’s a lot of mentor placements. And I think mentoring is just, I know you mentioned in those in your podcast, it’s so understated in dentistry. Initially, it’s gotten me to where I want to be now. And so when I came to the prosthodontic program, I’ve really placed quite a few implants. And that means it’s kind of like, on an upward slope already. And that means I can make the most of it. So Jaz is right. So you get out what you put in. And if you’re ready to put in a lot of work, you get another benefit from the program. [Jaz] I think that’s great. I think you’ve done it the right way, you know, to get some experience under your belt before you start a very intense program like that. And you know, just to mention, for those who don’t know you, you know, Salman’s got an eight month old baby, working practice, doing the specialty program. Do you find it, it’s like a really, do you find like, sometimes you’re like, Whoa, this kind of week just flew by and you feel like really stretched for time? [Salman] And I pump all the time. My supervisor thought I was a bit crazy in the program, because when I first joined us and having baby in a few months. In the first four months of pros training is like a ?? program, waiting long shifts in the lab, constructing all your restorations and then I had a baby along the way. But to be honest, I wouldn’t have it any other way. There’s no right time for a child. And to be honest, it just makes you, Jaz, you’ll know, when you’re looking at something just know, you know what it is you’re aiming for and what you’re working towards. In actual fact, it’s the opposite. It gives you the motivation to keep going. [Jaz] Absolutely. [Salman] That’s just not really a job. It’s for me, it’s like a career. So it doesn’t matter to me. [Jaz] And exactly that when I also listen to other people speaking on other podcasts and speak to other dentists, they always say that, ‘Oh, I just put my practice and we were expecting or I just bought my second practice and we were expecting or I just moved to Australia at the time, and we were expecting.’ So you know, there’s never a perfect time for a child to slot into your career. They just come and they’re a blessing and you take it in stride and you make the most of it. So that’s amazing. Let’s hit the main theme of this episode today, which is communicating Cants to lab so for those baby dentists listening right now, a cant is when something isn’t quite horizontal, when someone smiles they’re they’re off at an angle and you see maybe a lot more of the left side and not so much on the right side when they smile. Now, Salman, what are the different ways and we can go into each one of communicating a cant let’s if we start with the brush, the Micro Brush technique and then how your the way you shared or so clever. So if you start with a micro brush technique, if you don’t mind? [Salman] So as opposed to just like the reason I thought cants began so important for me is when I started at the Eastman and I got my first study models, study cast from my patient, and I put them on articulator and I got to the articulate and I looked at it and I thought, Where do I begin? Because there’s no starting reference points. And that’s where I got involved in the cant and figuring out how they work. So the micro brush, the stcik bite technique that people use, essentially, using silicone bite registration paste, you put it on the teeth, ask the patient to bite together, the little bit of excess at the front, and with that excess bite registration paste, you’re going to orientate a micro brush in, people use one or two, the first Micro Brush should be oriented to the interpupillary line. So a line connecting the eyes and you want that line microbrush to be parallel to that. For some people, you need to assess them before because their eyes might not actually be at the right horizontal level. And so in those cases, I use like the countertop behind the patient, the floor, I look for a horizontal references. [Jaz] Or the blinds behind the window, the blinds is too horizontal. [Salman] Yeah, my patient had a joke. He said you should bring a spirit level with you when you do this. [Jaz] I was always thinking about how to implement that because I know sometimes, I know some my colleagues who actually use a fluid level, spirit level on their facebow to make sure that you really are or this really clever Lukas Lassmann told me once that with some glasses and some patient sunglasses that they put on, before they take the portrait photograph, they put the sunglasses on the patient, just to make sure the fluid bubble is correct, then they take the glasses off, and then they take the photo. That was a pretty cool way to read. I mean, that’s a really high level detail, but you’re right. So you’ve got your micro brush in and now when you wait for the material to set, the lab gets that and then the lab is able to figure out that Okay, if as long as this Micro Brush is completely parallel to my countertop, I know the situation of the models is going to be closer to the real life situation. [Salman] Yeah, and then mounting, it’s important to know that they’re going to be mounting this cast at an aesthetic angle than a functional angle.  Since its we’ll talk about later anyway, I’m sure we”ll go in to it. But these microbrush, the issue I was facing was the fight. When you’re sitting right next to the patient, you’re lining up this horizontal line. And then you step back and you realize it’s wrong. You kind of restarting again, that’s the biggest issue of sets, and you’re done. And then the second issue is transport. Because things get broken into postings get distorted, and then it’s all off angle. A really good tip is [Jaz] It’s very flimsy, isn’t it? It’s very flimsy. So yeah, you had a tip with that? [Salman] Yes, take a photo of the first thing. As soon as you’ve taken your record, just take a photo of it. See, if you’re a few degrees off, when the technician sees that photo and mounds of bits on a computer, they can just really calculate and just as you need to, they’re just some kind of reference point that they need to begin with. [Jaz] That’s brilliant. And nowadays with the, you know, [Keno] and the different lines and the DSD sort of lines, and like I said, If anyone ever emails me message me, I’m happy to send you the ruler and the lines and whatnot. They’re really cool to have. And sometimes you can just verify on your laptop, okay? Was this actually done nail it, and if you didn’t, it’s okay. Just tell your technician, Okay, just make sure you shimmy a little bit, a couple of degrees clockwise or whatever. And they can accommodate for that. So tell us now about this really cool tip you shared about how to overcome this stick bite because it’s so flimsy. And I really appreciate because it was really clever what you did. [Salman] So when I started in the Eastman, there is two supervisors who really helped me out and give me a lot of tips of my cases. And two of them recommended that if you had some putty freehand, you place it over, you can place the teeth or even in edentulous ridge. And I mainly just go for the upper three to three, I roll it over. And then once it sets, you draw some lines to get a Sharpie marker. And the lines I drawn as a usual horizontal line, a drawn midline, we can even add in things like I’ve had people like messenged me on Instagram, they’re canine lines, full smile lines, resting smile lines, and because you can change it and adapt it, and the best thing is if you get the line wrong, you rub it out, start again and you just send it off and it doesn’t get distorted in the post, take a photo, some simpler. And that’s really helped me out a lot in practice. [Jaz] It’s an easy thing to do for all and it’s almost as though you’re creating a wax jaw registration, wax rim, right? And you know you’re able to draw on that. Now just because the nuances, obviously the putty can be a little bit curved, 3-3, we’ll have that labial curve. Any tips on being able to draw a nice line? Like you’re obviously looking at the eyes, assuming they got normal eyes, I guess, looking at eyes and you’ve got the ruler, or are you doing a freehand any tips and nuances? [Salman] You know, I’ve posted on Instagram, Harjot messaged me, he said you should have used the ruler. Because even the post is a little bit curved. But I think for me like draw in a pencil first and then just mark up with a Sharpie afterwards. That’s really the easiest thing to do. You give it a floss and bend it across the putty and use that. I think it’s nice that it’s actually on a curved platform. It’s actually better than a microbrush because your smile is naturally a curve. So a cruve may actually work better than doing a straight line. Yeah, this pencil is sort of the best thing that can be done. And as soon as you take that photo, you’ll know when you see that photo and you see what you’re sending to a technician, you spot straightaway what the mistakes are with it. Just today, you know, Jaz I work in NHS mixed practice, though, like half one day a week. And so I’ve been trying to figure all these tips I then I take what I’ve learned at the Eastman are very, very high level. And it’s applied this in a kind of practice setting. These are the kind of solutions that take away with me so much trying to figure out what will work for these patients and this time and financial constraints. Now showing you a business of the same challenges every day. [Jaz] We do. We have these challenges and we need something that’s quick and easy, quick and dirty to do these little tips are really helpful. Now, this begs the next question. Okay? When would you do, Okay, let’s so if we call the evolution away from stick bite to the putty bite, let’s call it the putty bite, shall we? The putty plane. The Salman’s putty plane, okay? When would you use this instead of your Facebow? Or are you often using it to supplement the Facebow? Either both in the real world. And in the ideal scenario in the most you know, ivory towers. [Salman] Yeah, ivory towers. Jaz, in terms of cant there’s so many I’ve got like nine or 10 ways I measure it within practice because there’s different situations I work with. So I’ll just share a few of them I fint it easy. So for example, I was prepping like an upper six unit 3-3 bridge a couple of weeks ago. And after I finished I looked in and said hey, I’m going to translate this cant to technician and I looked at the canine tips and I just held my ?? handle across the canine tips and looked at it match the patient eyes as like that looks about right. I don’t need to do anything. So when I send in prescriptions to one technician I just say you know what the canine tips mount it aesthetically according to that and that’s your cant stand for you right so if someone you’re going to go wrong, there’s an extra putty here to go over the top. And another way that I’ve started a temporary is amazing, I heard Basil’s podcast with you but by temporaries provisional restorations. If you’re happy to temporaries in your provisional cants, take an alginate ask for that copy. It’s a much easier technique and much more accurate than all of this that we talked discussing. And the last one is as I was prepping a 6 upper unit case again A couple of months back. And when I finished the preparation, my supervisor at the Eastman told me, what you can do is this with one of these teeth, just prep it according to the cant that you want. So the upper left one just shave off like point 2.3 millimeters, get in the right horizontal axis and just ask the technician to use that tooth as your reference points. [Jaz] Okay, that’s an interesting way to do it actually it and by that do you mean like a midline camt for that one? [Salman] No, even just even the incisal edge of the upper left one, just the way you trim it. And you’re done right? So that there’s someone who is doing this but the main thing is you got to think about the challenges that we give our technicians because I never appreciated it. And now I do the lab of my own patients, it’s blind if you think about it, the sooner the two cants and download the patient’s face in front of them. And then suddenly when work comes back and you complain, realize it’s our fault in the first place. [Jaz] Absolutely, I mean, you’re so right, all these challenges we face all the time and so the more we give our technicians the better so what point are you then supplementing these accessory techniques to communicate a cant with a Facebow and what are your views on always Facebow or let’s go very fundamental, Salman. And then we get this question all the time like when I was a new grad like I didn’t know anything about Facebows even though we had the module, it was just really confusing. You know, I didn’t really grasp until a few years afterwards. So what is the point of a Facebow? So some people listening are thinking, you know, why? [Salman] There’s just one thing like this podcast episode, I just like to be able to not be scared of the word facebow like, it creates so many, like random thoughts and mysteries that I don’t understand at all until I got to this Dental hospital. So the Facebow is purely just a way of measuring the relationship between the teeth to your jaw joints, okay? It’s just a utensil that we use, okay? Now, two reasons why we would use a Facebow, there’s aesthetic reasons and there’s functional reasons. So the aesthetic reasons to use Facebow would be to translate a patient’s cant to the lab. But that’s definitely not the primary reason of a Facebow. Because the old style Facebow, well, even the face was that we use that arbitrary Facebows, which means we use them in the ears as our reference points. And people’s ears are not necessarily parallel to the interpupillary line or to the floor. But it isn’t a majority of patients. So if you’re taking a facebow record, a secondary benefits will be that you get to translate cants to your pros technician. But if I needed to translate cants, my primary thing I pick up a that party and a Sharpie marker, rather than an actual Facebow record. [Jaz] That would be supplementary to your Facebow record to verify, right? [Salman] Yeah, because when we figure out when in articulator, it just our guesswork of what the jaw joint’s there, right? And when we put on maxillary and mandibular correspondence, we can either mount them in a functional relationship, which is how Facebow works. Or we can mount them on an aesthetic relationship, which is when I send my putty to the technician, I told the technician just mount according to the putty line. But I know that might not necessarily be what’s in the patient’s mouth. It’s purely just to give it a horizontal reference point so that the aesthetics for me come out correct. And so the question that people will then ask is, what’s the point of a Facebow? Why use it? Because if you imagine things not with Facebows and the workout fine, what’s the actual reason for this? And this is the, there’s a huge debate on behind the scenes in this for dental hospital about [Jaz] And just for you reveal the answer there. I mean, you’re totally right, I’m gonna echo those thoughts. So if you have a successful putty, with the line going across communicating the aesthetic plane, and the technicians able to mount that on an average Value Articulator without the use of the Facebow, and then you’re getting good results. And then therein lies the question, what additional benefits is the Facebow giving? [Salman] Well, this is the big debates, right? Because they’ll be things I say that people don’t agree with. So let’s see, we have just a [rigid] patient we’ve got upper and lower 7-7, which a sound and I take an upper impressions, and I thought a technician to mount it. Now when the patient puts, when the technician puts this cast together, and they might have an ICP that’s a static relationship. And me sending a facebow record to get that static relationship has no benefit whatsoever. Okay? But if I asked the technician to raise the OVD, will increase the OVD about one or two millimeters, increase a wax up in that position, I’ll have to go back to basics, Jaz, because I’m making sure that so there’s different types of articulators. The first type of articulator is a hinge articulator which just goes up and down. It doesn’t affect the patient’s jaw at all. He doesn’t need a facebow records [Jaz] I mean, even more primitive than that, Salman, is the old wristiculator. [Salman] You know, Jaz the evidence shows that the hand articulator is more accurate than the actual hinge articulate. In fact, if I’ve got like a six single unit crown, I’d rather my technician man sit on his hands and figures on the excursions rather than puts on a hinge articulator because that just has no relationship to what happens. [Jaz] Very true. [Salman] Okay, the second type of articulator, it’s like a fixed average movement articulator which has general averages that work for, like it’s multiple patients have been assessed or the angles of an articulator and your mandible cast on there. Now that articulators it doesn’t accept the facebow record, you position the cast on that either just randomly, or there’s certain prompts that you can mindset using, which I can discuss if you’d like to? [Jaz] While we’re on that topic. Yeah, let’s go into that. So you just we talked about the evolution, we talked about the wristiculator, which actually Salman said that evidence suggested may be better than a simple hinge. So therefore, let’s avoid the simple hinge. let’s skip that. And then now we’re talking about an average Value Articulator and then in that you, you know, you imagine you’re a technician, you get these cast through and you’re trying to put it in somewhere within the articulator, and here is lies issue, you’re just guessing. So what clues can we give to the technician, I think is what you’re coming to, to help them to almost be as good as what the perhaps a Facebow may give. [Salman] Yeah, so like, if you look at Denar for example, like the companies will sell a special mounting plates for these cast to go on top of. And there’s mounting plates that do this. And there’s ?? for features like there’s a simple one triangle, bond angle. And essentially, this is set parameters that is a certain number of centimeters, I think it’s 11 centimeters from the condyle to, like the mandibular incisors, and you know that this measurement is fixed. And so when you then put your mandible across on the articulator, you put it according to what we call [formulas] triangle, you set up there, and then you put the maxillary cast on the top. And you know which angle to put out because a bulk this angle, and there’s all these degrees that you can put on and start with that first. And then you’ve got some kind of average to begin with. So that when you then begin to move to that maxilla and mandible around, you know, that may be related to what was going on in the patient’s mouth. So that’s the fixed average artuculator. [Jaz] And I mean, the other thing that we can also do here to help our technicians and something that you know, you’ll be doing all the time is sending some full face photos, and also even the full face photo with some retractors so that when they bite together, you can see all the gingiva. And then a clever thing to do then would be to get that all, make sure all the planes are correct a little bit of tiny rotations and degrees. And then when we take our intraoral photos to make sure everything lines up and you can nowadays you know, on Photoshop, whatever, put your or superimpose your intraoral photo on the facial photo, and just make sure everything’s correct. And by giving that level of information to the technician, they can now as they’re about to set the model, on the average value articulator, they can look at your photos and be like okay, this looks look a little bit like this. And I’m going to do like that and then you can even have a side view, a profile view showing Okay, this is the best guess of how it’s going to be and that’s just it little things we can do to give our technicians more information so they can recreate the patient’s actual anatomy on the fake bit of anatomy that we’re trying to recreate with an articulator. [Salman] Some people might be asking, like, why do you just mount it in. So even the maxillary occlusal plane we know it’s not straight, right? ?? sphere. It’s like down the tools, even all these little things when you got new articulating plaster, if you’ve used it sets like this, like when you’re holding that model or suddenly moving in with a set, you’re stuck in that position. So it’s not an easy job that technicians have everything that we can give them makes it so much easier. Then we go on to the semi adjustable articulator. So these are the regular ones that we use at the Eastman Dental hospital for regular cases. And these are ones that accept facebow records. And so what that facebow record does is you take it and for those who don’t understand facebow, it’s the maxillary cast which sits on top of your facebow record, your facebow record inserts into your articulator and then that maxillary cast gets stuck into the articulator at the correct position. So the semi adjustable articulator has like a fake jaw joint on it. So it’s all kind of It’s looks like a jaw joints, and then your maxillary cast can stuck there and then you put your mandibular cast underneath as an ICP or an open jaw relation position. And that’s kind of more accurate than a fixed average Value Articulator [Jaz] Yeah, it’s good because when you are moving something on the articulator, we’re hoping that’s going to be closer, representing what’s happening in the patient’s mouth, compared to what the average value may give you. Because you’ve got that extra, it’s essentially getting I’ve got a diagram for this I can put it on at this point is like the different arcs that are made, that your the arc of closure is going to be more hopefully, more closely representing what the patient’s mouth is. But, you know, as someone who uses articulator or facebows very, very little nowadays, there’s more digital I go, the thing that really annoyed me, Salman is like, seeing some of these virtual articulators, right? And I didn’t understand the following, which is on the actual, you know, Denar articulators, for example, it’s the upper member that’s moving, but we’re sort of visualizing it as the lower’s moving but it’s the upper one that moves the way it’s designed. But even on the virtual articulator, they still design so the upper moves. I’m like, Well, why would you do that? Just make the lower move. Like, you know, why would you design it that way, even a virtual when we have the power virtually to change all that. So that was like, what the hell is this? [Salman] Yeah, and Digital’s coming into everything it’s like articulators, a purely our guess, our best guess of what’s actually going on in the patient’s mouth. And so the next articulator to semi adjustable is fully adjustable articulator and these articulators they’re complicated like that you take like full pantographic tracings of jaw movements in a patient’s mouth. You said they flap all of these, you translate all the information onto this fully adjustable articulator and has been shown that this does reflect because in the patient’s mouth, but is it really practical to use in day to day practice? I don’t think so. And we need to find the easiest solution. So that makes the best type of articulator, which is the patient, the patient is the best articulator [Jaz] Absolutely. [Salman] Like when you have temporaries or mock up so you can try something, you know, you’ve got complex restorations, just putting temporaries in the mouth, but lab provisionals checking the patient, if it will make sense, cement them in temporaries, see how it goes and when you’re happy, just take a copy and use that because that’s actually the best articulator you’ll get. And yeah, I’m sure it is for you, Jaz. [Jaz] I’m so glad you said that, because I was waiting for this. And then you said it. And I’m so glad you did. Because the best as Tif Qureshi told me many years ago, the best articulate is a patient’s own TMJ. And then you you raise a great point, look, the time as a dentist, we start using these tools, because all it is just tools, right? Articulators, Facebows, it’s just tools to help us to do less adjustment in the chair on the day of delivery. That’s essentially, you know, in a nutshell, it’s all it is, to help reduce appointment times to make sure that we and the technician can work together to do less work, make it easier for us, right? And then by having temporaries and IE doing complex work, and therefore we’re now having to use facebows and articulators, and therefore you’re probably going to be having a temporary phase. Now, this temporary phase could be in composite, in temporary crowns or a combination of both. And that is the time you work on it, you nail it, you Dahl it in you do your adjustments, you do your, you know, equilibrations within your temporaries because that’s what we’re doing essentially, we all are equilibrating temporaries and then you hit the nail on the head, when you said, we then get the in the future when we’re ready, when we’ve tested it, the environment, the human articulator of that patient, and then get the technician to copy the features. That is I think as as good as it gets and negates the need for any, you know, fully adjustable articulator would you say? [Salman] Yeah, the only big thing on earth is that this is not missing, your facebows at all because those initial temporaries have. This is the old school Eastern opinion I’m about to give you but those initial temporaries and we made from a wax up which you’ve had on articulated casts, which you’ve had an manage opening, closing the OVD, and you only get the accurate wax up and accurate planning and accurate diagnosis. But having a set of properly articulated study casts, you only get sort of the articulated study casts, in my opinion, with the facebow record so that you can open and close the pin properly. And so if you’ve got really great wax up, and then you make templates from that, and then you do this really minor adjustments to those temporaries, then you know, you’re almost perfect on the day of delivery. And I still have these even I personally, we do a lot of zirconia crowns nowadays, and like monolithic zirconia crowns should work amazingly well. But as you’re going to these kind of materials, the more and more difficult to adjust in the mouth. And for me, like the degree of precision you need is certainly going up and up and up. And so using things like Facebow and proper wax up, the first principle should always still be there in all of our minds. And the other thing to know the Facebows, there’s no harm in doing it whatsoever, you’re not reducing your accuracy by taking Facebow. For me, it takes less than five minutes to do a facebow record. It’s like when you start with an SLR photography, you’re like highly sensitive photos, you just keep it ready. And honestly, it’s so easy to just pick up and take that photo, just keep a Facebow ready in your surgery. And once you’ve done it two or three times it’s very, very fast, people overcomplicate it, undergraduate. So really, really simple technique. It’s not something only specialist prosthodontist should be using. It is something in every general dentist like [Jaz] Once you get slick at it and your nurse gets slick at it and your nurses in having to look for it. Which surgery is it in today and all we’re missing the bite for whoever and once you get you know, once you have, once you organize and you have it in place, and you rehearse it a few times, you know, I remember when I was in practice, starting to use the Facebow a bit more. And I was like on YouTube like refreshing myself or Dentinal Tubules watching these videos to remind myself so they’re like, I don’t know, like an idiot. And even like in the first few times I use it. The fork was facing, the actual fork was facing the wrong way. And the big pole was coming out on the left not on the right. And yeah, these little things you mistake you make it once and you realize oh yeah, that’s how it is. But you’re so right, it is actually a super simple thing. It literally is as easy as 123 and you screw and tighten everything up, obviously depending on which type you’re using. But eventually once you overcome your initial fear and you book extra 5, 10 minutes initially, it only takes up to five minutes. And then you can even take a photo when the patient’s got the facebow on as well just to make sure later you can look back and think Okay, then I have everything, did I nail everything? DId I get everything all correct? And this is all there to help you make better temporaries for less adjustments, and then when you got everything right in the temporaries we could transfer it to the mouth and Do the least amount of adjustment as possible to so you’re not drilling away your precious zirconia ceramic restorations. And that’s the way to think about it, what you’d say Salman? [Salman] There’s two or three like the other benefits of facebow we discussed earlier, you get this functional benefit and yours can be aesthetic benefit to the technician that is cants on that same articulator set of study casts. And then finally, for me like something I’ve learned at Eastman as the way we stage appointments, we’re not planning tooth surface loss cases is we will not take all our records in one visit and the next week the patient comes in for that mock try-in. The way we do it is the first visit we do a whole diagnostics, we take just upper and lower impressions. The patient will then come to the second visit when you do your initial records and your facebow record because then you’ve got casts sitting on your table. And we can then do on those casts as you check you verify them and so that Facebow, we take in we eyes impression compound, [using silicone various pastes], you want minimum accuracy so that when you’ve got us point contacts, and you can verify your cast is accurate, because before you ask the technician to do that very expensive wax up for you, you know that everything’s gonna come back exactly how it should be. So dividers are by cast ?? and jaw relations movement, I do my facebow record, I do my RAP like to prepare record, I verify everything fits on the casts, and then I send it to the technician. Because the last thing is you wanted in this and then technician goes, Your cast they don’t fit together on its facebows, don’thave enough its jaw relation records will direct me to do so that’s just a little tip out there. Separate appointments, it makes life so much more stress free. [Jaz] That’s so true. And it gives you that confidence that Okay, the first phase was correct. Now you can move the next phase and now you can move the next phase being the wax up. And you know that your minimize your errors, your accumulated errors. So dude, I’m so happy that we’ve covered that. Do you by chance? Have you got much experience with a DentoFacial Analyzer? [Salman] Is that the Kois one? [Jaz] Yeah, the Kois one because this might be a whole different episode with someone else. Cuz now that we’ve covered this, because what this what happens, you learn about Facebow, and someone comes along and say you don’t need to Facebow just use a DFA and you’re like, Oh my God, here we go again. Like, there’s so many different ways to skin a rabbit. Now, I don’t own a DFA. I’ve seen it being used in lectures extensively. Like, I’ve been so much occlusion CPD that I’ve seen it being used a lot. And I get the point of it, it’s clever. It’s quicker. I get it. But I don’t use it. So I want to talk about something and perversely in the way that haven’t used it for just wondering have you got an experience on this? [Salman] No, I’ve just haven’t use this. I wouldn’t want to comment on it without proper knowledge on it. Yeah, that thing is, even Facebow records like what case, the main issue that I had in practice was I was trying to pick which case is actually needed for. And some people will say, Oh I use it for all my cases, I used for some cases, I never use at all. So which cases is it that’s kind of like that massive differences? There’s two really interesting papers that I read this year. There’s one in ?? I don’t know if you’ve heard of his papers like dogmas in dentistry, you’d really enjoy it. It’s, he goes through kind of all these. [Jaz] It also talks about the wide centralization isn’t this magical point? Is it the same paper were talking about? [Salman] Yeah. It’s also like why primary and secondary impressions are not required for dentures. What’s the simplest way you can make a denture? What’s the actual clinic, this is actually change your clinical outcome or your final restoration. And there are quite a few papers out there that show that they had kind of randomized control trials, complete dentures, one on facebows and everything. Another one very, very simple approach, No Facebow, was a clinical difference in these patients 20 years later and a lot of them say No, there wasn’t difference. And then the argument is, well, dentures move around, they can adapt, adjustments were made. And so which cases should you be picking these facebows for? And I’ve got just a select few in mind that I always use it for. And the rest, I feel I can get away without it. [Jaz] Oh, we’d love to hear that. So that’s a great point. We can’t be uncovered yet is that when do you, when do we use it in practice? We took over the why. And therefore people can sort of extrapolate the data and figure out Okay, should I apply it to my case, but we like these guidelines. So what are Salman’s guidelines for using Facebow? [Salman] So for me, the first one is like articulating study casts before like, I’m planning a full mouth reconstruction. Because if you’ve got patient come with tooth surface loss, and you send your patient or your technician, just those upper lower casts, just the articulator together, you need to know how they move and dynamic relationships because if you’re planning in raising the OVD, then you’re going to open up the articulator pin you need into some kind of relation between those teeth and those jaw joints at the back. So if I’m planning any increase in OVD, then I’ll be taking a facebow record. So that’s the first one. [Jaz] I mean, essentially, when you are reorganizing, that’s automatically a Facebow, which makes total sense. [Salman] And then the second one is, this is my judgment call on this one. So if, we’re always going for mutually protected occlusion these days, which means you’ve got our posterior stable ICP contacts, and then for stable anterior guidance, so we see that the 3-3 we get good lateral canine guidance. And that means generally if you’re working on a 4, 5, 6, and 7 and the patient has a stable canine guidance, then usually you can get away without using Facebow. If you’re just restoring single two units, four, five, and six will get away with it. Then there’s the whole last tooth in arch syndrome which I’m sure like we get asked a lot. It’s a classic example of like, winning a lawsuit in our channel managers. What’s your opinion on that, Jaz? How do you restore [70 profit], and you just lose all the space. [Jaz] So me and Mahmoud are doing an episode soon all about this different nuances of lawsuits in the arch. So but no, I mean, essentially, it’s important to screen for that case, before you do it, it’s important to communicate to the patient that hey, this could happen. And once you screen for it, and this could happen, you’ve got to have that chat up front with the patient that Okay, we actually might need ortho, we might need a crown lengthening or whatever to be able to do this, before you start or just to know at the beginning that you might just need to prep a little bit more. And can your tooth handle that before you get to it, and then I’ve also done things like [Island prep] before and in various techniques. But yeah, you’re right, and having a Facebow on that can help you to visualize the challenges. What about you? Anything you wanted to add to that? [Salman] Yeah. Well, I was gonna say that a few matches study. So we’ve talked about facebows a lot. It’s also people will ask when do you mind casts in intercuspal position, and when to mind, I mean, that retruded access position. And that brings up a whole another podcast for us to discuss because it’s a huge topic. But essentially, if like you can pan a lot on articulator so you see if you can manage casts in the retruted access position, which is that Hinge Movement of the patient, you need to Facebow to do that. And then you can see the slide from that position is to RCP, and that slides ICP, and you didn’t know if that lower back tooth is going cause your problem before you even start prepping it. So it’s this whole is diagnostics that Facebow gives you, there’s a huge wealth of information that can be viewed just knowing when and how to use it. For me, anterior six, you know, push cases on nearly always use a facebow record a filler, the extra information just helps it up massively, I want to see how the protrusive guidance is going to work. Because I might be heading for the anterior guidance, and I need to recreate it properly. And the last one is the patient has very reflective. So 4, 5, 6, 7 are all ground down and very flats, I can just ask the technician do a handle that situation and making crowns and a four, five and six. But when he moves, everything’s kind of flat at the end, because he’ll just be copying what was there before. If I want to create my cusp to cusp relationship which should give stable intercuspal positions that I need to give the technician a bit more information. In fact, even the facebow record they can put it on an articulator and then they know how the condylar guidance works and the jaw movements work. And they can then create much more stable restrictions for me. So multiple units, increasing occlusal vertical dimension and full mouth reconstructions, and then diagnostics that for me, it’s like my use of Facebow. And static cants, but there’s easier ways. [Jaz] And I’m grateful that you share that with us. And yeah, just on that point about multiple restorations. I used to think multiple restorations equals Facebow and you should do it, it makes sense. But you’re completely right in that scenario, when someone is already canine guided, and they get near immediate disclusion already, that even if you’re doing you know the four, five and six, then you may not need it so much because you already have that disclusion in there. But if you’re conforming, even if you’re conforming, but you’re conforming to group function, and you want the anatomy of the teeth to exist and not just be flat, you’re completely right, because now the technician has to dahl it in and build it up in a way. But you know, the exciting thing going forward is that on the modjaw, you know, people are thinking they probably will enjoy this episode, okay, who needs a facebow when you got a modjaw, but you know, if you’ve got a spare 40 grand laying around, I don’t know how much it costs. But you know, if you’ve got a spare 40 grand laying around, and you want to get their functional chewing patterns, and then build those patterns into the restorations. That’s like the ultimate way to do it. And maybe that’s the future. But for now, as a tool to us dentist, there is a place for facebows we know that and hopefully then from this episode, we know how you can cheat and avoid using one. But really knowing when to use one and giving you that kick up the butt you need to pick it up and stop, you’re afraid to actually start using it and speak to your technician, right? Speak to your technician find out if they’re comfortable in working with it which one they want to work with. For example, My lab works with the artex one and that’s why I’ve got the Artex Facebow. And so it’s so important to speak to a technician. Any closing comments, Salman? [Salman] Jaz, even that this might even bring thinking again, but even that 4, 5, 6 multiple units. When that patient opens and closes, I still want a bit more information on how those cuspal inclines need to be in, so for me, it’s debatable, it might not make any clinical difference whatsoever. It’s that peace of mind so I can sleep at night and I’ll do a good set of provisional and I’ll adjust from there. But Facebow, for me, it’s four, five minutes, it’s no extra harm, don’t be scared of it because like it’s so easy to use. And I just recommend for everyone. Digital is definitely going to be like even I see, it is gonna be the way to go in the future. Because once we can replicate the board like the mandibular movements property, we don’t need to worry about this jaw joint position because we just need to know how to move in relation to each other. And then it kind of goes all out the window and I think that will be how it is in the future. And we’re just sort of waiting for it to happen. You probably know more about the digital side of it and how you find it so far? [Jaz] So far really good. But it is a lot of reliance on the temporary so it’s a lot of data upfront in terms of images, lateral excursions, full face, retracted, using the different DSD tools to communicate that lab, scans at the required vertical dimension. And then speaking to my technician, exchanging emails, they’re sending me digital wax ups, which is slightly transparent of reduced opacity. So I can see through this little wax up and see the existing tooth and stuff, and then just be micromanaging. Okay, make it like this, make it like that, and then transferring that to the mouth. Now, once we transfer it to the mouth, then there is initial hard work to do to make sure that everything is balanced, some testing period to make sure that the excursions are where you want them and where you design them to be. And once that’s been built in, then it becomes much easier. But there is no either way there is a work upfront to be done, whether you’re designing digitally, or the technicians are waxing up by hand to make sure that when you transfer to the mouth is going to be a aesthetically pleasing, which is super important but also, when they bite together, things are hitting at the same time and things are hitting the right times when they move their jaw, whether that’s a functional movement or a parafunctional movement, you got to sort of build both into it [Salman] Even the analog of it, even wants to take that facebow record for this diagnostic study casts. And I opened that pin and I figured out okay, I’m gonna open it this much, I’m going to wax up at this position, or then still go back to the patient and take my record at that OVD upon restore. So it just shows that I don’t trust the Facebow completely in terms of that movement of the articulator, I still need to, I need to make sure the patient can be in that position verified to accept that position and then work from there. So there’s no one trip that you just fixes everything for you. Jaz’ right. It’s just it’s multiple steps to get to that final results. And that Facebow, just one of the small steps along the way that may increase your success rate. [Jaz] And we discussed it in terms of a Michigan Splints as well once before whereby if you you know, yes, there are reasons to use a Facebow, you could do Yeah, you could totally do a Michigan Splints without a Facebow. So what are you sacrificing? You’re sacrificing some information to the lab is now going to be using average values which may or may not correlate to your patient. And then you may or may not then be doing a lot, supposedly, you know, we need these studies to show that okay with an articulator, with a Facebow, without a Facebow, how many more minutes of adjustment are you doing? That’s what you kind of need to decide that, Okay, if you’re only doing extra two minutes, are there any studies showing with respect to Michigans? [Salman] No, There are studies but I noticed that not this time, I couldn’t stop using Facebow. There’s studies that show pros and cons of each but there’s a study by for ??, who did like a study Michigan splints randomized control trial with Facebow, without facebow, no real difference in adjustments. But I would add. I would add with the Michigan splints, you’re creating a flat platform totally. And so do you measure the OVD that you want and the technician creates a flat platform. And is they just take the smallest of ramps are different, they’re going to get anterior disclusion. It’s not the most difficult thing to do, but really in full mouth reconstruction with cuspal incline and forces and everything, then you can’t translate what once they are shown on Michigan splints to automatic reconstruction. So yeah, it does work. It does work. [Jaz] Yeah, totally. And you’re totally right, you know, the Michigan is the you know, an Upper Michigan, the lower buccal cusps are hitting against a flat portion of the upper splint, which is much easier to dahl in compared to the nuances of cusp to fossa relationship. But you’re right, you know, the main key here is if you just give the lab the correct vertical, then you do massively negate the need for that facebow information because as long as it just like you said as long as the anterior, the ramp is steep enough to get some dislusion and here’s the thing, right? If the technician can give you something near enough, close enough, and they make it slightly steeper on the splint itself, you can adjust it intraorally just to make a bit more shallow to dahl it in to the effect that you want. So there are little ways around it and so there we are, food for thought. Salman, thanks so much for coming on and sharing what you’ve been learning in your program and what you’ve been applying. And you know, the main takeaway today is think of cant, think of using that little putty technique perhaps instead of the microbrush technique, stick bite if you’re already using stick bites, but also now if you’re someone who is afraid of that facebow in the corner, just pick it up, use it, just use it, speak to your lab, and it can give you lots more information to your technician. Then the ultimate aim is to reduce how much you got to do. [Salman] Yeah, well that’s it if you are using a Facebow just honestly meant for me like mentoring practice has been what got me to where I am now. Like I’ve stuck out in the same VT practice since qualifying, seeing patients come back and recall the samples for that’s, it teaches you amazing things. Take it on practice. Get a mentor. You learn everything you need to know honestly, you can keep adding on these little tricks that Facebows has and you can use in general day to day practice. It’s possible. I’ve done it. [Jaz] You’re testament to that, mate. Man, thanks so much for coming on giving your time that you’re super busy schedule. I know you’re with family today. So have a lovely time with family. And I hope we meet face to face very soon, where you can just you know geek out over some food and talk more about the nuances of Facebow studies. [Salman] Thanks, Jaz, really enjoyed it. [Jaz] Thank you so much, mate. Cheers. [Jaz] Well, there we have it guys. Thank you so much for listening all the way to the end. I’m hoping that Salman and I were able to have a little discussion, a bit of banter about facebows and how to do things by just photos only, or how to use the putty technique to get your cant correct. And it’s given you some food for thought. And one reflection, one of the favorite things I like to say is that the role of an educator is not to put everything that’s in their mind into your mind, the role of an educator is to open your mind. So I’m hoping that after listening to this educational episode about Facebows that your mind is open. So when you’re thinking about the next time when you’ll be using Facebow think about what you’re trying to achieve, why you’re doing it, and are there any other ways of doing it? Or maybe to pick up that phone to technician and discuss it with them, how do they prefer things? Or what are you trying to achieve with a Facebow that you can’t achieve through some other means? So hope you enjoy that. If you’re listening on Apple, please be sure to rate this podcast. That’s how the podcast grows and gets discovered and keeps me busy and make these episodes for you, which I love to do. Anyway. Thanks so much for listening all the way to the end. And I’ll catch you in the next episode.

Hello, Protruserati! Welcome to the first ever ‘Occlusal Adjustment’ episode! This is an opportunity for me to go a little bit deeper, have a little rant sometimes, or go off on different tangents based on a recent episode. This episode is Audio only – sorry YouTube family! In this very first Occlusal Adjustment I will be talking about how to plan your CPD, inspired by the recent episode with Dr Emma Courtney. Need to Read it? Check out the Full Episode Transcript below! “Knowledge is good. Knowledge is power…but implementation is king.” Dr Jaz Gulati In This episode I talked all about:   ‘Just in time learning’ 1:19 When is the right time to go on a course? 4:45 Importance of Shadowing 11:00 How to choose your next Course 11:55 Loss Of Earnings (LOE) 12:51 Importance of considering courses abroad 15:46 If you want to learn more about wisdom tooth extraction, be sure to check Dr Nekky Jamal’s THE ULTIMATE THIRD MOLAR EXTRACTION COURSE and get a 15% OFF with the code ‘protrusive’ If you’ve been dying to learn more about Bruxism and TMD and want to help your patients that parafunction then be sure to check SPLINTCOURSE – Registration for 2021 ends on 24th November. Click below for full episode transcript: Opening Snippet: In this very first Occlusal Adjustment, I'll be talking about how to plan your CPD. My opinions on which is the next course that you should do... Main Episode: In this very first Occlusal Adjustment, I’ll be talking about how to plan your CPD. My opinions on which is the next course that you should do. Hello, Protruserati, I’m Jaz Gulati and welcome back to another episode this one is an Occlusal Adjustment. So basically the whole point of an Occlusal Adjustment is sometimes I have these amazing guests on and I am just captivated by their story. And when they’re speaking and I’m listening, you’ve probably seen it for those of you that catch me on the video episodes is that I’ve got these facial expressions like I’m in deep thought. And my brain is like absolutely bouncing with so many activities and thoughts. And sometimes I want to ask certain questions or take in a different direction, but then we end up going on a tangent. So what an Occlusal Adjustment is about is an episode where I get to go a little bit deeper and give you my perspectives and my opinions. And that’s all it is really. It is very much my opinion. So everything I say on anything that I say on my podcast ever, always take it with a pinch of salt, okay? There’s just me and my opinions and my paradigms, which I’m very happy to share with you. But always remember the philosophy of listen to everyone and do what feels right to you. So this is an Occlusal Adjustment for the planning your CPD and burnout episode I did with Emma Courtney, it was just so great to hear her story and how she fought burnout and now she’s come back with a vengeance. She’s so passionate and purposeful, everything she does, and she’s doing a great podcast, herself. Fang farrier should definitely check that one out. Now, what I want to tell you about is my favorite type of learning as a dentist, my favorite way of getting my CPD hours in and something I like to call just in time learning. Okay? So very much the opposite of just in time learning is that, for example, many years ago, I didn’t know anything about Crown Lengthening surgery. And so one day I say to myself, Okay, I don’t know anything about Crown Lengthening surgery, so therefore, I’m going to open up a textbook, or I’m going to go on a course on Crown Lengthening surgery, okay? That’s a very erratic way of learning. And that’s a very random way of learning because you can look at your entire knowledge base and skill base and history base. And you can pick out easily lots of areas within dentistry, which you think you have limited knowledge in. The problem is if you willy nilly just go about learning in any direction, without having a goal at the end, then you end up going down these all these different learning pathways, but none of them ever get implemented, or certainly it takes a long time for you to implement your learning. And that’s the problem. Knowledge is good. Knowledge is power. But implementation is key. So when I started to learn about Crown Lengthening surgery, I exposed myself to what is the meaning of high crest, meaning of low crest, the rule of three millimeters, that’s like the distance between the bone and the future gingival margin is a rule of three millimeters. So it’s learning about all these things and whatnot, when to do an excisional cut, when to do an apical reposition that kind of stuff, right? So when I then many, many, many months later, maybe in a year later, I was actually considering doing Crown Lengthening, guess what I had to do? I had to go on another course because I forgot everything A to Z, everything I read, everything I watched, it all went to waste. All that practice I did on a pig’s head or something, it didn’t matter anymore, because it was so long ago that I did that course, that I needed a refresher. So the lesson here is be a just in time learner. When you have something procedural like Crown Lengthening surgery, for example, make sure you have a few cases ready. Or maybe you are working in a practice where Facial Esthetics is a huge demand for it. And I have zero interest in facial aesthetics, you know that because know what my face looks like. And, you know, damn, well, I have zero interest in that. But if you’re in a practice, where the demand for facial aesthetics is there, and your patients are asking for it, man, that is a great time. And of course, you have an interest in it, that’s a great opportunity for you to then go on a Facial Esthetics course, and implement that for your patients. Whereas if you just fancy the idea of learning about Facial Esthetics, but you don’t have the patient base, and you don’t have any cases lined up, that’s when learning gets wasted. It’s really sad when learning opportunity gets wasted. Same with implants. I know so many colleagues, it’s a real shame. I know so many colleagues who went on expensive implant courses, and they never got to implement it. And that is a crying shame. So don’t be that dentist. So implants another example. Right? Try and get a mentor, try and get a few cases, simple cases under your belt that are ready for you to implement your newfound knowledge on or maybe you have a patient that you’ve been seeing for a while that’s got some tooth wear, and you’ve diagnosed tooth wear, and you’ve given the usual you know, diet advice, reduce acid, screen for bruxism, the usual kind of stuff, and you don’t quite know how to treat it. But the patient’s expressed that you know what I’d like to do something about this, whether they are concerned about further breakdown, and maybe you are as well, or it’s an aesthetic concern. Now you don’t know how to treat it yet. But what you need to do at that point is recognize that okay, now I can go on a course and learn something and implement it on this patient. And what you won’t do is find the best person to learn that skill from. Now someone I was speaking to a recently Prav Solanki, really cool guy. He’s one of the co-hosts of a dental leaders podcast. He taught me that one of the people who taught me is that don’t think how, think who. So don’t think how I’m going to treat this tooth wear. Think who is going to teach me how to treat this tooth wear or who is the best person to have this done with but there is a problem with this that if you’re waiting around, waiting around there is a little bit of problem with this and this was exposed by my good buddy. Aneesh Dhunna, he messaged me on Instagram Hey Aneesh, hope you doing well, buddy. Thank you for being a Protruserati for such a long time. You’re one of the OGs for sure. Now, he said and he asked very badly, very good point he asked if you only book your courses after you found the right case, how can you time it so that patient is not waiting for such a long time? For example, let’s go back to that crown lengthening analogy. Okay? So you want to go into Crown Lengthening course. But you don’t have the patient yet. But then a patient turns up, and you’ve had that conversation with a patient, patient’s interested but then the next crown lending course, in your town is four months away. And now the patient’s waiting. So my advice, so it’s a great concern, you have that, Aneesh. Now, a few angles to consider here, a few things to consider. It actually reminds me of a poster I saw. It’s like an advertisement for a Spear Education. So shout out to Spear Education, great educators in Spear, I’ve consumed lot that online stuff over the years, learn a lot from them. There was a huge poster they had, like an online ad. And it was someone with a really worn dentition and is crying out for some comprehensive care, and really a full mouth rehabilitation. And the slogan or the marketing pool on that poster was ‘When he’s ready for treatment, will you be?’ When the patient is ready for treatment? Will you the dentist be ready to treat this patient, right? So that was a really cool ad, because it ties in very nicely what Aneesh is done like sometimes the it doesn’t work out this way, you know, patients aren’t perfect in the way that they’ll just turn up. And you can say, okay, yes, now I can go on this course and implement it. Obviously, that’s too idealistic. So sometimes the other flip side is that you have to prime yourself with knowledge to be able to diagnose and recognize and understand. And then when the patient is ready, then hopefully you’ll be ready at that point as well. Now, if you think about the bigger picture kind of stuff, when it comes to occlusion and tooth wear, like there’s a 93% chance that if you’re listening to this right now you are a general dentist, right? So because in the UK, only 7% of dentists are specialist. So I think it’s probably more in the US. But anyway, so chances are you are a general dentist, listen to this. And you know that amongst many different disciplines in dentistry, occlusion is an absolute fundamental key, okay? You don’t wait around for an occlusion case to go on an occlusion course. Okay? This is really bigger picture fundamental back to basis. Occlusion is something that you apply every day. So the lesson here is when it comes to the really fundamentals, right? For example, for GDP, get to a decent level when it comes to endodontics. And definitely get to a certain level when it comes to occlusion. Because occlusion is something that you will apply on a daily basis, whether it’s an occlusal examination, a single crown composite bonding, you will use the principles of occlusion. So sometimes when it comes to your education, and you figure out broad areas in your education, which you think is lacking from dental school, then for sure, don’t wait around for a case to apply for that kind of course, because that is a universal thing that you should be learning. So when it comes to bigger picture stuff, especially your first five years, you know, go on a Perio course, go on an Endo course, go on an extraction course. And this big one, right? We as general dentists need to be really good at extractions and pain management. I think I believe that all dentists should very fundamentally be able to get someone out of pain. So it’s really sad that some people go on implant courses, and they don’t know how to raise a flap, they don’t know how to Section and elevate a tooth, which I think is a fundamental skill. And once I learned that I was so, I was way more confident with my extractions. And you know about this already, from the episode I did with Chris Waith, you totally should listen to how to Section and elevate teeth, how to become more confident in extractions. Go back and listen to the episode if you haven’t already. So once again, you don’t wait around for the extraction case to improve your oral surgery skill. So some things are just fundamental. Now when it comes to a specific procedure, now again, going back to crown lengthening surgery, that’s quite a specific niche procedure. I think for that kind of procedure, unless you have a real desire or a hunger to learn for it, then I think it’s probably a sensible thing to do to get a bit more experience under your belt and find the case and the way you can pitch it to the patient is once you find a patient and you know what you need to be able to diagnose, right? You need to know which kind of patient would be suitable for Crown Lengthening, what the indications are, what the contraindications are, generally what the procedure involves because you don’t want to like A) miss the diagnosis. So someone who’s got a gummy smile and you don’t know that Crown Lengthening surgery could be able to help them ie a gum lift. So you need to recognize it. You need to be able to communicate with the patient. And you should be able to give the patient a good amount of information to consider that kind of treatment modality. So this kind of very fundamental information I think you can get from a webinar, you can get from a book, you can get from a paper, you can get from a chat over the phone with a periodontist for example, right? So this isn’t something you need to go into Crown Lengthening course for. The Crown Lengthening course is to teach you the how. And remember when you think how you, think who. Who’s gonna teach me this. Anyway, so you find that crown lengthening case because now you know how to diagnose because you’ve done your reading. You’ve been on your webinars, and so you can now say to the patient, Okay, this is the issue you have, you have a gummy smile, you could get this treated for x y z benefit. And actually, funnily enough, I’m looking to learn this technique is called a gum lift. Would you like me to email you, once I have done this course? And as one of my first few patients, I’ll make sure you get special treatment. But if you’re in a rush, I can refer you to Doctor Periodontist down the road. And you know what, guys, the patients who you’ve got good rapport and trust with, they will wait for you. They don’t mind waiting three, six months, okay? Sometimes they just need that amount of time to save up the money for that kind of procedure. So it’s good to give them like a ballpark figure, email them, keep in touch with them, send them photos. So with something like that, if you haven’t got the skills yet, but you want to, you gauge the interest with the patient. And you say, You know what, I’m interested in learning this technique, do you wnat me to email you when I’ve gone on my course, which is in some months away, and the patient might say, Yeah, sure. And if they’re in a rush, then you can always offer them a referral as well. So I think that’s a pretty good way that you can adapt certain procedures to make sure it falls under the umbrella of just in time learning. But of course, you know, life doesn’t work like this, patients don’t fall in this perfect, beautiful category. So if you really liked the idea of learning how to do Crown Lengthening surgery, and you don’t have a case yet, then the next best thing you could do is arrange to shadow a periodontist, or a dentist who does some Crown Lengthening, straight after the course. So you know, within a few weeks after the course, arrange a shadow. So now even if you’re not implementing yourself, you’re seeing the implementation in the real world in daily practice, okay, and you’re seeing it under daily stresses, and you’re not on a pig’s head, you’re actually seeing it being done on a person, and you can actually assist for that dentist. And I think you’ll gain so much more, especially having been on that course, your knowledge is really good. And now you gain a few levels up, you gain a few notches in terms of implementation, even though it’s not you doing it, you’re watching someone. I think that’s another good alternative way to do it. So Aneesh, I hope that helps. I hope that answers your question. Now, just two last points on this topic in terms of how to choose the next course. There’s one of the very common questions I get on social media, Jaz, Which course should I do? Which course would you recommend? Okay? So hopefully, you’ve sussed out that the answer is I can’t recommend a course. It really depends on you as a learner, what is your learning style? What is it, what is your demographic of patients? Have you got lots of elderly patients and your dentures suck maybe and you need to do more dentures? And you know what, go in a denture course, right? How can you serve your population base? How can you serve your future niche? Like maybe you’ve decided Okay, I want to niche in this. So you want to take your career in a certain direction and that’s important to consider, this bigger picture stuff is so important. And of course, if you’re in the first five years after dental school, then all of the bigger picture you know, occlusion, perio endo in general, the core fundamentals of dentistry you can’t go wrong. Just please, please, please seek mentorship and look to apply everything you learn ASAP to gain the most from it. Final two points. One is Be mindful of the famous three letters L-O-E, okay? LOE is loss of earnings. Okay? Time is precious. Time is money. Okay? So remember, knowledge is fine. But implementation is when you really get your money’s worth. So if you’re booking one, two webinars for the sake of it, and you’re like me, like anytime I see a flyer or some advertisement for a course I automatically want to do it because I’m just always so hungry for knowledge. Sometimes just have to step back and think, Okay, is this going to serve me now? Is this going to serve my patients? And how will I be able to implement it. And when it comes to going on multiple courses, even if it’s for like an hour webinar, you’re still giving up an hour away from your family, away from your children, away from your loved ones to go on that webinar, for example. So be always mindful of loss of earnings, loss of time, and pick and choose wisely. I’m also a big fan of online courses. Because with online, we don’t have to book a day off, necessarily. You can, you know, do it in your lunch break. You can do it in between patients. Sometimes you can do it your fellow time. You can do it in the evenings when your kids are asleep. So I’m a huge fan of online courses an example I’ve been doing a Nekky Jamal’s wisdom tooth, third molar Experience course. So if you’ve got something like basic surgical skills, these clinical videos of like, for example, seeing lots and lots and lots of horizontal wisdom teeth extracted, lots and lots of distal angular wisdom teeth extracted, you can level up your basic surgical skills through online course learnings. And by the way, if you want to do that course, Nekky’s very kindly giving you a discount. So go back a few episodes. To learn all about third molars. You’ll love Nikki’s tips, I believe the coupon code is ‘protrusive ‘usually is, it’s 15% off and that’s a third molar experience, which I’d implemented so much. So my background is I’ve never actually been on a formal hands on third molar course, I’ve just had some basic surgical skills in hospital and using that course, which I was really angry when I found this course because Nekky where you all these years ago when I needed you in Singapore? But anyway, really enjoying that course and on 24th of November if you haven’t enrolled to splint course yet, and you’ve been dying to learn more about TMD and your patients are a bruxing and you want to learn about occlusal appliances then 24th of November is my last day for intake for 2021. So if you’d like to join us, it’s 12 plus hours of content just a few hours ago, and I’m recording this on the 19th of November, just three hours ago I had some feedback from Kjartan. Kjartan is in Scandinavia and he had this say about my course. Kjartan thanks so much of finishing the course. So Kjartan said absolutely fabulous course. And this gonna make me blush guys. He said, Jaz, you are the peak of dental teachers. Wow, that meant so much to me. So I’m so glad you gained value from that Kjartan. So if guys if you want someone to teach you everything about occlusal appliances in general practice, the mainstream ones from anterior only appliances to full arches, B Splints, Michigans, Tanners, etc, how to do a proper soft bite guard, join us on splintcourse.com just a few days left for that. So 24th And remember once again is the last day. And the final thing I want to tell you about is the importance of considering going abroad. Now that COVID restrictions are lifting a little bit. I think it’s such a great thing to do to go abroad, gain a different perspective, learn from a different country, go get a tan, go get sunkissed, okay? Go to Dubai like I’ve been. I’ve been to India. I’ve been to Sweden. I’ve been to Australia on tax deductible flights and accommodation within reason obviously discuss with your accountant don’t get in trouble. But there’s so much you can do outside of your country that you’re in. And it’s an excuse to see the world, experience different cultures. So go abroad, take your family with you, you know, every time I go on a course I always think, Can I take Sim and Ishaan with me. And we booked flights together and yes, we might go for like four or five days and maybe one or two of those days I might be on a course during the day. But I still get to enjoy quality time with my family and I get some you know, tax benefits with the flight and the course and etc, etc. So it’s a great way to see the world. So do consider it. If you’re always just going on courses in your own country, consider going abroad you will not regret it at all. So yeah, that is the first ever occlusal adjustment. I hope you found that useful guys. And if you did, can you do me a favor? If you’re listening on Apple, can you give me a rating and some feedback? I’d really appreciate that because I’d like to read what you think of these occlusal adjustments and the podcasts in general of course. And as always, I really appreciate you listening all the way to the end. Hope you enjoy that. And I’ll catch you in the next one. Thank you.

If you refuse to whiten under-18s without any exceptions (perhaps because you are blindly following shameful legislation) – then you may be denying children their human right to health. Sorry if that stings – it’s the truth. The impact that white and brown spots on teeth can have on teenagers can be very negative for their mental health. I hope that in this episode with Dr Linda Greenwall you will find answers and gain confidence in treating patients who are in dire need of teeth whitening for health reasons. https://youtu.be/uaHNk_fPzgA Linda Greenwall was on fire! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: When taking before and after photographs of teeth whitening cases, switch to manual flash settings instead of ETTL in order to provide the same colour of your patient’s skin and gums.  Pre-register for the 21-day Dental photography challenge!  In this episode, we talked about: Dr Linda’s journey to Whitening Publications 5:32 GDPs and their knowledge about Whitening 13:00 Why dentists can’t do whitening under 18s 22:10 Molar Incisor Hypomineralization 28:43  Lower Age limit for teeth whitening 35:02 Can Dentists get in trouble carrying out whitening under 18s 43:34 Unique considerations for specific age group 45:29 Communication between patients about Whitening 49:52 Tooth whitening for the under-18-year-old patient PDFDownload If you want to read other publications on whitening, be sure to check Dr Linda Greenwall’s Publications and also don’t forget to visit Dr. Van Haywood’s Publications  Also be sure to visit Dr Linda’s Facebook page and Please do support her trusted Charity: Dental Wellness Trust  SCCNFP’s Study about the Safety of Hydrogen Peroxide: “Hydrogen Peroxide in Tooth Whitening Products” Learn more about the Molar Incisor Hypomineralization with THE D3 GROUP FOR DEVELOPMENTAL DENTAL DEFECTS If you enjoyed this episode you will also like Teeth Whitening Secrets for Success Click below for full episode transcript: Opening Snippet: So you're telling me that any dentist who had whiten before 2011, technically was breaking the law? (Linda) Yeah. (Jaz) That's hilarious. (Linda) Correct. But also, the General Dental Council were very clear in the direction. And they said, if this treatment of disease for under 18s, then it's appropriate to treat for whitening... Jaz’ Introduction: Protruserati. I’m Jaz Gulati and I’m not going to waste any time in this introduction. I really want you to get into the heart of this episode. This episode will really get the fire in your belly going. This is such an inspirational episode by Linda Greenwall. If you don’t know Linda Greenwall, which you should do, you should know Linda Greenwall. She is the undisputed queen of teeth whitening. What she doesn’t know about teeth whitening is just not worth knowing. And it all stemmed from a discussion on our Facebook group, the Protrusive Dental community Facebook group, which is a thriving group of dentists who are passionate about dentistry. So it’s great to have you all on there. Now, Protruserati, what happened is that someone posted about teeth whitening in under 18s. Now there are cases where you may need to do this for example, fluorosis, MIH, these are things that we’ll actually touch on in the episode. And there are some strong opinions by dentists that I really respect, really careful, really admire on the group that actually you shouldn’t do teeth whitening on under 18 in the UK, where it is technically illegal, it’s technically illegal, right? It’s against the law, because some silly European directive. So this episode, I’m hoping will give you the confidence, if you’ve got a child who’s getting bullied and they’re 14 and you feel as though you’re at a loss and you have to have no choice but to cut the teeth or plaster composite all over them and whereas all what they might need is some whitening this episode will really give you so much clarity. And I’m happy to my hands up and say I whiten for under 18s when there is disease. Okay? And that should be very much part of your protocol as well. I’m hoping you will see that after this episode. Now, so just before we joined this very contentious issue, I’m gonna give you the Protrusive Dental pearl, one of the things I found the most annoying in my own cases in the past and sometimes occasionally, because I’ve changed equipment so I see this is lighting differences in before and after photos. And I sees on social media all the time before whitening and after whitening and after whitening, not only have the teeth whiten but it’s a different patient’s gums and the skin has gone like 17 different shades whiter. So it is an annoying thing to have before and afters were not just the teeth have changed, but the gum and the skin has also changed. Therefore, what you need to learn to do if you’re not doing already is use a manual flash settings instead of ETTL. Now usually ETTL is more convenient, it’s quick, it’s a quick and dry and good thing to do for daily practice. But when it comes to teeth whitening, that’s where I’m gonna switch to the manual flash. I know that when I’m using my Canon MR-14EX II , that when I’m taking a photo on manual flash, well, when it’s a 3:1 ratio of photo, I know that I think I’m on about one 1/5 flash power. And that gives me a good photo that I’m happy with. So once the teeth whitening course has finished again, I’m at 3:1, I’m using that manual flash setting again, and no other settings have changed. Your aperture size is the same, for me, it’s 22. Your ISO should be the same, for me, it’s 200. And the shutter speed, for me is 1/125. It could be slightly different for you that’s cool, whatever produces a good consistent image. So really, if nothing’s changed, the color of the teeth should be different because you’ve whitened, but the gums and the skin should be the same providing you’ve taken at the correct angle and been as consistent as possible on your site. And that’s how you get better before and after photos. Now if this is all confusing you and you get confused by photos, and you need a bit of help to get good quality, basic dental photos, then I’m starting a challenge. I’m starting a 21-day photography challenge. So every day, you will unlock one lecture, it’s like a five minute little thing just to show you from equipment decision and choosing equipment to actually how to take your first few snaps, how to get consistent occlusal photographs, what are the settings you need to choose. So over 21 days, you will watch video after video after video. And you should be able to take from something like this like telephone style photographs or lack of consistency and framings before to something that’s better, the kind of photos that you want to be taking for your photography. So if that sounds appealing to you, jump to protrusive.co.uk/challenge and then you’ll be able to pre register so when I launched that you’ll get the email and don’t worry it’s not like a expensive course or anything. It is something that’s going to be very affordable and very quickly get you some results without having to leave your home and some of you could actually watch in the practice every day, on your lunch break and that’s very much how I’m designing it 21 days of you at work watching short little videos to get consistent and good quality photographs including whitening photographs. Anyway, let’s join Linda for this phenomenal episode. I know you’re gonna love it and I’ll catch you in the outro Main Interview:[Jaz] Linda Greenwall, Welcome to the Protrusive Dental podcast. How are you? [Linda]I’m good thank you. Thanks for inviting me. [Jaz]I am so pumped today’s episode Linda like for those very few people who don’t know you like you know you are the undisputed queen of whitening there’s not even a king of whitening, you are just the single monarch of whitening, like even last night, in the middle of night I like woke up and I thought, oh my god, I’m seeing Linda and I haven’t whiten my teeth for two months. You know how like patients apologize at dentist for not brushing their teeth? That’s how I felt last last night. If you think of teeth whitening, you think of Linda Greenwall. So tell us a little bit about yourself. And how did that come to be? How did you single handedly come to dominate anything and everything teeth whitening in a good way? I mean, like, wow, what I’ve been to your lectures and stuff. You’re so passionate about it, you’re oozing so many brilliant about it. Tell us about your journey with that. [Linda]So thanks. The journey is that I was doing my master’s degree at Guys. And I needed to find a research topic. Right? I love to learn about contemporary controversial issues as right been right from the beginning, just by the way. And I was interested in this whole debate about mercury toxicity. And patients complaining that their fillings were toxic, and they were being poisoned. And they were losing their memories and all those things. And at the time, dentists were ripping out amalgams to place composite restorations, because that was in their best interest. And this every life was going to be healed. The lives were healed not only their dentistry, but their lives because their amalgam fillings were removed. So I asked to do this research study and I said spent six months researching this to discover, what is it? What’s the real truth? And what’s the science behind it? Where’s the evidence that these patients are seriously ill and get cancer because of their amalgam fillings? And I spent a long time doing this and my conclusions were in case you wanted to know, my conclusions were that those patients who were complaining about their amalgam fillings, it was a really big study in Sweden, really big. These patients who were complaining about amalgam fillings and toxicity etc. were unemployed, were unhappy with their lives. And you know, there were other issues associated with amalgam fillings. What we did find, and this is really relevant clinically to this day, but if you have an amalgam on a buccal surface, you can there’s much more chance that you can get lichen planus. So if you have lichen planus associated with amalgam filling, or let’s say, on a lower seven buccal, then that’s a reason to take it out. And so, and then, and I’ve found from that research they’re doing that actually makes a difference for lichen planus, and can clear it up. So that clinically that was relevant. And then I was about to do my research study where you had to do you know, long research study, and my professor whose name was B.G.N. Smith said, No Linda, we’re not going to do the study. Because we know what you’re going to find and so was I, So you mean? I’ve spent, six months of my life researching this topic, and he goes, No, find something else. So I went off to the library. And I saw this paper, I saw this photograph of on the front cover of Quintessence. So this isn’t, I was started my master’s in 1990-92. And the first publication on why thing as we know, it was in 1989. And I saw in Quintessence this photograph, upper teeth were white, and the lower teeth were yellow. And I go, what’s going on here? How can this be? And so I read the article. And I took the Quintessence publications to the professor. And I said, Please, I think I’d like to research this. He goes, Really? So I said, Yeah, I’d like to do that. And so I started one of the very early studies. And what we did is we spun blood into teeth, we [created a whole lot of wisdom teeth], we spun blood into the teeth, we discolor them artificially, I then section them. And then we tested all the whitening products that were available at that time, because I was very skeptical. And I didn’t actually think that it worked myself. I wasn’t so sure. And so we tested and we found and then we created our own shade guide. And we found actually, that it did make a significant difference. And then I had to put the teeth into saliva while we weren’t bleaching and then I had to photograph them. It was a very intense study, a very long study. And I just become a new mother with my first baby. And I was stuck on Mother’s Day in the lab at Guys on the Sunday, taking photos when I should have been at home with my little baby. And so I did regret that a little bit. But anyway, and so we conducted the research study, I got a master’s for the research study. I got a distinction, like an award for the I don’t know, but the thing was that I read every single study in 1990-92 to see if it was relevant. How does it affect, for everything was we knew nothing about the subject. So how does it affect glass ionomer cement? How does it affect our IRM? How does it affect amalgam? You know, all the [effect] on existing dental materials, and then I went into it. And then a few years later, I was approached by a publishing house to write to do a book on it. Like it will be so easy, Linda, just take a couple of photos. And that’s all it is. And you know, like, seriously? And then I had a few more kids along the way. And so the first publication came out of that one was a 2001. [Jaz]Wow. So quite a few years after your research project. [Linda]So that was three then it was actually three years, three babies later, actually. And then yeah, so we published it in 2001. And then had another baby the next year, four sons, but what we, first of all, writing a book is really intense, it means a lot of hours. I used to do it at 10 o’clock on a Saturday night, when the babies were sleeping. And then I’d go 10 till 2 and I could sleep late on a Sunday, because, you know, doing dentistry, you have to be highly focused, you know, can’t have a bad night with no sleep. So yeah. So then, in terms of looking at every single research study, and trying to understand I then went to the original researchers, like Van Haywood, and I messaged him, and we became very good friends. And he’s a really, really kind man. So your readers should go onto his website, which is vanhaywood.com. And you can download all his articles, he’s published on whitening, which is over 250. And by the way, go on to my website, which is lindagreenwall.com. And All my publications are there as well. So please, please look at that. And so he was very willing to share his knowledge. So I traveled to Chicago to the midwinter meeting to meet with him. And we’ve stayed friends ever since. And then all those people who published those early research studies, I contacted them all. And I connected with them, and I went to meet with them. So Elon Rothstein, who published on the effect of amalgam and whitening, so there’s another, there was a link there. And he also published on the drop in your bond strength, 20% reduction in bond strength after bleaching. So that’s relevant to the state. So I’ve traveled to Paris. He lives in Southern California. So I traveled to Paris to meet with him to quiz him and pick his brain and ask him all those questions to try and find. But at the same time, what was happening, Jaz, was that the academics in the UK were very skeptical. And they would like push it to the side. So it was like considered a sideline, and they didn’t want to get involved. And it’s almost to this day, that they think, Oh, well, it’s just cosmetic. So they don’t want to get involved. So that’s when you say, single handedly, I’d had to do that, because people were not willing to listen, because it was considered cosmetic, and so therefore trivial. [Jaz]They can just say even within the undergraduate scheme of things at Sheffield, I felt as though we were taught very little on teeth whitening, and actually remember being a DCT at Sheffield, and I seen this young lady for non vital bleaching of upper lateral incisor. So I did the re-RCT. I did the whitening of that lateral incisor. And then now this lateral incisor was a beautiful shade of a B1+ you know, like B0. But all the other teeth were obviously darkened. And then we had to discharge the patient because we didn’t do cosmetic procedures. How crazy is that, Linda? That I whitened this one tooth, because that was pathology. And I couldn’t then give her more bleach or more whitening job to do the rest. That for me was an eye awakening moment in 2014. That’s when I sort of discovered you and all the message that you sent. So listening to your story there. Firstly, kudos to you. Well done for grabbing these opportunities by the horns and going for it traveling to US and then France to make these things happen. You know, get the wheels in motion about this, and you’re just such an inspirational woman and your work ethic is just amazing. [Linda]Thank you. So in terms of controversies, because the academics didn’t want to listen, they therefore didn’t make it a serious subject in which you teach the subject. So now it’s bee, so that publications 1989. So now it’s like 32 years, where we have a body of evidence of scientific literature, of efficacy, of safety, of effectiveness, of, you know, impact and all those things and quality of life improvement. And you know, we’ve got all that evidence just from this one technique, the home bleaching technique, so you know, so you can’t ignore the research and the science. And what I find is that most dentists have actually never done a proper training on whitening. So yesterday we did a whole online training with ICON and whitening and it was training mainly the dentist in Scotland. And we went through and discussed all that. But most dentists, they make it up as they go along whitening. Nobody’s trained them, they just see what does the principal do, they don’t know. So they use the wrong concentration. And they just wing it. [Jaz]Can I share my experiences, Linda, with that? So as it as a DF one, I didn’t know how to whiten at that point at that stage. Because I wasn’t taught as an undergraduate. I didn’t know about tray designs, I didn’t know about which gel to use. And so the classic way is just like you suggested, I asked, my principal said, Hey, I think I need to go in some sort of whitening course. And he said to me, you don’t need to go on a course I just write your prescription and you know, just do it, it’s fine. And Linda, I had to learn the hard way. Like, you know, firstly, you learned the importance of medical legally to take photographs then had to take good photographs that are consistent before and after, then I went some of your lectures and I learned about the importance of motivating these patients, seeing them two weeks later, and see how they’re doing. So you gave me so many gems and tips and even things like which I’m happy to share with everyone something that you teach is if you have someone, you start teeth whitening, and you taught me that if they suddenly come back with severe pain, then that could be because there’s a non vital tooth in there. And then someone posted on Facebook around about four months ago saying, Hey, guys, I whiten these teeth and the show it with some intraoral photos. And then she’s complaining of severe pain from the lower incisor. And I said, Hey, Linda taught me that this could be non vital, take a PA. So then he took a PA and lo and behold, had apical infection. And that was all thanks to you. So these are the little fine details. And there’s so much more to it, obviously, that we miss out because we think that whitening is just this little procedure that is easy to do. You’re so right. [Linda]The thing is that on a patient’s journey, patients want to have whitening because they want the benefits of it and they want to look good. But on a patient’s journey, whitening is the beginning of the treatment plan. So therefore, and the legislation in the UK is very strict. It says, first treatment cycle, first examination to exclude pathology. And that means that every discolored tooth needs periapical radiograph for exactly what you’re describing. Because even though there’s a tiny color difference between two central incisors that could have had a cosmic metamorphosis or something, but there are other things that go on. And you know, dentists, there’s a whole debate another controversial issue, should you be taking radiographs? And I saw a whole debate on Facebook where the American dentists take radiographs, post cleaning, to check for palque. [Jaz] Post cementation of crown [Linda] Post cementation, and almost again we don’t, but preoperatively when you, you need to know what you’re dealing with on a new patient. So yes, it’s my experience that I’m a prosthodontist training. And so we take periapical radiographs on new patients on all the teeth. If we don’t then take again, that they may know what we’re dealing with, because whitening becomes the first part of the treatment plan. Then, as you know, 85% of patients opt for further aesthetic or necessary or restorative because they’re motivated from that. So you need a baseline on which to start. And we also teach that most dentist because they think it’s trivial. They don’t do comprehensive treatment planning. And so to do comprehensive treatment planning, it means the patient has to be away, patient goes away, you have the data, you have the X rays, the notes, the photos, the microscopic, I take the little intraoral microscopic photos, and I sit at my desk and I do you can’t see what it just here. But I’ve had three screens, I have that at home now I’ve installed that since lockdown, where things were like chaos at home. We’ve installed three screens. So on one screen, I have my patient photos. On the next screen, I have the X rays, and I have clinical notes on the third screen. And I sit and I dedicate time every week to just doing treatment planning because then when you’ve got clear time, you know we are so busy as dentist and we doing a lot of diagnosis on the go every three seconds when the patient comes in to diagnose etc. Medics don’t do that you have to wait for hours in the hospital to get your X ray to find out what the story is, you know, we just making instant decisions. But when we talk about a new patient who has hopes and aspirations, we need clear thinking time where nobody disturbs us and we can look at those x rays and see what we need to see and work out a clear defined comprehensive treatment planning. And in terms of dentists, if more dentists would do that take an hour out of their day. They’re not doing dentistry, but planning treatment, things would be much easier, you do better dentistry, comprehensive dentistry, your patients appreciate the value of that more and you get you know, you get to enjoy doing your dentistry because you get to do the dentistry that you love. [Jaz]I love everything about that and it reminded me very much if I think about episode 48 we had Zak Kara and what you described there about you know we are diagnosing on the spot and then we are splurging these treatments on the spot without giving it much thought unlike our medical colleagues and that’s what Zak termed as a shotgun treatment planning so we need to move away from that and move towards comprehensive dentistry. Linda, thanks so much for that amazing inspirational introduction. I feel like I know you a lot better now as well. I’ve been to so many lectures, but I really liked that insight you gave. This episode is about a very controversial topic. Now there are so many controversies in whitening and maybe at the end, I might just ask you about how we’re going to combat all these beauticians and non dentist doing whitening, maybe you can say that might be a whole another episode. But this episode is about the contentious issue of whitening under 18s. Now, the reason this came about Linda, the reason reason I reached out to you as the authority in my opinion for this is I have had experience in the past where like many dentists, you see a child that’s being bullied at school, maybe 12, 13, 14 I just find it ludicrous that nothing can stop me from placing composite veneers or ceramic veneers or whatever. But I can’t do whitening because [Linda]or cutting them down [Jaz]Or cutting them down or doing something additive, which you still know when you know that you will get a predictable and good result with teeth whitening. So I will put my hand up and I say I do illegal teeth whitening. So I do it. Okay? Because technically, I’m breaking the law because under 18. But in my eyes, I think the patient’s best interest and the moral interest patient is beyond that of some silly honestly, I think it’s a silly law. Personally, I’d love to hear your opinions on it. Now I do take it very slowly. So the child has to be you know, bullied or has to be bad enough. If it’s really mild, a couple of white spots, I’ll wait till 18 just because practicing defensive dentistry, but I’m happy to whiten for a you know, 12, 13, 14, 15 year old in the right cases, if they’re being bullied, if it was my own child, I would. However, when I posted this on the Protrusive Dental Community Facebook group, some dentists I really love and respect, they were like, I don’t care, don’t do it, you’re going to get into trouble because the law, if something happens, then you’re breaking the law. And this is illegal. So then this is open a can of worms. So my first question to you, Linda, is how have we ended up in this situation? How what’s the Genesis and a couple of minutes in terms of how do we end up in a situation where we could do this whitening treatment before and now we can’t or supposedly we can’t, in a quotation, we’ll come on to what you actually recommend. [Linda]So here’s the story. The story is that we’ve been lobbying, you know, we used to be in Europe. So we used to comply with European legislation. And the story is that we lobbied for change, because before that the law was even more draconian, where it says all tooth whitening was illegal and you couldn’t do it. You couldn’t use more than 0.1% and you’d be locked up in jail for six months if you did whitening. That was until 2011. And in 2011, they made changes to the law, which came out in 2012. So we lobbied in Europe for changes and I went to Europe to meet with the European Council of Dentists, you see, I do travel to meet and to make, you know to make these decisions. So we went, we arrived in Brussels. [Jaz]Linda, I’m so sorry had to stop you, I’m just going to ask because it’s playing our mind now, that context of we couldn’t use more than 0.1% that specifically for under 18, right? [Linda]This was for all of UK. [Jaz]So you’re telling me that any dentist who had whiten before 2011, technically was breaking the law? [Linda] Yeah. [Jaz] That’s hilarious. [Linda]I know. So that’s why, in 2008, we established the British Dental Bleaching Society. I was lecturing one day. And so Paul Barrett’s furred who’s a dentist and an MP. He said, Linda, I understand your South African accent, don’t worry, and I understand your humor not everybody understands your humor. But I get the message that you’re trying to explain. And that is that we need to make some change in the UK law, we do need to make changes, this is wrong. So we established the British Dental Bleaching Society with the basis of educating dentists in competency and clinical skills in whitening and also in trying to explain, create awareness of the situation will things can be changed. And so then there was also controversy. The other controversy was that there was, Do you remember when we shut down the whole of the UK was shut down for bleach? There was a patient complaint and the patient complaint was given this is before the sub. Over the counter, she was given 10% Hydrogen Peroxide as a take home, which damaged her clothes. And she wanted compensation for her clothes for the damage that the bleach had on her clothes. And then the dentist asked another controversy, the dentist said Well, let me see your clothes a bit [like long and Monica Lewinsky] but like let’s see that evidence. And then instead of just saying, Sure, settle. What happened it went to the Trading Standards. And so the Trading Standards took this matter up and actually managed to shut down all the supplies of whitening. [Jaz]I had no idea. When was this? [Linda]This was about just before that also. And that was another controversy. But coming back to the under the 18 win, so when they change the law, there’s two really good studies to look at. It’s called that SCCNFP. If you Google SCCNFP, hydrogen peroxide, [Jaz]I will put these links on the on the show notes, Linda, so I’ll put it all there for everyone. [Linda]Thank you. SCCNFP, 2008 and 2005. They did a comprehensive study of hydrogen peroxide. And they looked at how toxic was hydrogen peroxide if a baby should get hold of a bottle of hydrogen peroxide and drink it, how toxic would it be? And so they gathered evidence for hydrogen peroxide to check the safety. Because there’s always a question on safety, which shouldn’t be, it shouldn’t be. And so these particular papers were commissioned by the European Council of dentists to be able to present this evidence it as we said, the law was changed in 2012. And that we comply with that. So this is nearly 10 years, but because of safety and lobbying from other countries in Europe, and they thought, well, let’s just only have it available to adults. There was no reason to not permit, I’ll just go slowly on this. There was no reason to not permit under 18. The European Council at the time said We don’t know. And we haven’t seen enough evidence, not that we don’t think it’s safe. And so we presented a lot of evidence. So then we went back, the UK commission to Europe and that included Kathy Holly, Dr. Kathy Holly, who’s a pediatrician consultant, pediatric dentist, myself, Paddy Fleming, and Paddy Fleming was head of the European Association of Pediatric dentists. The reason I’m telling you this is that Paddy Fleming said, it’s against a child’s human rights to deny them the right to health. So you cannot do this in the UK, deny these children the right to tooth whitening, because it’s in the UN Charter. So you know, stop all this nonsense. Every single child has a basic human right, which is the right to health. [Jaz]Amazing. [Linda]Okay? So that’s why, all this chitter chatter and all this, you know, nonsense, in the end of the day, every child has a right to health, and that includes mental well being and includes the whitening. So we’ve got actually no leg to stand on. And all this fuss is actually puts it into perspective, when it’s the human rights of a child under 18, to have the right to health. [Jaz]So it’s safe to say that, Linda, your own opinions and views and what you practice is that as long as there is a case to improve, some a child’s health that you will advocate, teach and do yourself teeth whitening on under 18s, is that fair to say? [Linda]Correct. But also, the General Dental Council were very clear in the direction. And they said, if this treatment of disease for under 18s, then it’s appropriate to treat for whitening. And so we’ve produced a paper with Kathy Holly, my son Joseph Greenwall Cohen and Van Haywood and underlying the 10 reasons why it’s appropriate and when it’s appropriate to treat under 18 children, not just because they’re going to the school prom and they want to look super stunning or be a love Island contestant. It’s because they want to, they are suffering because they’ve been teased at school. So what’s happened is that there is a now a you know, we in COVID at the moment, but there’s a bigger pandemic, which is the problems with MIH, Molar Incisor Hypomineralization. It’s one in eight, children’s teeth erupting have white spots, white marks and discolorations on teeth. You know, we never used to be like that 20 years ago, we were dealing with a little bit of fluorosis but now we’re dealing with a major pandemic, a global pandemic of MIH [Jaz]I certainly see it loads, Linda and actually we have it very international audience here we have dentist from Canada, part of Taiwan, all over the world. Now, when I was doing my elective in Vietnam, I was with a group of Canadian dentists and they were, you know, 25 years my senior at that point, they were celebrating 25 years out of dental school at that point. And when I told them about MHI, so I was this back in 2011, I recently learned about it, I was documenting it, they had no idea and a lot of my international colleagues had never heard about MHI. So it just if you spend a minute just telling dentists, who maybe our international audience, I feel like in the UK, we have a better grip on this, but what is MIH? [Linda]It stands for Molar Incisor Hypomineralization. And the reason that we have this is that there’s basically there’s 100 reasons why. So anything that occurs when the cell is developing , the tooth cell, the enamel cell. The tooth cell is developing in utero, Anytime there’s oxygen starvation, there is likely to be a defect and white spot, but also, this affects the enamel, the dentin and erupting tooth occurs at the time when the sixes are developing, and the central incisor tips. And so anything prenatally, perinatally or postnatally, anything that happens, mother is ill, mother is exposed to antibiotics, mother has a hospital admission, the baby, this affects the baby. And so anytime oxygen is starved from this in that developing enamel cell, the ameloblast will result possibly in wide spots. For example, twins, twins are more likely to get it premature birth you likely to get it anytime any antibiotic is administered and any childhood fever and illness. Those are the basics. Celiac disease, for example, Vitamin D deficiency, all those times is when something affects, so there’s a medical situation that affects the baby or the mother, and the baby’s teeth are born with it. We live I think, we live in a more toxic society, more polluted society. So there was a story in Sweden which was reported there was dioxin in the rivers in Sweden, and they found dioxin in the breast milk of these babies, and the babies were developing later on, they were developing these white spots on teeth. So it’s hypomineralization, the enamel is not forming properly. And it can result in white marks, brown marks, yellow marks, a breakdown when the tooth post eruptive break down. But the main thing is that there’s a wide variety, from minimal to extreme. And extreme cases, the children are so sensitive, they call them cheese like molars, the child is holding their hand in front of their mouth because when they breathe in, it’s so sensitive. They’re not faking it. We think it’s overdramatic, but they’re not faking it, they have super sensitive teeth, the teeth have post eruptive break down, they just like cheese peeling off. And extreme cases, those children at age nine have to have the molar teeth extracted, because they’re in so much pain, [Jaz]Very classically difficult to numb up and also misdiagnosed as caries. And the whole spiel about you know, diet advice, and that’s wrongly directed to that child who just had a genuine, you know, Oh, does my child have weak teeth? Like no, they don’t. But in this case, this child generally did have weaken teeth in those more moderate severe cases. [Linda]Absolutely. There’s, again, there’s a really good Facebook site, an MIH Facebook site, which publishes articles, research that any publication related to MIH, which is really nice is shared on that site. And there’s a really good website, which is called thed3group.org. That’s for patients, for clinicians, for academics, for researchers, all about MIH, and the causes, and how to distinguish, for example, between fluorosis and MIH. So to understand that, so these children is a one in eight of the UK children, let’s say have MIH. So therefore, you can’t, from a mild point of view, the treatment is whitening from the mildest point of view. From the major point of view, it’s restorative. So it’s combination with restorative and anesthetic, but you know, you have to do early intervention, and you can’t do normal seals on the children, you have to do glass ionomer. And treat as soon as that you see this post eruptive break down. Don’t leave it, you know, so we that’s what our conference was on Friday, all about treating these kids with that. And so what happens is that enamel is so weak and poorest that soon after eruption, the teeth become brown because they’re absorbing all the food. And this is when the children are teased at school walking around with brown teeth. So I see this kids. And what we are doing with permission from the mothers is we record the child’s story. And we record the mother’s story. Because sometimes at the end of treatment, the mothers cry and it’s not because of the fees associated with the treatment. It’s because of the impact on the child that what we did is we took them on the journey for wiping and microabrasion and resin infiltration, but we sorted it out so simply. And that’s all it takes for the child to feel good about themselves. And most of the biggest impact is the children in your six when they’re just finishing junior school and going into high school. They’ve had already many years of being bullied and often we treat these kids when so just before the end of junior school, those that last term, we get these seeds sorted so they can go into junior school and say Wow, look at my teeth now and stop the bullying. So when they move into high school, that is not an issue for them. [Jaz]What’s the lower limit in terms of age, Linda in terms of, can now we’ve gotten past the fact that okay, even though this silly law says it’s illegal, whoever, we’re, you know, when there is a health issue, and it falls in the category and you can improve a child’s mental health, and you’ve accepted that, what is the the lower age limit for whitening that you would suggest? [Linda]About 11 or 12? There’s no. So again, I consulted my mentor Van Haywood, to ask him what is the lower limit, there is actually no lower limit, because it’s perfectly safe. So Jaz, I just want to tell you that the person who’s done the most research on whitening for kids, his name is Kevin Donly and Kevin Donly’s in the US, he’s a pediatric dentist. So in 2019, we brought him over to the UK to present at our conference saving kids teeth. And he presented his evidence and research to show that it’s perfectly safe. So the law, it’s a matter of classification and clarification. It’s not because it’s not safe, because from his research and other research, just because the child has a large pulp doesn’t necessarily mean they’re going to be sensitive. Actually, it’s the other way round, it actually helps to clear out the whitening gel through the pulp. And actually, that’s an advantage. So there’s no question on safety. There’s another researcher whose name is Yiming Li, at the University of Loma Linda. So his life’s work, his last 30 years, they’ve been dedicated and devoted to safety of whitening. And again, all of them categorically have looked at this. It’s not a safety issue. So now we’re going back to it. Okay, what can we do to change the law? You have to go back and we’ve met with, we’ve consulted with many people, and we come back to the same argument about is it safe? But we know the law was only a matter of admin. That they said, Okay, well, let’s just not allow it, there was no reason for it. So when you try, I’ve been lobbying for this for a long time, like 10 years, lobbying the people say, Okay, now we’re not in Europe anymore. So we don’t have to listen to the European legislation. Let’s just make our own rules. Let’s just do this, and what is it going to take to change the rules? And so we’ve been consulting to see and can we do this? And can we do this? And then we have to consult with the chief dental officers of the United Kingdom. Now, as you know, during COVID, they’ve got a lot of other issues. So tooth whitening to them is trivial, because they’re solving other world problems in oral health and oral health inequalities. But to that child is being bullied at school, that is not a trivial situation. So we are consulting with psychologists to be able to look at this to measure the impact of, it’s basically measuring the impact of appearance on a child who’s suffering because they’ve been bullied from their appearance, to be able to present that evidence. We should not even have to present the scientific story that we are, we busy collating for the Royal College now, a whole new document. So just to rewind a little bit, we in Europe, we presented a document to the European Commission of dental CED. And it was really well done with all the evidence in the literature. And they sort of said, Oh, but it’s only 66 pages, not 100. And we’re like, seriously? And so and when we got there, the Belgians are a little bit concerned, they were like, So what’s gonna happen? I said, Don’t worry, nothing’s gonna happen. It’s all gonna be fine. And then the next minute, we were out of Europe, and it was a whole show, but the other European countries are not listening. They don’t follow the whitening that, you know, we are so strict. And so then when we presented our paper on the under 18, when all here are the 10 categories, this is when you can do it, just go ahead and do it and do what’s in the child’s best interest because these child’s are being impacted. [Jaz]Linda, can I can I share that paper with the Protruserati? Can I put that in the show notes? Yeah, thanks so much. Brilliant. [Linda]Yeah, it’s on my website for download. But absolutely, I’ll give you that paper. But actually, it’s really important that everybody knows that they can go ahead and do this whitening without being worried. In my textbook, which was published by second edition 2017. It took me another 17 years because I had another baby started a practice and started a charity, you know, all that stuff. And so I wrote an impact report an index of treatment need for whitening, you know how we have an index of treatment need for orthodontics. I’d wrote an impact index of treatment need for bleaching into five categories, which is that you know, which is the most severe if, for example, if the child is impacted, you know, and they’re suffering then absolutely, that’s the right all different categories are you know, How much stain? What’s the situation? Is their sensitivity etc. If the mother is impacted, but not the child, it doesn’t really need to be done because the child isn’t, you know, so these are a whole lot of scenarios, but I wrote that up because I had to give it clear thought as to when is the best time for undertaking the treatment for the children. So that is, in my opinion, but age 15, you know, your teenage years are really stressful, I feel sorry for these kids. So there’s 11, 12, 13, then 15, they become even more body conscious, at 15. And then they, and then again, they wanted and at 17 is just before the end of high school. At all ages, is when it’s appropriate if their child is being impacted. And if all you need to do is change those brown marks to white or to, you know, to sort this out through whitening microabrasion and whitening microabrasion, resin infiltration and bonding, minimally invasive, that is the best option for patients. So then we took this evidence to the medical defense union and spoke to them and said, Okay, here’s the story. You know, we need to change, you know, in terms of how you’re going to cover for indemnity, how are you going to cover the dentist in the UK? Here’s the information, here’s the stuff. And they go, I can’t see a reason why you can do whitening, there can be no legal reason for doing whitening. And we said absolutely not. That’s really, that’s not the case. So we are still in debate. And I’ve disgusted with other medical defense organizations to explain this is in the child’s best interest. This needs to be done. You can’t leave the child for six years. Now. I’ll just take it personally, my child was born with a hemangioma, my fourth child was born with a hemangioma on his face. And it grew and grew to the size of a little cherry tomato. And I was sitting in a lecture at the ADA conference when the child was 2, listening to the impact of these children’s suffering from they used to call them FLKs, they’re not allowed to call them FLK, that called funny looking kid. You’re not allowed to say that anymore. But they were suffering from the appearance. And I thought wait a minute, my own child is sitting with a strawberry, cherry, a hemangioma on his face and look when I’m doing to him. And somebody stopped me in the street and said, you know, you can get treatment for this. So again, I went to the UK dentists, UK surgeons and nobody would operate and we had to fly to Germany. And the child could have this hemangioma removed. In age 2, his whole personality changed, because that hemangioma was removed from his face. And to this day, he weren’t eat strawberries or cherries, because of this experience. He’s now going to be 19 next week. But when it came to his teeth, he had trauma to his teeth. We you know, I repaired them. I whiten them, you know, it’s a very important, their appearance. And, you know, we’ve done whitening for him, of course we have to you know, to help him. But so it’s a personal story as well. When I realized from these children, they’re not impacted. It’s the right thing to do. And we need to act in the child’s best interest. When it comes to a complaint, it’s not only the clinical dentistry, its notes, its communication. There’s all other aspects which all medical defense organizations, protection societies, that’s what they cover. It’s not only the clinical dentistry, because that’s a tiny part of it. So I think we blowing it out of proportion. And everybody gets very, what’s the word? They all got these opinions, but they’re not listening to the science and the research and the evidence. [Jaz]Dentists are very afraid, Linda, because they’re worried about backlash. They’re worried about going against what the authority is telling us, they’re worried about will if something happens if the proverbial hits the fan, will my defense society back me up? What I really want to know is do you think a dentist could get in trouble with the law by carrying out whitening in under 18s? [Linda]No. [Jaz]Good. That’s exactly what I was hoping. [Linda]No. But as a dentist, I’ve had to do a lot of medical legal write ups for you know, as an expert witness, but when we learn about what can go wrong, you need to practice good dentistry, it comes back to the basics of professionalism at all times. It’s always about professionalism, about doing the right thing of making contemporaneous notes and asking the patient what’s you know, what would be your hopes and aspirations? I asked the child what would you like to happen? What would be your hopes and ask the mother and then we, I do ask a child, Are you being teased at school? Are you being bullied? Is anyone saying nasty comments about your teeth? I’m not a psychologist, so we can’t go into the psychology but I do ask them directly to get the impact, Is this impacting you? And based on all that, will absolutely do the treatment and as the treatment progresses, after we whiten you know when we break down the whitening, the protocol is that whiten for the upper first, but as long as you take the patient through the journey, and you see how their self esteem is building up, because those yellow marks are now removed after two weeks, how they life has changed. I mean, we don’t say anything, but you see it in themselves, the kid feels better about themselves, they got more confidence. Some of them wear the white t shirt, because it’s white teeth and the white t shirt. And you know, they’re starting to feel better about themselves and all, you know, the child needs right to dignity and respect. And that’s all it takes then absolutely. [Jaz]Are there any changes or modifications to your protocols that we into for teeth whitening in general, that because of the age, so let’s say you’ve got a 14, 15 year old, they have a brown appearance of the teeth, because maybe potentially MIH, and we’re starting some teeth whitening, because we don’t want to let them suffer mentally. And we don’t want to hack these teeth down or add any compensate and it’s the right thing to do. So that’s exactly what we do the basis of what we’ve discussed so far. But in terms of your protocol, is there any unique considerations for this age group, that might change your usual protocol? [Linda]I think that one mistake that most dentists make internationally, is they use too high of concentration of bleach. In the US and Canada, they go straight for the highest strength. And the rule is that the higher the concentration of gel, the more the sensitivity, okay? And so and then the more the child if it’s too sensitive, then there’s likely to stop treatment or terminate treatment. So we go, as we’ve always done low and slow, low concentration, whitening over a period of time. And most dentists and I talked to many dentists about whitening all the time, they go for the highest strength first to go, Oh, let’s be quick. And if it’s too quick, then you get regression of the shade. So by building it up low and slow, appetit first for two weeks, then you review, look at the canines see what shade they are. Then you go into the lower, the lower is longer, the lower’s more sensitive, and so the app is quicker and no sensitivity or less sensitivity. You take them on this journey of confidence building, value building and trust in the dentist as the patient is going. Wow. And you get the improved appearance in the oral health. Let’s come back. I just wanted to tell you one, a couple more things. [Jaz] Yes, please. [Linda] Carbamide peroxide is used in neonates, in eyedrops and ear drops. In 1968, the orthodontist whose name is Bill Classmen, in North Carolina, did a report of him using this technique in the children’s retainers for 40 years and reported that, you know nobody, there was no breakdown, there was no need for you know, no one needed a root canal, broke a tooth, you know, as a result of this technique. So it’s been around a long time. So when you turn it all around, and it’s not about aesthetics, it’s about health, Hydrogen Peroxide heals the gingiva. It heals, it stops the swelling, and stops the retention of plaque, it heals root decay, heals tooth decay. The carbamide peroxide elevates the pH, and elevates because it contains urea. So all this is about health. So when you start with before anything else, as dentists, we are oral health healers, and we always wanting our patients to have oral health sustainability, improving, their oral health is improving, and it’s about oral health, and hydrogen peroxide is about oral health. So, you use these products, so often on patients we use whitening for the purpose of healing the mouth. So, we use the whitening gel, so we make a bleaching tray. Then instead of giving the, instead of giving 10% Carbamide peroxide, we used 5% Carbamide peroxide. 5% Carbamide peroxide is known as NOVON® mild. NOVON® mild is from Optident, that’s lower strength for healing the gingiva. Elderly patient as well poor oral hygiene, arthritis, they can’t brush, they can’t hold the toothbrush, root decay, you clean up the mouth by using carbamide peroxide in a bleaching tray. So when it comes back to it, these children have been, the treatment has been done on children for healing the gingiva post ortho. So it comes back to health again, it’s always about health for these kids. And just by the way, for those kids during ortho. Do you know you see your kids if their kids come back off to ortho and their teeth are a little bit more yellow or orange or brown? Post ortho? There’s a reason for it. The reason is that as you having the braces put on this microbleeds that occur in the bone from on the ligament, there’s micro bleeding and that bleeding causes the discoloration post ortho that you see, [Jaz]I did not know that. There we are. I’m sure a lot of listeners learn something then notes so much on this episode. We’ve got a couple minutes left and I want to ask you this final question for I just open the mic to you to you know, your passionate plea is in so infectious, or we definitely need to do something to reset everything actually make everything right. But the question I had was communication one, when you have a child who is potentially being bullied, and you’re considering teeth whitening, is there anything you say to the mother and the child to say that Actually, here’s what I’m suggesting. Technically, if you Google it, it might say it’s illegal. But I think I’m passionate about this because x, y, and z, or do you think we don’t need to go in that direction? I personally do say, technically, it’s illegal, but I’d rather do that, then cut your teeth down, or add composite or this, and I have that spiel, what do you do? And what do you recommend? [Linda]After I’ve understood again, this is Stephen Covey, it always says, first seek to understand. So after we understand from the child, what it is that’s worrying them about it? So I mean, we’ve treated children who need major ortho and the teeth are all sticking out like that. But actually, it’s the color that’s really impacting them. So I asked them what it is that you would like? And then we discuss and I say to the mother, that it’s their child human rights, it’s their right have the right to health. I don’t, do you realize I could be locked up in jail for doing this? Because it’s what is in the patient’s best interest? And, you know, it’s all about the patient with proper notes, with proper photos, with explaining that the law says in the UK that there’s no whitening for under 18 inless it’s a disease. So that’s how I tell it. I said, we can do this. If there’s a disease process under 18, we can do that, your child has MIH, amelogenesis imperfecta, stain from the medication, white spots, brown spots, trauma, then this is the right thing to do. Often, I mean, if it Yeah, so that’s how we handle that. The mother, I’ve explained to the mother why we’re doing it, I’ve given the diagnosis, I’ve given the options for treatment, do nothing, observe, monitor, composite bonding, whitening, ICON microabrasion, I’ve given the whole range. And then again, if it’s an MHI patient, treating restoratively first, take them out of pain, and then take them on the journey. [Jaz]Amazing. That covers it really well. So that’s one of the other things that people are asking on our Protrusive Dental Community Facebook group. Okay, how do you even communicate this once we actually go over the fact that a lot of dentists are passionate that we shouldn’t be doing this in under 18s and these are the Dentists that I respect and I love so I’m so glad to share the opinion and advice of someone who I respect so much in their arms a teeth whitening. Linda, you’ve absolutely given so much value in this episode, I want everyone to check out your website, please tell us your website again, any courses that you put on because I think everyone who hasn’t done a whitening course and is not getting great results and you need to follow some of your techniques and pearls. I would love for them to join you on that. So if you just please tell us about that. [Linda]Thank you very much. We do a lot of online hands on treatment by the way that I’m training because of COVID. So you can do it wherever you are, and do the hands on with ICON and resin infiltration, etc. The websites, also my Facebook please look at Greenwall Dental, Greenwall Dental Education, Dental Wellness Trust for my charity, and lindagreenwall.com. Go to resources, all my publications are there, the list of courses and events and look at our study groups, and all that it’s all online, all the information. [Jaz]I’m going to link that all in the show notes. So do click on and check Linda’s work out, please support what she does, because she is you know, doing so much by profession in terms of making teeth whitening, where it should be. And I applaud you and I encourage you, Linda, keep fighting the good fight. We need people like you to do that. And thank you so much for making time to come on the Protrusive Dental Podcast. I’ve really enjoyed it. [Linda]Thanks so much. Thank you. Jaz’ Outro: Well, there we have it. Hope you enjoyed that episode with Linda, I told you it was something special. And I hope you like how we covered this very controversial subject. You know, I’m no stranger to controversy. You kind of have to have thick skin and be able to deal with controversy if you’re putting yourself out there like I do with the podcast. I’m totally cool with that. But it’s all about sharing different views. And I’m definitely on Linda’s side here. Like if I have a young patient who’s getting bullied for their health, it’d be a wrong thing to deny their human right of it. So teeth whitening may be part of that. So I’m all for it. I hope you are now as well. And if you’re not that’s totally cool. You do what feels right to you. Now if you’d like Linda do check out her website. All the information you need is on the show notes on the Protrusive website, including the wonderful charity work that she does, please do show her your full support. So I’ll catch you in the next episode guys. Thank you

This episode is deep. Burnout is a syndrome of chronic workplace stess that has not successfully been managed. It is unfortunate but it does and can affect so many of our colleagues. In this episode with Dr Emma Courtney, we discuss how to identify when someone is in a difficult patch or experiencing burnout and how to cope with it. The second half of this episode is about planning your CPD/Dental CE appropriately. https://youtu.be/0M9BocLGQBk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Before starting on a course or program, be sure to have a patient in mind already that will benefit from you going on this course or gaining this piece of education. That way you will be able to apply what you learned ASAP and implementation is key! “One of the the components of burning out is that emotional exhaustion – that kind of depersonalizing and trying to distance yourself from things” Dr Emma Courtney In this episode we talked about: Dr Emma’s journey moving to New Zealand 7:42 Dr Emmas’s personal experience with burnout 18:02 Dr Emma’s source of stress and burnout 26:03 How to overcome burnout  34:56 How stress and burnout affects Dr Emma’s dentistry life 39:21 The importance of help even outside Dentistry 50:27 How to think differently about your CPD 56:04 Check out Dr Emma’s Podcast The Fang Farrier  If you loved this episode, you will like How to Win at Life and Succeed in Dentistry – Emotional Intelligence Click below for full episode transcript: Opening Snippet: The physical injury turning into complaints turning into a lack of faith in my own treatment and trying to avoid more complicated treatment leading to probably borderline supervised neglect because it was easier not to do risky treatments than to feel like I was risking a complaint... Jaz’s Introduction: So we’ve all heard about burnout in dentistry and how it can be really catastrophic for your career. Now, the guest I have on today, Emma Courtney went through a period of burnout which was cause interestingly, by a major earthquake. So all the different things that could affect your life is fascinating her story based in New Zealand how a major earthquake rattled her life so much, excuse the pun, that it set her in a cascade of events, and she experienced a burnout and she left dentistry thinking that she would never join dentistry ever again. She’s now a passionate dentist, she’s a fellow Protruserati and it’s great to always have Ems’ support and feedback on the podcast. So Ems, thanks for being with the journey of the Protrusive Dental podcast over the last three years or so. You’ve been a big part of it. You’ve been early adopter. So thank you so much. In this episode, we discuss Ems and how she moved from UK to New Zealand to practice dentistry. And what are the cascade of events that lead to burnout and how we can look out for the signs of burnout. So if you’re in a difficult patch, right now, EMS and I will hopefully discuss in a way, that’ll help you to identify the signs of burnout and how you can overcome it. And it’s interesting that we talk about burnout and CPD because the other theme that we’re gonna explore in this episode is picking your CPD and deciding what’s part of your personal development plan. And it’s interesting anytime in my career, where I have felt jaded or burnt out, I’ve always found learning something new or going deeper and delving deeper into an area of dentistry, ie through in courses or further education has actually been the antidote for my burnout. So I find that by learning new things and keep myself interested that that’s helped me to overcome the burnout. Whereas in some people, it might be that you’re doing too many courses, and you’re burning out. So it’s it, we explore themes like that. Now, because I want to give lots of time to Ems’ a story, I want to do my own little section. So I’m starting a brand new wing of the podcast. So we already have the group functions. We’ve already got the interference cast, which is like the non clinical ones. We’ve got the main PDPs. And now I’m introducing the Occlusal adjustments. Okay, so occlusal adjustments, if ever, I have a guest on and where we’re covering so many different themes and we’re going kind of past that one hour mark. Sometimes I just want to do a little mini segment to just give my thoughts, okay, have a little rant sometimes, or have a little opportunity for me to go on different tangents and go deeper into my philosophy on a certain subject. So I hope you gain lots of value from this episode with Ems about burnout and CPD. And I’ll catch you in an occlusal adjustment in a few days, where I’m going to give you my own guidelines as to how to choose CPD, there’s a balance between Yes, any new education, any knowledge that you gain is never wasted, it’s always good thing. But also sometimes wasting your money on doing courses, which you don’t get to apply. I’ve been guilty in the past of doing that. So I want to share that with you. So keep an eye out on this occlusal adjustment, the first one coming very soon. I just want to give a quick shout out to Dr. Zachary Smith, I believe from Texas, this awesome email that he sent. Dr. Smith, thank you so much. I really appreciate it from the bottom of my heart. It’s messages like these that really keep me going. He said Dr. Gulati, just call me Jaz, man. ‘Your podcast is by far the best podcast for dentists. I’ve listened to you from the beginning. And I’ve seen so many other podcasts start to flounder, but yours is truly life changing.’ Oh my goodness. ‘Thank you so much and keep it up.’ I will definitely. I will and I really really appreciate. I appreciate you and all the Protrusearti who listen and send feedback and support, I really appreciate. Thank you so much. The Protrusive Dental Pearl i’m going to share with you is very relevant to choosing your CE or CPD. And it’s this, when you next are considering on enrolling on a course or signing up for a program or whatever, I have found this technique to be very useful. Think of a patient who will benefit, just one, it has to be just minimum one patient that you think will benefit from you going on this course or gaining this piece of education. And then can you apply that course to that patient within a reasonable timeframe to be able to gain the most from the course? And if the answer is Okay, I want to go into Crown Lengthening course and you don’t have any Crown Lengthening patients ready and you just like the idea of knowing about crown lengthening, then maybe you shouldn’t go on that course. Or maybe if you don’t already own a laser and you don’t have any case that you think okay, we’re using a laser on that don’t do what I did and go to laser course okay? Yes, I had access to a laser but it’s happening. Patients already planned in my head. Okay, I might want to need to use laser on this patient. So really, I think that’ll take you save you a lot of heartbreak and a lot of missed opportunities and then to be able to direct your learning towards more relevant courses for your population that you treat. So let’s try and keep your education as relevant as possible. So hope you enjoy that Protrusive Pearl. And let’s join Ems Courtney now on this episode on burnout, something very serious and picking and choosing your CPD Main Interview:[Jaz] Ems Courtney, welcome to the Protrusive Dental Podcast. I’m so happy that I’ve got a fellow Protruserati on the show today. All the way from sunny New Zealand. Please tell us a little bit about yourself, Ems. [Emma]Thank you, Jaz. I’m just I’m stoked to be here and to be able to give back to the community because I’ve really enjoyed my experiences. My name’s Emma Courtney. I’m a Liverpool graduates of 2000. I have been in New Zealand since 2005, after a five year stint in the Royal Navy, and I’m a mom of three. Practice part time in private practice and the rest of my time, I’m either studying so at the moment I’m studying for a positive psychology diploma, or I’m blogging and podcasting also. [Jaz]Yes, Fang Farrier. Odder name. Love it. Tell us about your podcast, what inspired you? What kind of themes you discuss? [Emma]So it’s a lot about probably the mental health aspect side of it, but how to deal with stressors that we come across in every day that people maybe take for granted that they’re just things that they have to put up with or have always been there. And things they might not think that they could do better and come out at the end of the day better and have a higher energy clinical day, but have you know more energy and time for themselves when they come home to because it can be quite a draining career if you let it. So just Yeah, trying to save people from burnout, which is ultimately kind of where I started my journey with that side of things. [Jaz]One, this is exactly why I’m speaking about burnout. And it’d be great. It’s always great to hear the different guests and their own personal stories and experiences. So I guess what I want to start is just share your story about moving and if it ties in with burnout fair enough, but just moving to New Zealand, because a lot of people want to know, explore that possibility. I’m sure you get message all the time from people in the UK, like, ‘Hey, how do you do this thing called moving to New Zealand as a dentist kind of thing? Right? I mean, I was bombarded with that when I was in Singapore, and I came back and henceforth I made the very first episode of podcast, expat dentists in Singapore. And that’s how the podcast funnily enough began, because I got sick and tired of being on the phone to someone every single day, explain and answering the same questions. So I want to ask you, what took you to New Zealand? What was it like? What’s your story behind that? [Emma]So it probably started at Uni. I started to get interested in New Zealand in terms of a holiday destination, not necessarily somewhere to live. My exposure to it was through TV and movies. So I’d seen a lot of things that were set there. And I’d seen those beaches and those mountains. And I mean, this is pre.. [Jaz] Are talking Lord of the Rings? [Emma] This is pre Lord of the Rings. So yeah, so the first trip there, they were actually still filming Lord of the Rings. So yeah, no, pre Lord of the Rings. It was like the piano and the TV series, Hercules and Xena. And they were just, it was just all outdoors and breathtaking landscapes and I am an outdoors person. So I love to get, you know, strap the boots on and pack on the back and go off, record tramping here in New Zealand, but hiking. And I’ve always had that in the back of my mind. And when I graduated, I’ve got a friend that was doing a gap year or an away in Australia, and we’re based in Sydney. So I’d got a couple of months before I had to join the Navy. So I graduated. And then I didn’t have to go straight into a job I had until September or late September. So I thought well, I’ll go to Australia. I’ll catch up with them. And we’ll travel around Australia for I think it was six weeks, we’ve got plans, I’ve got a return trip to Sydney. And then about a month before I asked you to go they turned up on my doorstep because they’d had financial problems and had to come back so I was left with this. So that’s it for this return to a trip to Sydney, which isn’t a bad place to be at but suddenly having to kind of plan six weeks whereas I was just going to coast along and just kind of get a ride. And it dawned on me that the place I really wanted to go was New Zealand. So I did spend four weeks in Australia and I went up the east coast but I kind of tripped in a side trip of Manchester to squeeze in a side trip to Auckland and then did some traveling around the North Island and just fell in love with the place so much so I went back the following year to kind of do the North Island properly well as properly as you can do it in kind of two weeks. I suppose within the Navy I was very privileged in that I had paid leave I mean that’s something I’ve never seen since that’s always a bonus and then I did a MaxFacts SHO job in my fourth year there, so kind of four years out of dental school. And that was it. It was a big year. It was a stressful year I’ve got my MFDs under my belt and I managed to kind of accumulate three weeks leave together. And I so I’m going to go back and I’m going to see the South Island, and it kind of coincided with my commission was coming up in the Royal Navy. So you sign up for five years, and then there’s a board for extension, and that was kind of coming up. And I think it was gonna be just after Christmas. I was considering [Jaz]Sounds like remortgaging your house. [Emma]Yeah. The next stint was going to be another 13 years, I think or something like that. So yeah, it was going up for the medium career commission. And then I was considering specializing. So what to do there, whether to stay with the Navy, because it might not have happened immediately. But they’re very good in terms of CPD and looking after you say I felt sure that I would specialize in something, had I stayed on, and I was looking at outside, I wasn’t too keen on going straight into the NHS from the experience I’d had in the Navy was quite again, privileged, I would say. And yeah, I looked at [Jaz]And working in the Navy, just to put some context and some ideas for people who may be considering that route. What, how many patients would you see? Is it kind of like private practice, you get to do what you want, or was there a bit of the treadmill effect and requirements? Just give us an idea of that. [Emma]So I’ve never worked on the NHS, I’m not a great one for exact comparisons. But in terms of kind of comparing it to the private dentistry I do now. Timing and time for patients was reasonably similar. It’s more focused on getting people dentally fit. So you’re just, I mean, I suppose that it’s more kind of in line with NHS dentistry in terms of you not trying to go above and beyond to try and get people out of pain and functional, and so that they’re not going to experience toothache at sea or whilst they’re away and things like that. So we weren’t kind of pushed timewise. But we did have a moment, I suppose our figures that we were accountable for where what percentage of our patient base would dentally fit. So with the Navy, that would, you’d got lots of people going to sea without a dentist and then they’d come back and they’d need sorting out. I was actually based on submarine base for a lot of that time, which was a bit different, they have a lot more kind of base time. But yeah, just you weren’t seeing as many patients, as I understand, you’d see on the NHS a day, you had a bit more freedom of treatment, but then you were quite restricted in terms of materials you could use, there was a budget for crowns for the year, not per dentist. But if you wanted to kind of like fly a crown, towards the end of the financial year, you might find it was kind of like now not this time round. But there was no problems between, you know, kind of root canal and exo, it wasn’t, you know, it wasn’t a financial choice. And it was very good in terms of you, sound horrible to say you didn’t need consent, of course, you need to consent for treatment. But they weren’t paying patients, you were on a salary, you have a lot more freedom to just, as a new grad, it was excellent, because you could just get that volume under your belt, get that all the basic stuff that you’ve been taught with [Jaz] get that 10,000 hours in. [Emma] Yeah. And without the pressure of feeling the need to suddenly accelerate to implants or crowning everything you see or [Jaz]And not having to discuss money. I mean, that’s something that is a strange thing when you enter private practice from dental school, right? So yeah, I imagine you don’t have to do that. [Emma]And that, I guess, is a double edged sword because it was great as a new graduate. And it took an awful lot of practice. It took a lot of pressure off practice, but when you come out as five years, or whether it be 16 years or 20 years graduate, and you realize that actually, you’re probably more suited to the private dental world because of the experiences you’ve had is that suddenly nobody’s mentioned money and it becomes Yeah, I guess the later you leave learning about those conversations and how to have those difficult conversations, not just about the money side of things, but also about the consent side of things because you didn’t in the Navy have, well, my time you didn’t have patients asking for a certain treatment that maybe was borderline appropriate or not necessarily destined for long term success and having those really difficult conversations because I think that’s a skill in itself. And that was something I felt quite dropped in the deep end when I did start, but you know, we get there. So yes, I came over here on a working holiday visa that came with a brochure on picking fruit. So I’m still under 30 so you could come over for a year I think it was at the time. I got my first job through the BDJ actually. Just an advert in there and I was, it was incredibly surreal as anyone that’s had an experience with recruiting in New Zealand because this has certainly been for most of the jobs I’ve had here as it’s very casual. I’ve kind of, I’ve been told I was getting a phone call that was going to be you know, coming interview for this job. And I’d braced myself for something formal. It was, I was in Gibraltar at the time, so I was in the mess and it was, you know, like a million degrees with no aircon. And I sat there on my bed in this tiny room and I was all set up for it. And I’ve got my CV out in front of me and all prepped. And it was just kind of, it was just like a general conversation about say you like New Zealand, Do you want a job and that was pretty much it [Jaz] Excellent. [Emma] And then the logistics of registering with the dental Council and stuff like that I’d actually gone through a company that are still around called [LANZ], which is an acronym LANZ which is Locums, Australia, New Zealand, I think is what it stands for. Okay. And they they recruit from the UK to for Australia and New Zealand. And although I didn’t use them to find a job in the end, they do that too. But they walked me through the process in terms of applying for a practicing certificate and things like that because the degrees [equivalent] so you don’t have to sit a practical exam. Yeah, but you do have to sit like an open book theory exam on local practices, Māori culture and Pacific culture and prescribing I, cause you’ve worked in Australia, haven’t you? Jaz, was that right? [Jaz]Singapore actually it was Singapore. [Emma]Okay. I don’t know whether that’s I think that’s reasonably in line with kind of what Australia do and it’s how it put it down. It’s like a mixture between American and European practices, both in prescribing and yeah, just it’s a bit of a blend. So it’s not massively far off. But there are one or two things that are kind of same same, but different. So yeah. And then I came over I managed to get, I applied for residency when I got here because it was on the high priority list at the time. I’m not sure if it is now. And yeah, so I had that within six months. And I met my now husband within that time as well. And yeah, I was working up near Auckland, and he was moving down to Christchurch and I didn’t particularly want, I wasn’t really interest in Christchurch, just having a lovely time in Auckland. But but you know what? This guy seems like the real deal. We’ll give it a go. And if it doesn’t work out, I’ll go home. And well, it did so. So here we are. [Jaz]Amazing. And then so you now you move to Christchurch? [Emma]Yep. So that’s where I am now. [Jaz] Okay [Emma] I’ve been here since 2006. [Jaz]Well, tell us a little bit about, you mentioned about burnout and some of the big themes. So the two big themes are really explored you is burnout and planning CPD. That’s the kind of the main thing. And I think they can go hand in hand for example, if you do too much CPD, and you do too much at work, and so much going on your life and you experience burnout, and you’re not an effective learning, you’re not effective family member, you’re not effective friend and all these kind of things. Do you have a personal story with burnout? [Emma]Yes, so I mean, I didn’t ask many people. I didn’t know I’d burnt out at the time. And it wasn’t something that was talked about as much as it is now, thankfully, so something that people are more aware of. I just felt broken. I suppose if I had to pick a starting point, because that I mean, the definition of burnout includes the fact that it’s a chronic state, it kind of creeps up on you. It’s not an overnight thing by any means. And for me it probably started with the earthquakes here in Christchurch. So we had some major earthquakes in 2010, 2011 which we practice through and but it was a huge shake up I mean, half the city was pretty much kind of destroyed if not immediately but needed rebuilding including our practice needed had to be moved off its foundations and rebuilt and things like that. And we anyone that had any experience of earthquakes know that there’s lots and lots of aftershocks which makes life interesting, makes practicing life interesting. And [?] oh my goodness. Well it’s a bit like being at sea. You don’t realize how [Jaz]So as you doing your crown prep, your handpiece is just like bouncing around. [Emma]Yeah, it’s kind of so, I suppose you get more attuned to general movements anyway, after an earthquake, you’re kind of waiting for them and anticipating aftershocks. But if you’ve ever worked in a city or on a main road and you have like a really huge truck go by and it rumbles the building that’s kind of like your real base level, like kind of on the Richter scale, maybe like 2, 2.3 something 2 to 3 kind of side of it as it just you get a bit of a movement. And then beyond that, it ramps up but you normally get a bit of a start to it doesn’t tend to jolt straight in so yeah, so you realize how quickly you can kind of get instruments out of people’s mouths and foots off pedals. But I think it was one of those things, I didn’t think about it at the time, because you just get on with it. But it’s another source of chronic stress. You’re running on cortisol. You’re running on adrenaline, and it’s not for weeks or months. It’s for years, I mean, we’ve still got stuff being rebuilt now. And yeah, it just kind of, it’s hard to describe, but it was at the time. I mean, we were without a flushing toilet for six months, we had no water for two weeks, the roads were trashed, the local facilities around the side of town were so like all the gyms and the whole community halls, everything that kind of had a community sent to [us all], or part of routine was kind of gone from this side of town, managing small children and working out what to, their managing patients and their anxiety. And the I mean, it’s as anyone that’s practiced for a while be aware, you know, the dental chair goes back, and it can be a bit of a psychiatry couch, in terms of the stories you hear and the experiences of your patients. And what they were going through. Our practice was on the edge of the red zone. And so we were zone, the red zone was houses that weren’t going to be rebuilt, and were waiting to be paid out by insurance or various things like that. But those people would flush the toilet and it would the sewage would come up in the lawn. And this was like a year later. And just living in just real third world conditions in a first world kind of country. It was. Yeah, it’s a lot of shared trauma, I guess. And I think anybody individually, if you talk about kind of burnout is that everyone’s got, we’ve all got this capacity to cope with stress. And as dentist, I think we take it for granted that we’re actually really good at it. We have a really stressful job. But for the main part, you know, we, you know, manage it like a boss. It’s just so natural to us that it just comes off. But the problem tends to be when you have life events that increase that level of stress. So I always kind of look at it as like being stress and your coping tools has been like an arms race, one will bring the other up. So we need a certain level of stress and a certain level of challenge to bring up our coping mechanisms and skills and grow and move forward. But the problem can be as it’s going like this as if you have a life event like a divorce or a death or is suddenly your stress goes up and there’s a lag, you can’t just suddenly bring those resilience skills up to meet it. So those tend to be kind of the most kind of at risk times that if you’re under a lot of stress, and you have events like that, particularly if they happen in short succession. And you don’t necessarily have the support, you need to kind of go through them, then those are going to put you at risk of depression, and burnout. But I kind of like into it. Because I do a bit of speaking when I talk to dental crowds here, I would say that it’s like not just having a death in the family. But suddenly everybody you know, had that same death. So it’s not you just kind of going up here. Because in that way your community can support you and they can bring you up because they’re not under the same stress. They’ve got the capacity and reserve to help kind of you out. But when the whole community is going through it like with COVID, It’s exactly the same. It’s hard, because you’re dealing with all your patient stresses and you’re dealing with all you know, you’re dealing with the stresses of everybody you meet, everybody’s on a short fuse and having, not necessarily having a bad day, but it’s not necessarily at their best self or their most tolerant self. And it then makes it very, very difficult. And I think that that’s one thing the earthquakes have taught me is that it’s a long recovery. We want it to be a short recovery. I remember it and the main quakes here with February 2011. And most of like the accommodation stuff was trashed the sports grounds the rugby fields are trashed, and it was the year we were hosting the World Cup. And Christchurch we’re going to pay hosting England. And the in those first day is everyone’s Oh, you know, we’ll be back on track for the World Cup in like October or whenever it was. And, I mean, that’s human nature to have that hope. But it’s a long game [Jaz] That optimism [Emma] and COVID is going to be the same. It’s forever changed our landscape. It’s forever changed how we are going to practice dentistry. And it’s another trauma that we’re going to have to be aware of not just from our patients, but from our staff and our colleagues in terms of everyone’s dealing and managing with it in different ways. And that stress is putting stresses on other things that we can’t see like at home, like marriages, and relationships and health, all sorts of things. Sorry, I’ve gone on a bit of a sidetrack. [Jaz]No, I’m just trying to know. That’s fantastic. Your input and devastating what you’ve experienced in terms of earthquakes and the impact it had on you and your community. Was clinical dentistry a source of stress for you that you think contributed to your period of burnout? Or do you really think that it was mostly what you’re going through with the earthquakes that was responsible for your personal story of burnout? [Emma]Ah, combination. So I mean, the earthquakes didn’t help. I was also I’ve got two children under two at the time of the quakes. And then, two years later, I had my daughter who, I don’t look at it as a stress, but it isn’t, I suppose it’s there are extra things that need doing in terms of she has a Quadriplegia. So she has a disability. So she did require more care, particularly more so when she was, you know, kind of under five and working three days, with three kids under five for a while. So at preschool, and it just puts an awful lot of strain on you’re not sleeping properly, as much as you’d like to think you’re kind of functioning well, it’s that you’re just pushing, I’ve just been pushing all the boundaries for a long time. And I suppose you only have so much energy to give. So my response to that had been to almost kind of withdraw, you know, like Dentistry was just something to get through, to afford to do the other stuff, to facilitate the things that needed doing it, it took kind of a backseat in priorities. I was at a position at that stage where financially wasn’t great. There’s no maternity leave as such here. No paid leave, no paid sick leave. So obviously, when you’ve got children, and you’ve got to take a day sick for them, that’s no pay to. And all of those things start to kind of creep in and be a pressure and part of me, I guess just I would have much preferred to have just been at home and be the mom that I wanted to be rather than being in work. But that financial side of things also cuts down what you can, what’s available to you CPD wise. So I had not neglected my CPD, but it had been just online through journals and stuff that was local and free and didn’t take up too much time because I couldn’t really afford the clinical time off either. And I think first actually, I kind of broke physically, which is something people don’t talk about with burnout is that when you’re that rundown, and you’re that fragile, it’s a whole body effect. It’s not you know, you don’t, you can’t just separate mind and body, you, I hurt my neck taking a tooth out for the random things to do. And I couldn’t raise my arms. So I didn’t want to take time off work because I didn’t have time to take, you know, I wasn’t gonna be paid for my time off work. And you kind of battled through it. But I’d have days where it would go into spasms and I just have to kind of canceled my day at 10 o’clock, you know, I’d come in my neck would go and I’d have to go. Went down the medical side of things and actually ended up seeing the All Blacks doctor at the time, because she deals with a lot of neck injuries through rugby. And and she said to me, she says, Can’t you do something else? So can you not just not be clinical? And got the end of the orthopedic lab. Just kind of like you know, it’s almost like a you have a neck and compatible with dentistry. Well, what are you going to do? Can you sideline outfits? Well, not really. And the only solute physical solution they had to that was I think they wanted to inject cortisone between my vertebrae or something like that. I don’t know something along those lines. Suddenly they didn’t really appeal. But in the meantime, I’ve actually become a personal trainer. And it’s like, well, I shall, I’ll find a way to fix this, surely, it’s just timing rehab. And that worked out. But when you physically having issues like that, so that was leading me to having kind of time off and unpredictable time off, which then leads to canceling patients and messing around patients in terms of because we know how it is you can’t cancel them, but only if you can get hold of them to actually stop them coming in, or all sorts of kind of funny things. [Jaz]It’s always Sod’s law, that when you cancel that patient the next time your neck would go would affect the same patient. And it’s Sod’s law that. It’s just Yeah, [Emma]And I had one of these and it turned into a complaint. And it was a really nasty complaint. And in the end, there was nothing to answer to as unfortunately, most of the nasty complaints are because it’s more emotions and communication, but I wasn’t firing on all cylinders with those. Because one of the, as I say, I didn’t know I’d burnt out. But one of the components of burning out is that emotional exhaustion that kind of depersonalizing and trying to distance yourself from things but and at the time, when you’re in it, you think, Well, I’m doing enough, I’m not gonna go over and above, but I’m doing enough and you’re almost in like a protective self defense. You know, I’m only going to do this because this protects me, but patients pick up on it in the same way that they pick up on, if you’re feeling rushed, or if you’re feeling stressed. And they will take their own or put their own story in their own meaning to that. And this lady. [Jaz] Perception is reality. [Emma] Yeah, I thought it meant that I didn’t care about what was going on with her. That, and again, this is someone that in hindsight, I would say was another person that had also been through at the time, you know, six years worth of post earthquake, had her own stuff going on, and that this was the final straw for her. And I had that and I had another Oh gosh, the most ludicrous complaint that was a pain to deal with as well, I had, we’d done a, like a voluntary Day, which actually, I would never do again, that sounds really heartless I won’t do free for three days again, because I’d had someone come in and I don’t know how they’d found the way into the books the criteria for the day where you could have a checkup or a simple filling or simple extraction for no charge. Nothing complex, just almost kind of like pain management. But it was also for carers, and people who had just had that distraction, which is a great cause. And 90% of the day was very rewarding. I had someone came. Come in but didn’t really know what they wanted, it was a very confusing situation. But the short story is that I found a upper six, I think it was that had what I can only describe as like a bin lid filling that opened and closed on it. So it’s like it must had a GI with a pin somewhere that was keeping it on. But it’d been dressed for a root canal forever ago, and just been left. And I found this and I said, Well, you know what would, I can’t do root canal for you. If you particularly want the tooth out, I can take it out. Or I can just kind of dress it so it’s not gonna fall apart and you in the next wee while or whatever it was. So I addressed it. And then he came back to the practice a couple of times because he was confused about something. And I explained and I went through his notes and this and the other. And then I got a formal complaint through to say that I’d taken his tooth out without his consent, which hadn’t happened. But it is one of those things. You think it’s one of those things that, Yes, everybody’s got a right to complain. And we have to answer to them. But it was another stressor on this. And then amongst this, I just, I didn’t want to be there. I didn’t want to be at work. I didn’t want to have anything to do with Dentistry. I didn’t want to, I would go into a cold sweat if I saw I got a call on my phone when it wasn’t a work and it was from work. I didn’t, I withdrew. I didn’t want to go to staff functions. I didn’t want to have anything else to do with dentistry outside of dentistry, and that impacted my CPD as well. I did what I had to but I didn’t want to go sit in a room of dentists and I didn’t want to hear how great everybody else’s experiences were when I felt broken when I felt that I couldn’t do it and I didn’t know why. That I hadn’t been able to fix myself and the things that I had found easy and had just been second nature for so many years were so difficult and so stressful. And I just I [Jaz]What you described there Emma’s of the cold sweats and feeling broken and not wanting to socialize your peers in the same way they used to. Unfortunately, a few of my colleagues have told me the same feelings about about work. And that’s what I knew, Okay, we need to talk or the, you know, my friend needs help, or this might, this colleague of ours needs help. So how makes up any dentist who could be listening to this may be going through a rough patch in life, we are humans first, dentist second. So as a human, there may be relationship issues, like you mentioned divorce as an example, for example, there could be something catastrophic going on in life or in their lives, and then that could be feeding them. And they could be having very similar emotions, feelings, experiences that you’ve described. So maybe we can take learn from your experiences, how did you overcome the burnout? How do you recognize it? How do you overcome it? And so that we can inspire and give hope to any dentist who may be in need. [Emma]So recognizing it was months later, so I got to a point where I just knew that it, it wasn’t working, I couldn’t fix it from where I was. I had tried things, I tried getting interested in new procedures. I’d got, my boss was very good in terms of trying to get me interested in other things and other avenues to find something that could help kind of drive me through [Jaz] Get a spark inside. [Emma] Yeah, get a spark. Because he could. I mean, you think, I guess you think you kind of operating on just like a level but your colleagues can see that you’re just on this downward trend, and they can see you lose interest and see things being different. I mean, I’d been at that practice 10 years, I think had been with a lot of the same personnel. And in the end, I took a break. In the end, I actually stopped and I left and I thought I would never set foot in a surgery again, I thought I couldn’t do it. I thought and I didn’t. And I still didn’t know what I was burnt out. And I still I didn’t I mean, I was quite probably depressed, but I wasn’t diagnosed with anything. Because I don’t know, I think it’s part of that kind of perfectionism that we have is that it’s me and it’s mine to fix alone, which is nonsense for anyone that’s listening to this. There’s teams around you and people that would love to help lift you back up. And, John, that time I decided, right? Well, I’m going to go be a personal trainer, I’ve got a qualified personal trainer, I’m going to coach. I did some sports and nutrition stuff. But after a couple of months, I started to miss it. And the national conference here, the NZDA conference was featuring a psychologist who is quite humorous, and it’s actually as it turns out married to a dentist. But he was doing that the main presentation on stress in dentistry. And I mean, I still had in the back of my head, I still didn’t understand what had gone on. And I wanted to know, I wanted to know. So I went along and there was this, he did this amazing presentation, which was life changing in itself. And I was sat there not literally in the front row, because I was like I’m gonna absorb all of this. This is what I’m here for. And I’d already kind of started along the lines of wanting to try and help make dentistry less stressful for people. So anyway, I sat there through that, but what I hadn’t realized or hadn’t really acknowledged was immediately following it was Dr. Fiona Muir, who was presenting the findings of the NZDA wellness survey and what they done in 2016, which wasn’t published until I think last year or so. But what they did was they did a big cross sectional survey that went out to most NZDA members. In fact, I actually remember being late for work because I was filling it in, because it was one of these, you know, one of those ones where you pick and it’s like you are 2% through this survey like it was, I remember doing and she suddenly painted a picture of burnout. And as she was describing it, and she was saying what was involved. I just I literally kind of like, it was a real lightbulb moments like that was me though. And I started I was just crying. I couldn’t control it. I couldn’t help myself. There was at the front [Jaz]This is at the conference? You were there, the covering just crying. [Emma]All these stoic people sat around me and she was telling my story on stage. And I just I couldn’t believe it. I’d never. And I kind of came out of that. And I was almost in shell shock for the rest of the conference. In fact, it was like a morning tea break afterwards and ended up on one of the stands with some of the reps that I knew. And I was just, you know, kind of sat down and just explaining kind of what gone on and what I’d suddenly realized that it wasn’t me, that this was something that happened to loads of dentist in fact, the survey had found that over a third of New Zealand dentists that have completed did it and it was a statistically significant number I can’t remember what but identified as burntout or with suicidal ideation, a third of the basis of the study [Jaz] That’s just terrible. [Emma] And another site oh my goodness, I kind of went from relief to knowing that it wasn’t just me to actually being quite angry that I hadn’t been prepared for this. Why is nobody talking about this? Why is it you know, was I just not paying attention at dental school, you know, kind of what’s going on. And from there, I started to kind of work back and piece together, how it happened to me in terms of what had gone on that the physical injury turning into complaints, turning into a lack of faith in my own treatment, and trying to avoid more complicated treatment, leading to probably borderline supervised neglect, because it was easier not to do risky treatments than to feel like I was risking complaint kind of judging patients on past experiences, I’ve seen this kind of patient, I’ve seen this kind of treatment before, I don’t want to part of it being overly anxious about focusing on negative outcomes. And in that I’d seen yet the stress and the coping with all the things that had gone on with life for the last 10 years. That connection, and that I’d really I self isolated, which is quite common thing to do when you’re depressed or down or running, is to withdraw because you don’t want to bring other people down, you don’t want to be the Debbie Downer in the conversation that turns the happy, excited conversation to, you know, you don’t want to be that person. And you don’t want to say it out loud. And as I say the CPD side of things, I could see that I’m someone that I love learning, I’ll take a course and I run with it. And the only thing that saved me from worse than burnout was the fact that I had started on this fitness journey. And I suddenly realized, after trying to do as little dental learning for as long as I could, that I missed learning that it really it woke me up, it lit me up, it made everything else easier, not just what I was studying. It made homies, it made work easier. So I started off as a Zumba instructor as you do. And then I did some certifications for my group fitness. And that all got back into physiology and I thought oh, and then I did my personal training. And every time you think you’ve left the Krebs cycle behind it finds you again if you enter. And then I did some Sports and Nutrition coaching, which got into kind of like the psychology side. And I found all of this just lit me up. So for a while there, I kind of get rehabbed myself out of it by throwing myself into learning things that weren’t dentistry, that weren’t bringing up those memories and associations and got me back in love with learning and growing and doing things. And then I started picking courses, that dental courses that did like me that. I did just because I wanted to not because it was something I felt I should know, or I shouldn’t do. So I would say [Jaz]At this point, you are not doing any clinical dentistry, right? [Emma]No. So I took maybe nine months off. And but I think the other thing that I realized with the time off is that Dentistry was such a huge part of me, of my life. It’s very difficult when you know, because it is, it’s part of your identity, I am a dentist to suddenly put that down and completely dissociate from it. But also going into something like personal training is actually you go into a different kind of realm of work and you realize that you’ve no experience, that you’ve got other experiences you can draw into it, and you suddenly start to feel actually, I had loads of experience at what I was doing, you know, like I wasn’t Yeah, it’s that you suddenly start to value the experience you had when you have something else to compare it to. And I initially went back in as a locum I did some work on the West Coast, which is reasonable drive away. I’m on the east coast of New Zealand. And, but it was actually, it was very therapeutic in that I knew it was locum. So I knew short term, it sounds horrible to say that I knew that they weren’t my patients, but they weren’t going to be my patients for a long time. So that there was a lot of pressure off, there was no, they didn’t know my story, [Jaz]It would ease you back into it better than going full on full time into where you were before perhaps. [Emma]Yeah, but it was like, Well, I can angle like, into kind of like PTSD, it was very hard going in there. My anxiety levels were through the roof. I would see things on the day, like [Jaz]So your first day back at the clinic, you had the the cold sweats again, and the anxiety again? [Emma]I would say, Gosh, I would say it was probably the first probably took a good month to get that like kind of it was almost like exposure therapy, you know, I kind of put yourself in there and see those things that had been your triggers before. And just ride them through and realize they weren’t as bad as you remembered them that this time it could be completely different. But it probably took me because I went from there into some local kind of part time jobs, it probably took me the best part of a year or two, to get comfortable. And to come home. And my husband would be like, Geez, you’re happy. It’s like, yeah, I’ve actually come home from work happy, you know, like, I’ll be in a good mood at the end of the working day. And tell you something, one of the tools I got there actually was your podcast. And this might sound silly, but I would listen to your podcast on the way to work. And I will use it to because I’ve got like a 30, 35 minute commute and I listen to you on double speed, it’s quite nice to hear you regularly. [Jaz]Well done for keepin for keeping up to 2x. [Emma]And it was kind of like my, you’re kinda like my pep talk for work. I would have you, I’d have you in the car. It was like having someone sat in the car next to you talking dentistry but not just talking dentistry, but being super enthused about it. And I would literally kind of get to work and whatever had been discussed and be like, Ah, I could try that out today or I could have a go at looking at. And I started just switching that mindset. And I still listen to you on the way to work, I don’t actually listen to your podcast any other the time [Jaz] That means a lot to me. [Emma] I, it just sets me up for the day. And it’s really helped bring that spark back in, that spark to suddenly say, Well, actually, there are bits of this that I really enjoy. And there are bits I didn’t appreciate that I could find enjoyable because I hadn’t looked at them for so long. So nothing kind of massive, but just you know, small things Oh, I’ll try that with a matrix strip, or maybe I’ll try that with a wedge or maybe, you know, and just enough that I’d kind of gone from by the time I’ve gone from home. I’d kind of left that behind and gone and completely prepped myself for day of dentistry. And would share mine with that. And at Darfield where I’ve worked two practices at the moment where with my colleague Julia, shout out to Julia. I introduced her to the podcast and we come in and we chat about your episodes together which again. [Jaz]It’s been great to connect with Julia she is and thank you for recommending her to SplintCours even both in on and Julia has been, you know, whizzed through it and yourself as well. So it’s great to her to have you too, so keen, enthusiastic about it as well. And it’s been amazing. I think the podcast for me, has helped me to connect with people like you all over the world as is really special to have that connection, I think. Or people who become like minded, little bit geeky, little bit funny in that way, but it helps to stimulate your day, I think. [Emma]Yeah, and I think that’s probably something to be said for someone that’s finding it very hard to enjoy their dentistry or feel though they’ve lost that kind of spark is that it’s okay to borrow someone else’s enthusiasm. It’s okay to kind of tag on, you know, hang on the coattails of it because it is infectious, and it will rub off. It’s one of those things. I mean, it’s been studied in positive psychology a lot is you know, like the contagion of smiles and laughter and things like that, it does, it just helps and it can be the first step on that ladder that you need. It can be the spotlight in the darkness to just show you that first step so that you can get on and then start to make the rest of the journey around. It doesn’t, there’s not necessarily one spot that you find it but that’s just the one thing you need is just that one, that one boost up. And [Jaz]And you can get that from anywhere. I mean, any thing that you enjoy or that inspires you, it could be nature from wherever for you, you found it from fitness, from reconnecting with learning, just being a learner for you was a big driver for you to get you back to you know, your best you. [Emma]Yes, exactly. [Jaz]But if I was to suggest that perhaps in hindsight, do you wish and perhaps the advice that maybe we’re giving to anyone who’s going through a really tough patch, is to seek help from somewhere, obviously, you didn’t identify until you’re crying at that conference, that was such an epiphany for you. I feel as though perhaps you endured so much into that journey. And if only you had that lecture sooner or whatever, or you had that connection sooner, so perhaps people need to, and you said now it’s so much more widely available as well, the mental health side of things and the burnout. So you know, you should seek out help. [Emma]And I think, help outside of dentistry, and it doesn’t have to be kind of formalized help. Sometimes it can just be opinions, because a lot of the stuff that we kind of put up with and we think, well, that’s just got to be the way it’s got to be. It sounds horrible to say if you talk to a normal person, if you talk to someone outside of our world, they’ll just be like, That’s ridiculous. What are you, you can’t carry on, like, you know, they’ll help just put it into perspective for me. The people I work with, they’re having an occupational counseling program, which, again, I actually didn’t find out about until after I’d been through this, which is a fault in itself. But I kind of sing the number from the highest rooftop as it were now. But just I think that the stigma around mental health, around not coping and about not being able to do it all on your own because you should be able to. That’s the voice not what, yeah. Is that message is so strong and so ingrained in us that there’s a real fear and I can remember I did look, I knew that I needed some help. And I knew that I needed some psychological, I thought I needed a counselor, certainly other and I didn’t even know how to start, where to look, who to talk to, just to begin that conversation. And that was very difficult. And it shouldn’t be that difficult. It should be, I would love to see on the, I’m you have the kind of same thing I can’t remember about the recertification as with the GDC but here with the Dental Council in New Zealand you have your new recertification thing, you know, you have No, I’ve not been convicted of this. And no, I don’t have you know, I don’t have substance abuse problems. And thankfully, now they’ve put Yes, I’ve had an eyesight check, because that’s a different matter entirely. But on there, it should be Have you checked in with a mental health professional this year? Because it should be ordinary or routine or [Jaz] Very true. [Emma] It shouldn’t be something that you’ve got to be in dire need of before you seek it out. Going back to the psychologist that had presented, he started off and he said, I’ve something to confess. So I haven’t had a dental checkup for eight years. And you can hear this in take a breath from the crowd. He says, we’re still He says, My wife’s a dentist. But he turned this round to say, Now, why do you think that your mental health is going to be okay, without somebody checking in on it? How is it any different to that dental checkup? How [Jaz]That’s a powerful way to send a message dentist driver? [Emma]Yeah, how, if you had a patient with an infection, an acute infection, that and this will go on to gray zone because it’s antibiotics but the required antibiotics, you’d want them to take the antibiotics to get over so you get on with your treatment to get past that acute phase but we have such a stigma around taking antidepressants and being diagnosed with depression. When actually when we go back to that discrepancy between the high stress and that time lag between your resiliency skills coming up. If you need antidepressants here, what they’re going to give us that time to build the other resiliency skills so that you can meet the stress that you’ve got and match it. And this stigma around that is huge. And I would even go back to the definition of burnout and the World Health Organization only got around to acknowledging it or defining it in 2019, which I find quite shocking. But there you go, so they have it down as an occupational phenomenon, not a medical condition, a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. But to me that stigma again has not been successfully managed like, you have it because you haven’t been able to sort of [Jaz]Painting a picture of failure. Right? [Emma]Yeah, it’s, I don’t know. I mean, maybe it’s because of where I come, my experiences where I come from, but that just feels like a big finger back at you, you know, like the cause of this lies at your doorstep. And I don’t know what, [Emma]Well I hope what you’ve inspired for anyone exactly. You know, what I’m hoping is that anyone who’s in a tricky situation that this conversation with Ems tonight, today, it would have inspired you to seek help, because at any one point there will be humans, not just as humans who are in a low point, some will be high point. But if you’re in that low point, and it’s affecting your dentistry, affecting the care that you can give to your patients, then take lessons and it’s really lovely to hear you openly share your story, Ems, that takes courage. So thank you, and how you overcame that. That’s really, really great to hear. And it’s so good that you have your mojo back in dentistry. And you’re you know, you’re able to practice with full enthusiasm again. One other theme that I want to explore now is CPD and I we were discussing before we started to hit the record button about you’re going to go to tell me about the different cycles of CPD because the initial question was asked who is any advice to young dentist about planning their CPD because I get messaged by young dentists all the time saying, I don’t know what next course to do, or how many, you know, should I do this course, Should I do that course kind of thing. And I think you have a really profound answer on how to think differently about your CPD. So let’s get about a flavor about how to plan your CPD as a dentist? [Emma]So yeah, we were chatting about kind of the new graduates. And as I was explaining that, in my viewpoint, kind of, you have such a massive experience of dental school, obviously culminating and finals that you are all the time is learning things and getting your head around it. And there’s probably, you know, you look over those five years, there’s been a heavy slant towards theory learning and book learning than there has been towards the practical side of it. So in terms of kind of phases of advice that I would give for dentists is that that first kind of two, three years, is that you still, I guess you kind of consider yourself, you are up to date, because you’ve just finished finals, you’ve got your BDS or whatever your qualification is. And you actually need to kind of take pause to reflect on that, absorb it and practice it. Because the, you’ll have far more in terms of kind of knowledge than you’ll have experienced at that stage. And just really get the volume under your belt to put all of these things you’ve learned into practice to see what you enjoy what works for you, what you do find anxiety inducing or doesn’t feel quite the same as it did at dental school. And I’m not saying neglect your CPD because we’ve got requirements that we need for recertification. But really just getting it done is enough. So the easiest way to get through it. And that might be through a journal and online things, it might be subscribing something that has all your content for the year just looked at it so that it’s just one less stress, and one less thing to worry about. And then as you come out of that you should start to get a better picture of what it is you want to do or what it is you want to improve upon. And it’s not. I think there’s an over emphasis, and it comes from dental school, because it’s about any education system, really, is that education systems are about promoting further up the education system, you know, so dental school, you know, that you, the specialists are held in regarding the consultants are held in regard and that the career pathway that you’re kind of shown? Or is [Jaz] The exposure that you gain here. [Emma] Yeah, yes. It’s all the exposure you gain. And it’s all that you really get to kind of talk and know about and I think, yeah, I think [Jaz]Which is why I wanted to be a restorative specialist, I want to go be a consultant restorative when I qualified, and that was dead set that was gonna do that. [Emma]Yeah. And I’ve wrestled with the thoughts about specializing my whole career even recently, I was like, more should I could, I’ve still got time in my career, I could still make use of this. And I think there’s no shame in saying that you want to be a specialist generalist, you know that. You want to be the jack of all trades, and you want to be the person [Jaz] The hardesr of all specialties. [Emma] Yeah, that you want to be the person that could be in a rural practice and deal with 90% of the things that are thrown at them and still acknowledge when you need to kind of refer on but to me, you know, that’s a superhero dentist right there. So, but that’s not, It’s not held on a pedestal. It’s, you know, it’s not glorified, it’s not seen. It’s not even really kind of illustrated as a career pathway. Because it’s not acknowledged, and there’s no title with it and there’s no formal qualification that goes with it and on all the things that we love, our certificates and our, you know, letters and all those kinds of things. So yeah, don’t be too pressured to go into specialism not to say that we need specialists and other people there that are massively suited to it. But maybe don’t make that decision one, two years out, maybe give yourself a couple of years just to, to feel out because the other thing and just you’ll know the same is that the best specialists that you refer to and have a relationship with are the ones that have had a decent general dentistry background before because they can appreciate beyond their scope. And they’re not locked into their tunnel vision of their specialty. [Jaz]Tunnel Vision is the best way to describe it. Absolutely. [Emma]Yeah. So that’s probably the first stages is concentrate on getting hours under your belt at the coalface is, you know, get some work done, get some fillings in, get what works for you. But use that time to seek out mentors. And I think people get a bit put off by the term mentor in terms of that, it might have to be some kind of formal agreement. It doesn’t, it just means learn from the experiences of those around you. And even the worst mentor will have so much to teach you. Because it might be teaching you what not to do and what you don’t want to do down the track. But those are valid lessons too. And I think people get hung up on being in sounds horrible to say bad practices or under bad bosses, because I don’t like that kind of black and white, good and bad, it just might be something that doesn’t suit you and doesn’t suit your values. But, man, if you do some time under that you’ll still learn, they’ll still have things they’ve got to the position they’re in because they’ve managed to do something right. It might not be something you agree with. And yeah, it’s just everybody around you as a mentor, your senior nurse, your hygienists, particularly, and your therapists, if you’ve got anybody says or say anybody that’s senior to you has got experience in this setting that you don’t have and that you can learn from. So yeah, so look for mentors, don’t worry so much about your CPD. And then the next phase is starting to think about those things about what’s your place in dentistry, and you’re young enough that you can explore things and backtrack, you know, I did my maxfacts here and my MFDs. And I was gonna specialize. It’s not that I backtrack, but actually, I don’t feel the need to see this through, I can do something different. But, again, as we were talking the, I think the danger zone, and this was this was highlighted actually, in the results of this study, I can’t remember exactly, but the peak kind of risk for burnout and things was about that kind of 10 to 20 year points. And the good news for those of you who are in it is it gets better after that. Whether that’s just with experience, in terms of kind of life experience and dental experience and just chilling out because you’re on the other side, you know, the more Twilight side of your career, I guess, I don’t know. But apparently, the results of the survey say that it does get better after that. But that’s the time when you probably need the most support, the most help with your motivation, the most, you need to seek that inspiration from somewhere else, because that’s when it’s going to be struggling, you’re likely to be struggling because it was also the time that people are having families, getting married. People you have got married and it hasn’t been the greatest to having those painful early divorces, you’re buying houses, all these commitments that suddenly go up and all of a sudden, it’s not that dentistry got any more stressful, it’s just that life around it got more stressful. And that can make it harder to be enthused about work because all of a sudden you’ve got other things that are starting to compete priority wise and it’s not that they’re, not that you should view them as competing, but it’s that you shouldn’t necessarily neglect your working life as well because it is a large time percentage of what you do. And you’re at that stage where you’ve got you know, 10 years experience under the belt and you run the risk of you know, day in day out syndrome. I’ve just got to get through this and you know, it’s just another filling or it’s just another crown [Jaz]Also risking or being on autopilot and losing the love of the minutiae of the detail and the care and that fire in your belly, you lose it, you can lose it. And I remember my trainer in DF1 telling me that at 10 year point is roughly when a lot of dentists may get some complaints because of the complacency, right? They’ve done extraction so many times before and I take the you know, don’t check the medical history or little mistake, because you’re just running on autopilot. When you’re running on autopilot, then, you know, it can not lend itself to the best kind of care that you can give customized to our patients. So yeah, I think you’re so right in that phase, you can fall into these traps. [Emma]Yeah. And this, something springs to mind is what you’re just describing there’s mindlessness. So in terms of kind of you just operating on autopilot, you’re going off rules that you’ve been given ages ago. And you just, you kind of your present actions are dictated by past events. And, [Jaz]And is dragging and is the complete opposite of the flow theory, you know, the flow theory is that you’re completely engrossed in something, and time you look at the timer, or where have the three hours gone, kind of thing. Whereas, yeah, when you’re, when things are dragging, it’s not a nice place to be. [Emma]Yeah. And it kind of ties in with Ellen Langer’s definition of mindfulness, which is different to the kind of the main one we think about that being present and things like that. And her definition of mindfulness comes down to kind of noticing what’s new and different, and being open to differences and exploring things and challenges so that you’re not operating on that mindlessness kind of front, is that you are treating everything as what is new and different here. What can I change or change up? And like, what would you say about the flow, that is, the way that the flow works is it’s that kind of graph of challenge versus skill level. And if you’re not upping your skill level, then the challenge is going to drop. And you’re going to drop into the like the corners of that graph, that once you’re outside a flow, and you get kind of arousal control, you end up in anxiety, or relaxation, or boredom, or the bottom end. So the opposite end to flow on this chart is apathy. And that’s when you’re at risk of burnout, because it ties in completely with that. So I mean, the way I plan my CPD now, because I’m, gosh, what am I? 21 years graduated? Is that I, I still take care of the basics in terms of I’ve still got my box check. And that the same that I would say for my new grads, just so that I don’t have to think about meeting the requirements. But beyond that, I look for stuff that lights me up, stuff that I can see is going to have something immediately actionable that I can take away from it. And I think we have to kind of broaden our views of what CPD is because I mean, while the weren’t podcast when I came out of dental school, but your podcasts, your blogs, your, these are your mentors from around the world that are available to you that you don’t need a formal relationship with, that you can learn from but also, yeah, but also that kind of padding out of and I guess this comes to be you know, yes, if you you can stay in general practices and be that specialist generalist is start to learn about business and marketing, even if you’re not running your own practice, start to have an appreciation of it, start to seek out communication courses, start to look into and I would something I would never think is kind of the like coaching qualifications have helped me because they’ve helped me communicate with my patients better. They’ve helped me work out what it is they really want because what they’re saying isn’t necessarily what they want. And we’re kind of stuck in a profession that still, it’s other professions sometimes feel still stuck in like the 19th century, No doctor says you do kind of the end it’s with consent and everything else. It’s not that straightforward and probably as, you saying you were talking to Sean, he would probably talked about it as well in terms of you’ve got to know what the patient actually wants. You can’t run with the first thought of Ah got this, they want that. Because then you’re, both of you are happy until the end of the treatment when you realize that you’ve satisfied your treatment outcome, but not their needs. And that’s where you’re going to come up with complaints. That’s where you’re going to have less kind of thing. So you know, even just, it sounds quite basic or dismissive. As you know, communication skills are huge. If you want to avoid complaints and have more satisfied patients and that would be a starting point for anyone. So yeah, so I make sure I’ve got my hours tied away somewhere else but the rest of it is actually personal growth, not just professional growth and things that can kind of tie into that because, as I said, it’s some of these, you might think, well, that’s not overly relevant. But you go on these courses. And sometimes it can surprise you, I can remember I went on a health and safety course, which sounds, you know, like most people would rather put nails in their eyeballs. But we had a change to our health and safety laws recently, and we went along and it was it was quite amusing because we went in and I think 90% of the dentists in there were hoping for basically just a checklist of how to comply with the new laws. Now, the guy that presented the course, he was someone that dealt with workplace accidents, and particularly workplace deaths, actually, and he had a lot of stories about not dentistry, but a lot of stories about other workplace incidences. And talking about like we were talking about on the autopilot that your highest risk is your 40 to 50 year olds that have been doing it for so long that they can do it in asleep. So the electrician that puts two wires together that an apprentice would never have gone near but they’ve been in that mindlessness state. And it’s fatal. And it was the most surprising course I’ve been on. Because it was nothing that I expected. It turned out to be about aging and resilience and mindfulness is what it turned out to be. So go explore these things. And I mean, it’s always going to be dictated by what time you want to spend, what money you want to spend, where you want to go for it. I always have my eye on something, sometimes and it’s not always the the monetary value beside. Sometimes I will spend more than I want to spend on a course because it’s either something I can’t get through any other means or medium, or it’s presented that I wouldn’t be exposed to normally. And I guess once you’ve done enough courses, you start to get that filter of Well, yeah, I can see there’s going to be value in that or I can’t and yes, sometimes you get caught out but do try and challenge yourself. [Jaz]And I’ve said on multiple times or podcast before for every clinical course you do, do one non clinical. And I think even you mentioned coaching, that’s an example, right? That’s something that has been made, that’s made you a better communicator with your patients. That’s an example of one because there’s only so many non clinical, but anything that could improve you and your mindset, and your demeanor and your the way you speak, your body language. These are all important things for you as a communicator, because as I was discussing with Sean today, dentistry is so little of what you do with your hands and so much more what the patients feel and the communication aspect of it. So you I think you’ll enjoy that episode. And just like I hope everyone’s enjoyed our today. CPD at the end but really, in the kindest way to share your story and makes us vulnerable. I really appreciate that. But I do feel whilst it might serve many of the Protruserati, just generally they might be listening to think okay, you know that this is interesting. But a small minority, I think this episode will really really allow them to give themselves permission to seek help. And these small numbers will be helped massively and I’m always up for helping small number of people in a big way. So Ems, thank you so much for giving up your time today, on father’s day in New Zealand and I know you said you got your husband a nice big box of meat. [Emma]Yes. He is a carnivorous at hearts. So yeah, it’s steak dinner today. [Jaz]Amazing. Well, if you have any closing comments, please tell us about your podcast. Where can we listen? What’s the full name of it? [Emma]Oh, yeah. So I have done courses on marketing and self promotion. This is how good I am at them because I’d forgotten to mention it the whole time. It’s Fang Farrier, which is a other words, a slang term for a dentist. That’s the name of the podcast. It’s the name of my Facebook group and my Facebook page I think ‘It’s a dentist life’, which is only different because there’s only so many times you can change the name of a dental Facebook page. So I can’t change it to find very, but yeah, [Jaz]Well, I’ll be sure to put the links on the show notes so people can come and listen to you more. We’ve got these different angles to share with the whole positive mental attitude and your history and fitness is very different genres that you explore non political stuff, which is so so important. [Emma]Excellent. Well, thank you so much for having me. It’s been absolute pleasure. I’d say I’ve taken a lot from this community and from your podcast and SplintCourse which I’ve thoroughly enjoyed, and highly recommend. And it’s just great to give back. [Jaz]What that is again, it’s so nice to be speaking to a fellow Protruserati from across the globe at different time zones just amazing. So thanks so much and have a lovely Father’s Day with your family. [Emma]And you have a lovely evening. Jaz’s Outro: Well there we have it guys. Burnout and how to identify it and how to overcome it and how to plan and navigate through the world of CPD. Hoped you gained a lot of insight from that, particularly if you’re early on in your journey and you’re thinking about okay, what’s my path of learning over the next few decades. Very soon I’m a post up on Occlusal Adjustment so do check it out. And of course if you’re not part of the protrusive dental community on Facebook, what are you waiting for? Go on Facebook, search Protrusive Dental Community and join over 1700 dentists who are the producer it just like you listen and love the podcast and I love that and I really appreciate that so much

Learn TMD and Bruxism Management as a GDP – SplintCourse launches on Monday! Register for the Big Update Being a good learner, on a fundamental level, is the very foundation of becoming a great clinician. In this interference cast episode I host Dr. Ferhan Ahmed, a dually-qualified Dentist limited to Implants and the author of the book ‘Unstoppable’. Ferhan teaches us mindset hacks and the power of visualisation to being an unstoppable force in Dentistry! https://youtu.be/yQZ3qTjeDxk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “Always put learning before earning. Increasing your knowledge is immensely, immensely powerful, and it will never hold you back.” – Dr Ferhan Ahmed In this episode we talked about: Ferhan’s journey from dental school to medical school 5:57 Advice to young dentists in pursuing Masters or medical school 9:33 Power of visualization 16:09 Kind of learning styles 22:26 Takeaway message of the book ‘Unstoppable’ 29:17 Rewarding yourself 35:38 Communication tip 38:55 Grab a copy of Dr. Ferhan’s Book: BEING UNSTOPPABLE As promised, the books that recommended by Dr. Ferhan ‘Atomic Habits’ By James Clear (Jaz can also vouch for how awesome both these books are) ‘Rich Dad, Poor Dad’ By Robert Kiyosaki If you enjoyed this episode, you will also like 6 Signs You are a Comprehensive Dentist with Dr Jaz Gulati! Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and Welcome back to an interference cast. Now, if you're new to the podcast, welcome. It's great to have you. An interference cast is a non clinical interruption. And if you're a usual listener, welcome back... Jaz’s Introduction: In this episode, we have Ferhan Ahmed. Now Ferhan is an awesome clinician. And he wrote this book called ‘Unstoppable’, which is a great contribution because it does so much for charity. But it’s one of those books, which is very much in the realms of personal development. I’m a sucker for personal development books, I love anything in that genre of personal development. So the reason I like this book by Ferhan, is that it’s personal development book, but it talks to me. It talked to me as a dentist, because he is a dentist, turn medic. And now he focuses on full arch implant work. And it was very inspiring. I think it’s something that you know, we need to focus more on the non clinical sometimes, be it the mindset. So what do you expect to gain from this episode is to explore a little bit about your learning style, what is your learning style, and really focusing on bigger picture type stuff. And one of the biggest takeaways, I think, is the power of visualization. Now, let Ferhan do the honors explain a bit. But yeah, the times where I use visualization is like, macro visualization, like bigger projects, like, when I’m developing the podcast, I’m visualizing things, when I do public speaking, or lecturing or whatever, I am going to be doing some visualization in my head, I would have given that talk, my eyes closed and when I’m in bed, and I would have spoken to people how I’m going to look, how I’m going to say things, what I’m going to say. So a lot of times I’ve rehearsed things in my mind, but also, like, if I’m doing a surgical wisdom tooth that is just beyond my comfort zone, I will mentally rehearse that surgical procedure. Or if I’m doing anything complex, multiple crowns, things that are just stepping out of my comfort zone, I’m always rehearsing it in my mind, what could possibly go wrong? How am I gonna accept the instrument for my nurses hand? Like to this tiny little details. So one big takeaway from this episode is the power of visualization. Anyway, hope you enjoy this interference cast with Ferhan, and let’s become unstoppable. Main Interview: [Jaz] Ferhan Ahmed, welcome to the Protrusive Dental Podcast, my friend. [Ferhan] Thanks, man [Jaz] We already had a little spicy intro there. So I already get so much value here. We talked about morning routines already. We talk about productivity so I know it’s gonna be one of those at a million miles now but in a good way. I mean, all quite positive. I know I’m with you, now. I’ve seen you on Instagram. I know that you fly around to different clinics and you mentor them on implants and complex dentistry. Which is amazing. So tell us, for those who don’t know who you are, a little bit more about what drives you and your passions. And we’re going to get into more of it. I feel like I know you already because I read some of your book now. So tell us a little about yourself for the listeners. [Ferhan]Yeah, thanks, Jaz. My name is Ferhan. And I see myself, I initially saw myself as a dentist, then I went through a phase in my life where I saw myself as a medic and then add kids and as a father. And then I, it’s a question I’ve been really asking myself, What do I see myself as? And I just wanted one word. And the word that came to my mind was creative. I want to be a creator. That’s what I want to be known as, that’s what I feel is I can be most closely aligned with, yeah, I teach, I mentor, I’m a dad, I’m a husband, I’m a son, I’m a brother. But what is closest to my heart is someone that’s the people who come and think ‘Yeah. He’s quite creative. He’s always looking to do something innovate and create.’ And as I’m going into the fourth decade of my life, that’s what I want to really focus on and being a creator. So yeah, I’d love to think of me as a creative or a creator. But most people know me as an implant dentist, and I have a passion for education and training within implant dentistry. And that really stems from impact. That’s one word that I think about most days, and that’s impact and what impact you know, I asked myself the question for what impact are you having? What impact are you wanting? And in 10 years time, what impact have you had, and the pandemic and it was, you know, none of us really expected it and it changed everything. It was an unforced rest at home, three months, and I was like, What am I going to do? And I was like, you know, I’m going to make the absolute most of this opportunity. And for me, I’ve always felt my impact comes from the work I do. So I was an implant dentist that rehabilitated a lot of people with filling or denture wearers, rehabilitated them and give them fixed teeth. And really, how I felt, how can I ask myself the question, How can I have a bigger impact? Well, how much full arch implant dentistry can I do and do. It’s tiring. It’s physically, mentally draining. And so I could do maybe four cases, five cases a week. That’s 20 a year, that’s 240. 20 a month. 240 a year. But what if you could train a thousand dentists to get the predictability, the reproducibility and the consistency that you can get with the full arch implant dentistry, then the impact will be bigger. And so that’s where the online program came from. That’s where the when one to one mentoring comes from, that’s where the live courses aligned with it online. And the community I’m trying to build within full arch implant dentistry is coming from, it’s all based around one word, impact, that I can from 10 years down the line, look back and think yeah, I did all I could to have the biggest impact that could around this particular area within implant dentistry. And that’s for full arch implants. So yeah, impact your career. [Jaz]How did it develop into that? So you went from dental school to medical school, most people who do that have got Maxfacts in their mind? So what made you opt away from the typical maxillofacial route and treating oncology and being a restorative consultant that and I’m thinking, okay, you know what, I’m going to go into implantology and private practice. Yeah, so [Ferhan]I suppose it’s the best way to look at it is doors, you know, we all have a vision to get to an endpoint. And that may be door 10. But I always looked at life, just taking a small step, and just going to door two opening that door and see what happens. And then opening the next door after I’m through door two settle, let’s see the opportunity. And so when I thought about doing medicine, I was in the environment around maxillofacial consultants, and they inspired me, they impacted me, and I wanted to be like them. And so for me to be like them, I had to pursue a second degree. And that happened to be medicine. And I went down to Liverpool and did a full year of postgraduate degree. However, I also was aware of that, it’d be okay not to follow that career. I was okay with that. Because one of the other reasons I want to do medicine was just that, seeking more knowledge to be a bit different, to just better myself. And so I went down to do medicine with the proviso that yep, I could do maxfacts, or it’d be just good to have a medical degree, it’s never going to hold me back. It’s always just going to be an advantage. It’s going to make me stand out from the rest. And what’s the worst that could happen? Yeah, four years have gone, but I’ve got a degree, and it’s a worthwhile degree that will just add to my dental ??? And so that’s really the sort of medicine came. I did. And then once I finish, I’m also one of those people once I start, I don’t stop, you know, so yeah, there were times where this is tough, you know, working on calls and nights, weekends in between, in between all the learning that was going on struggling with money, but I was like, no, no, I got to keep going, got to keep going and then come towards the end, it’s a big relief, you’re like, great, and then you have to kind of do the foundation years, just to get the full registration on to the GMC, etc. And then an opportunity arose for me to step out of that journey into becoming an official surgeon. And I had an option and I chose the option to join a group of dental practices that were growing and become a partner. And that was it. So really, I was at, you know, door three, I went through and I had a couple of options. And I choose one that involved stepping away from the training pathway to becoming a maxillofacial surgeon. And a going towards where I would be much more independent, I’d have much more that freedom to do what I wanted and not have to fit into a system. And it was simple as that. And I look back now and feel that it was the right decision. However, I’m also that type of person that’s just optimistic and just grateful for what I have, that if I’d gone down the career of a maxillofacial surgeon, I would have, I feel I would have made the most of that. And I would have looked back but yeah, this was the path that I was meant to follow. And it’s all good. But at this moment in time, you know, I’m very fortunate for everything that I have around me, and that sort of freedom to do what I want and see work when I want work with who I want. And that ability to, you know, support my family. So yeah, very grateful for that. [Jaz]Well, there are many young dentists listening who may be pursuing a full time Master’s or medical school could be living just like it was for you. So just give us a bit of advice to those people who may be pursuing a MClinDent as well for example, right and that’s very immersive time away from family, time away from earnings. So the LOE, loss of earnings factor comes in. What advice can you give to them, you know, in your, the most darkest moment during your medical training, when your friends around you are earning and spending and holidays and that kind of stuff, and you are still a perpetual student that never ends. What advice can you give to those who are in the midst of that? [Ferhan]Well, what I would say about that is a motto that I hold dear to my heart is always put learning before earning and learning and upskilling. And increasing your knowledge is immensely, immensely powerful, and it will never hold you back. But what I do see is, especially now within dentistry, medicine, there’s such an abundance of courses, training programs, qualifications, you have to be careful, and make that decision wisely. Because it’s a huge investment. And not only of your time, but financial investment. But you’ve got to think about your return on investment. And once that course is completed, or once you’re on that course, really, how is that going to, you know, sort of propel your career forward? How are you going to utilize the skills that you’ve learned, and really sort of push on? And I see this all the time, I’ve been involved in teaching and attending numerous courses, and clinicians turn up to these courses ill prepared. And what am I mean by is ill prepared, they’ve not really prepped themselves on how they’re going to move forward, once they’ve learned this new skill. So for instance, they’ve done a bone grafting course, and then they come up with a bone grafting course. And then they don’t actually apply any of the skills, the knowledge you’ve learned until a year later and then they forgotten to, you know, what I say to clinicians that I work with is you’ve got to be continuously learning and looking to apply simultaneously. Otherwise, it’s pointless, it’s pointless to get involved in training upskilling, if you’re not going to be applying it, and the application doesn’t just happen on its own. It’s active, and sometimes it’s not in your control. So let’s take example, implants. Now, you could be, most clinicians are associates, they work in a practice, and there’s a principal or with a corporate. Now, the question, Is that practice environment going to help you get the work in? Are they going to market for you? Are they going to build a team around you so you can support implant patients? What’s the point of doing an MSc in implant dentistry, if there’s no plan to get patients in, you’re not going to have that opportunity to reinforce the learning. And so really what it is, it’s just sitting down and planning around formal further education and how you’re going to apply that. So really, it’s about that and really think taking this holistic approach to training, and really thinking about return on investment, because that’s what’s really important. So you can fork out 50 60,000 pounds for MSc, loss of earnings, investment in the course. But are you getting that money back? And how long is it going to take you? Otherwise, you know, please don’t do it. That would be my advice. [Jaz]Now, as I say, you know whether it’s a big program, like you mentioned, or if it’s a smaller course, I mean, nowadays, I mean, I did so many courses in my first five years. But nowadays, I definitely agree with you. Before I book onto any course now, I will make sure that I have got a couple of Crown Lengthening patients, for example, it’s Crown Lengthening course, ready to be treated on when I come back from that course. Or if it’s a composite course, now I’ll make sure that for example, I’m looking forward to doing Dr Kostas, injectable composite course. But I know that once I’ve got three or four patients lined up who are in treatment plan for that, and they’ve agreed, the fees agreed, and they’re ready for it. Only then would I go on such a course. Now my mentality’s changed a lot. Whereas before I was very much exposing myself to new knowledge and stuff. I think now, especially with the current environment, definitely you have to make sure it’s applicable. First thing and you mentioned about the whole working to learn not to earn. I was in one scenario when I got back from Singapore, where I was offered two positions, one in Harley Street and one in Windsor. And both had good principles and good support networks enough, but was told by my friend Biju , Biju Krishnan if you want to work with this principal, you will make a lot of money, but if you’re working for the other principal, you might not make a lot of money, but you’ll learn a lot more and I definitely picked the one to learn a lot more. So I worked in Windsor with Dave Winkler, I think is one my you know, that’s why I think we’re a bit quite similar, similar ethos. And I echo that for all young dentists listening. The next question I had was a [Ferhan]Sorry, just on that note, and I couldn’t agree with you more in some of these missions when I worked with them on a one to one basis. I have really frank conversations with them, and I openly disclose how much I make. And I openly have disclosed the history, the evolution of my earnings. And I’ve said This is what’s happened to my earnings over the years, because I’ve done this, this, this, all you do is just copy that. I have invested, I’ve invested. And now I bear the fruits. It’s a no brainer. You know, it’s not about short term gain. It’s a long term sustained gain. And yeah people see me flying about working. That’s choice. I’m at such a fortunate position now, when I don’t need to work anywhere near five days a week to have a really good life. And that’s because of all the effort that I’ve made in the past. And now it’s purely like it’s a choice. I thrive off the high paced environment that I work in. But if you just, you know, sort of invest the time, where the focus isn’t, how much am I making, what percentage are my own, and actually thinking about the people and the exposure you’re getting. Then it will honestly, it will always bear fruits, if you have that sort of open mind to opportunities. You’ll never regret it. Never. [Jaz]Absolutely agreed. And on that similar theme, you go from these posts and courses and you apply. And yes, you might be doing a training post like a DCT posts, you’re not earning as much. But you look five years later, and you’re earning way more potentially, than your colleagues because you’ve been through that hardship, you’ve been through that struggle, and you gain that, a-mass that knowledge. And like you said, every opportunity to learn as one, you know, from your book is one you should take. And so one of the other things that you talked about in your book is a power of visualization. And I really liked that because on a macro level, I used to even do this before I became a dentist because before even getting to dental school, that’s all I wanted to be, I wanted to be a dentist, that was my big dreams, I was age 14. And so I used to visualize myself with an offer in my hand or visualize myself at dental school. So that’s like the macro level thinking. But I also like that mental rehearsal, you mentioned that whereby, before a big procedure, I always close my eyes, and I jot down the exact equipment I’ll use as in when I use it so I can then give that to my nurse so she knows exactly what I’m gonna need at what point because I’ve already mentally rehearse that, you know, that case, that procedure. So I’m a big fan of that. So just tell us a little bit expand more about the power of visualization, in terms of yielding better results for you as a clinician. [Ferhan]Really, Jaz. It’s exactly what you’ve said. And for me, when I would particularly as you start to take on more complex cases, it becomes more important that you know that you really are able to visualize everything in front of you. And almost, you know, I’ll close my eyes or the night before a big case. I’ll be in bed, and I’ll just think about it. And then I mean, I don’t know if you’ve seen the Queen’s gambit? We’re, what’s her name? Martha? Melissa? [Jaz]Is that the one that chess right? [Ferhan] Yes [Jaz] Yes. So she’s laying down and seeing all the chess pieces above. [Ferhan]Yeah, that’s exactly what happens. Yeah, I can lie in my bed. And I can see the bone. Because we’ve worked everything out in a CBCT. And we’ve planned it on a CBCT until I can see exactly what it is that I’m doing, because we’ve got a 3d render. And sometimes actually, we print those 3d renders. So I can actually hold the bone. And it’s about closing your eyes, or actually, you get, you do it so much, you can do it with your eyes open, you just see it all, how you’re going to create your incision. And the steps you’re going to go through to create your incision, what instrument you’re going to have in one hand and the other, and how you’re going to paint brush the tissues, open everything up, control the hemostasis, how your assistants going to position their instrument so you’ve got the correct access, be able to visualize everything. It’s critical step is specially in the learning. And as you upskill in a particular procedure, then it gets to a point where now if I was doing simple, in a lot of full arch work, I don’t do that. But when I’m doing anything complex, or anything that I don’t do on a routine basis, I go back to a have to have to mentally rehearse that, visualize it in front of me happening. And that’s not once. That’s multiple times. And back to what you sort of say there’s writing out. Yeah, I’ve been there where I wrote every single step out the local administrating eight cartridges of articaine at this point, at this point, at this point, everything all written out. And also it’s really nice to then share that written sort of rehearsed treatment protocol with the team. So they’re aware of exactly each step. Because what we must remember is that we’re only as good as our team, especially when we’re doing big complex surgery, your assistant and other team members that are in the room need to be aware of each step, because I get into this state of flow when I’m operating. And I don’t want anything to sort of bring any sort of jeopardy to that system [Jaz] Disrupt that [Ferhan] Yeah, disrupt that flow that I’m in, because it just, it can throw you off. So I don’t want any disruptions, we follow the silent corporate protocol, we have very calming music in the background. And everybody knows exactly the steps involved, what their role is. And then all being well. That’s how you execute the procedure. So that’s, you know, I really can’t emphasize the importance of visualization when it comes to surgical procedures. But like you sort of mentioned, it’s, there’s visualization professionally, but there’s also personal visualization. And so I will often visualize, if you look at sort of read books by David Goggins, ‘Can’t Hurt Me’, he talks about, he has a visualization mirror, a board, that people talk about visualization boards, where they take a picture of their dream house they put it up, they take a picture of their dream car, they put it up, the clothes they want to wear for the holidays, they want to go, and you really, if you start to look at these things every single day, then you start to believe that’s where you should be, that’s the house you should live, that’s the holidays you should have, that’s the car you should drive. And then when you start to see yourself living that life, then it’s just the way the world works, you’ll start to sort of be follow that path that will lead you there. I mean, I’m a big believer in that. [Jaz]So am I, Ferhan. So am I and I do practice it. And you know, you just mentioned briefly about how I know I told you, I like to write it down, you said you like to write down, I read in the book about you being you know, you’d like to watch videos, and then write things and draw things. And so I first realized that I’m a visual learner, when I realized that every time someone not Indian or not English mentions their name. And I’m like, Wait, how do you spell that? Or how do you spell this? And then when they spell it, in my mind, I’m sort of writing it out. And then when I have the visual and mental image of it, that’s when I’ve absolutely going to etch it and pronounce it perfectly from then onwards, basically. So I know I’m a visual learner, a visual person in general. How else can people figure out what kind of learning styles there are? Because for you, as an educator, you need to also suss out what kind of learner someone is, but how can you assist learners in finding out what their learning style is because one of your inner themes in a book and one thing I, you know, we’re both very passionate about is the importance of lifelong education. So I think the sooner we figure out what kind of learner we are, the more empowered we can be. [Ferhan]Yeah, so sort of going back to when I really discovered learning for myself is back to university days. And you go through this sort of journey of discovery, where you’re trying to figure out the best way to learn this essay or biochemistry, physiology that you need to write, it’s hard to learn anatomy. And as soon as you go through a process of trial and error, working out and actually realized that I was, I liked colors, I like writing things down repetitively, I like to have big chunks of text, and then start to break them down. And then work out acronyms. I love to, I used to have a friend that I used to pair up with an a great way of learning is I would teach him something, he would teach me something back, we would stand up in front of each other and go through just describing what we’d learned over the last hour. And that reinforced learning. So it’s really discovering yourself having that self awareness. And looking back, because without realizing, you probably know what it is that is the way that you learn in the bit, you know, sort of your specific a learning skill is and learning technique is, and it’s just sort of taking a moment thinking, I went through university, I’ve done this, this is how I learned. I didn’t enjoy that. You know, I remember, actually now that you’ve sort of asked this question, I used to have a tape recorder. And I used to record like chapters in a book. And I used to go to sleep, because I don’t know where I read this. But I have it. If you can listen to something while you sleep, it sort of sinks into your brain. I don’t know how true this is. But during dental school, I recorded hours and hours of content that I would have on a tape recorder and I was walking. I would just plead to myself and reinforce learning, reinforce my learning. I don’t know how much that had an impact on me. But now I mean, I’m an avid listener of podcasts, including your podcast, podcasts in general, audio books, because audio is another great way that I liked to learn. So different ways, and it’s about discovering it. Are you visual? Are you audio? Do you like the print? Or do you like to get creative with your learning where you start to record yourself seeing things, summarizing it, but another one great way to learn is, I think this is one of the best ways to learn, I find myself and when I work with other clinicians, they also find this really helpful is, is teaching others. When I get up in front of people, and I’ve given them a lecture, one of the first things I like to say to them as I want three takeaways. I want after we finish this step of teaching, I want you to take away three things, and I want you to write them out. And I’ll ask you at the end. So three takeaways from this lecture. The other thing I like to see is you have to approach this learning as if you want to teach it to someone else in 40 hours. And what that does, it deepens our understanding on our concentration during that period, when we approach it in that manner where the thought process, I’m going to have to teach this to someone else and how would I do that, and then go and do that. And I think that’s really powerful. So these are some of the things that I sort of bring up when I’m lecturing, when I’m lecturing, teaching other clinicians that this is the type of approach, but it is discovery, it’s self awareness. And it’s trial and error. It’s reflecting what works, because we all are individual, and I really believe learning should be personalized. And it’s my responsibility as an educator to understand the clinicians I’m working with, how it is that they learn, or it’s my responsibility to help them discover how it is that they learn. Because you can be a phenomenal clinician, surgeon, whatever it is that you do, but you can be a poor educator. And I think they’re two different roles. It’s not that they can’t be aligned. Absolutely, they can be aligned. But they’re two different skills. And that’s my approach to it. [Jaz]You mentioned you listen to podcasts, well, do you do this thing, which I do where I listened to the podcast at two times normal speed or 2.2 times? Have you know, is that the kind of thing that you practice as well? [Ferhan]100%. Absolutely. Because what that allows you to do is listen to the double the amount of content, so I drive a lot. And when I say I drive a lot, I do about 40 to 45,000 miles on the road, every year. So I drive a lot, I get through a lot of audiobooks. I get through a lot of podcasts, and I listen to them at [Jaz] Driving University. [Ferhan] Yeah. And it’s really amazing how your mind, your listening capacity, becomes quickly trained to listening to audio books through audible, or podcasts at to two and a half speed. And actually my online module, [Jaz]The first time you do it, it’s like what the hell is this, but then it becomes so easy. And now I’m creeping up more and more and more and still saying that now when I listen to people speak, like, why he’s speaking so slowly, but because I’m so used to listening two times that everyone else seems really slow. [Ferhan]Yeah, no, I think it’s really worthwhile. And it’s amazing how quickly you adapt to listening to things up to two and a half speed. What’s funny is sometimes I’ve had a passenger in my car, and I’m listening to a podcast, because I don’t mind who’s in the car. I was like, Yeah, I’m listening to this. I’m gonna finish it off. And then they’re like, I can’t make sense of it. I was like, Yeah, you’ll be fine, you’ll get used to it [Jaz] Gibberish [Ferhan] Gibberish. Yeah. They’r like, how do you understand that? I was like, Yeah, it’s absolutely fine. But yeah, I think that’s what [Jaz]My wife’s the same when she’s in the car actually. It is and you pick it up. So that for those who listen to this podcast right now, come on, crank it up already go to two times, you’ll get more episodes, I promise you that. I only got through to up to about Chapter Four in your book. So I want to say of the rest of the chapters. What is the big takeaway, a big lesson or something that you’re really passionate about in the rest of the book? Because I covered a few themes that you talked about in the book already. What is the main takeaway message that yoy want to get dentist to know that you’ve covered in the book, that you think would really be impactful for those listening now. [Ferhan]The main message of the whole book is the title, it’s ‘Being Unstoppable’. For me, that means having this inner drive which is so deep and consistent, that you keep going regardless of challenges, and it’s striving for those goals and dreams that you have. So that’s the main theme and the reason why I sort of a the message behind the book And it was created because for me, there’s different ways I can feel I can have impact. And I just had this opportunity, you know, when the student appears, when the student is ready, the teacher appears that be missing. So I didn’t realize I had a book in me. But I encountered an opportunity and someone was there to help guide me and, and bring it to fruition. In terms of other themes through the book that I’ve, that you’re going to come on to. One is mentorship, and having mentors and heroes, I am very fortunate in my life, my career, not just from school, but all the way up to today, I have had people that have been profoundly influential in my career, and have allowed me to become the clinician I am today. And for them for to them I am forever grateful, I wouldn’t be here without their guidance, their support, and mentorship and having heroes in your life. So people that you look up to, maybe they’re not, you don’t have a direct link to them. But you look up to them, you’re inspired by them. And you look at them, and think to yourself, yeah, I can strive to be to get to that level, because that we need those types of people in our life too. So I think that’s a really important aspect. And then the final chapter talks about charity. And that’s something that’s very close to my heart. Back in 2014, a group of colleagues set up down to eight network, their friends based around where I grew up in Glasgow, a lot of us were at dental school together. And the sort of aim of the charity was to help children in conflict areas with basic dental care. And so we’ve led numerous missions to Africa, Middle East, Asia, where we treat people that really wouldn’t have access to basic dental care. And when it comes to charity, I think it’s so important to be able to give back, not only give back, when you get to a certain level and help people along the way, I think that’s important. But charity, we’re giving back and helping those less fortunate as dentist within a really privileged position, comfortable, earn well, it’s important to give back. And one of the sort of aims of the book is to hopefully raise my target is 50,000 pounds sell, that I need to sell around 10,000 copies of the book. And I’m hoping to build a dental clinic in Kashmir. So it can provide basic dental care for a community of children in a particular area. So I think charity, mentorship is two themes that you want to make. [Jaz] That is absolutely brilliant. [Ferhan] So I mean, yeah, again, [Jaz]I just want to say, Ferhan before you continue to just get on that message, you know, it’d be great. If you’re going to do I think you will achieve that number. Because that’s such a wonderful thing. If you could do that, to build that dental *clinic in Kashmir is a wonderful thought to be able to do that as one say for the perfect for those who maybe are new to this book, or you know, I know it’s launching soon at the time of recording. I know it’s launching soon. But one thing I liked about it was that that people there’s a lot of people who talk about motivation, there are people talk about visualization says you know, I’m already attuned to that. But coming from you, someone who’s walked the same path that I walked before coming from a dentist, or wet fingered practitioner, it made it much more relatable. And then you have the sort of comparisons to actually real life dental scenario. So that made it come much more to the surface for me. So that’s why I’d recommend that book to all the dentists listening right now. And of course, with with an amazing aim that you have here. Your everyone should be rushing out to get this, and we’ll put the Amazon link on the blog post as well, for sure. [Ferhan]Wonderful. I really, really appreciate that. But yeah, so I would love to hit that target and build the dental clinic. And then, you know, it’s about sort of, again, back to that one word, impact, where I’ve managed to create a piece of written work, if that can then go and help other people and it can be a lasting legacy where the impact is ongoing, it’s consistent, and it’s hopefully talked about, it’s all the more rewarding for me and I’m hoping that it will then inspire me on to do more and more. I like anything when we’re pushing ourselves to try to be as creative as possible. We rely on people accepting what we’re putting out and what we’re doing. The clinicians I teach, you know, I want feedback from them, that I’m doing a good job, that I’m making a difference, that I’ve had an impact on them for them to upskill and sort of do the work that I plan to teach them and they’re doing it independently, that’s massively important, because then that sort of pushes me to do more, to become more myself. And so it’s a two-way process where the teaching side it’s to be I rely on the clinicians I’ve worked with to spur me on to be better. And then in terms of the, what I’m trying to create through written or through audio or through pictures, I rely on feedback from other people to see what works, what doesn’t work, how I can change things, to have that bigger impact. That’s really, really important to me. [Jaz]How do you plan to reward yourself because one things he talked about was we do all this visualization, mental rehearsal, but then when you actually achieve something, okay, after you’ve rehearsed it, sometimes I’ve been guilty of not rewarding myself, whatever. And I’m slowly working on that. But how do you intend to reward yourself once you get the launch out? Because it takes a lot of work to produce something like this. [Ferhan]Yeah, probably. I don’t, I think it is important to reward yourself. But I just, you know, sort of going back probably what I’d say is good. You know, I talked to myself and it. Well done. That’s good. That’s done. What’s next. And if you’ve read any of the books by Tim Grover, on ‘Relentless’, and so Tim Grover, if you’ve not heard of him is the guy that coached Kobe Bryant, and Michael Jordan. He’s got a new book out, I forgot what it’s called. But he’s got one book called ‘Relentless’. I’m pretty sure got ‘Relentless’. And it’s a phenomenal read. And it’s like, what he said about Kobe and Michael Jordan really resonated with me, did work their socks off, did when the NBA that year did get the ring, and then they’d be like, right, okay, I’m after number six. And then I’m after number seven. And so for me, it’s like saying to myself, yeah, that’s great. You’ve built a community of a hundred Implant Dentist that you’re working with, you have the books in print, it’s been launched. For me, it’s what’s next? It’s what’s next. And, yeah, I see. Yeah, great for him. That’s cool. You know, I see Well done, that’s an achievement. But for me, it’s always what’s next. And, you know, I’m not one of those, I should take some time off. I should, you know, buy myself something nice. That doesn’t do it. For me, it’s for me, it’s what’s next. And then I suppose the reward really would be as coming up with something better next time, and being able to push myself to be better continuously. That’s my, that would be my reward with I’ve done something right. So how am I adding to that? How’s it, How am I going to make this better next time? How am I going to create something bigger? That’s really what sort of drives me. And that’s, that’s my reward, if I’m able to do something better next time. [Jaz]Brilliant. Now, I know you’re into really into your books, as well as the mind or the audio books you just do. In fact, funnily enough, when I was reading about visualization, I was preparing a quote to share with everyone here, as I turned the page, that exact same quote was was the one you had on the top of that chapter ready, which was, everything is created twice, first in the mind. And then in reality by Stephen Covey. So I was really glad you shared that. But tell us about your favorite because I got a section on the on the website for books and whatnot. Just shout out some of your favorite books. So you mentioned about the Hal Elrod’s book The Miracle Morning, we can obviously, we can also do a shout out to 7 Habits of Highly Effective People since you got Stephen Covey’s quote there. You mentioned Relentless. What are your other favorite books to drive us? [Ferhan]So Napoleon Hill, Think and Grow Rich, absolute classic. Yep, I’ve got a pile of books here. I love a Tim Ferriss. I’ve got the 4-hour workweek there. That’s a phenomenal book, you need to let me go into my audible and remind myself. [Jaz]All right, while you’re doing that, then my last question was going to be while you’re doing that, is just tell us, just so you can think about it is you’ve got a whole bit on communication with patients. And then we haven’t really touched on that theme. So I’d like to get from your, extract from you your biggest communication tip that you can share with us. [Ferhan]I think empathy is absolutely crucial, especially in our line of work as clinicians where you step back and really try to understand your patients why it is that they’ve come to you and what it is they really want. It’s not white teeth. It’s not straight teeth. It’s not what the patients come in. It’s not. Patients are there for a reason. And it’s more than just white teeth, straight teeth, shiny teeth, whatever it is. Patients want confidence. They want the ability, they want comfort, they want confidence. They want to be able to offer a lot the patient I’m managing we want to have function, to eat with comfort. And it’s empathizing towards patients about the difficulties that they’re going through with their dentition, which is really such a crucial part of the face, the smile, and it’s really trying to understand patients, when it comes to them presenting in your clinics. So I think that is absolutely crucial. So having that empathy and being able to give your patients’ trust. And that, yeah, it’s hard initially as you’re a young practitioner upskilling, gaining experience, but it comes. And it’s something that you need to work on, reflect on, and always look to improve and evolve, beginning patients’ trust. And then when they trust you, you know, that’s really when the magic happens when patients come in, and I just, you know, after years and years of having patient interactions, it’s such a relaxed part of the work I do, we can just sit there relaxed, give the patient a smile, and just go, how can I help you? Or what can I help you with? Or I understand that this is a problem, how is it that I can help you with that. And it’s nice to be in a really kind of calm, comfortable place internally as a clinician, when you’re having that conversation with patients. And it’s hard to describe it, and see what it is that changes. But something happens when you start to develop that and it becomes that that’s the clinician you become. And then patients sense that, patients sense the comfort and the peace that you’re internally, sort of that what’s going on inside you when it comes to that conversation, they sense that. I don’t know what it is, but they sense it. And when they sense, they like that sense that this clinician is putting me at ease, he’s understanding, he’s empathizing, I trust this guy. And then they’re like, yep. And when they trust you, they accept your treatment plan, they accept your advice. And then you that’s the start of a real strong patient-clinician relationship. And that’s what we want. Because at the end of day, we can never predict how treatments going to, with 100% certainty how the treatments going to go. But if you have that trust, then patients are much more accepting of potential hiccups that can occur during that journey. Now, let me see where that [Jaz]Whenever I think of trust before we get that out. Whenever I think of trust, I remember somebody Raj Rattan, my old training program director during DF1, taught us about trust. And it’s interesting thing he said, trust with patients, you earn it in little drops. So you earned it in drops. But when you lose it, you lose it in buckets. It’s one of those things basically. So you have to keep working, keep earning that trust. And with some patients were more trusting Yes, it’s easier. Others you just have to you know everything about you the environment, you’re in the way you present yourself, the voice tone that you produce, the confidence that you have in yourself. And it’s not like egotistical or overconfidence, it’s just like, reassuring the patient that you know what, you’re in safe hands, and we care. And on that topic of care while you’re just getting those books out, Is what I liked was that you still get nervous before big procedures and you talk about this because same here, right? When I’m doing multiple preps or large provisionals, and stuff, very different the nature of what you’re doing. But I still get little bit nervous. And the reason we get nervous beforehand is because we genuinely care about the person at the end of that treatment. And we want them to have a good result. So it like you said that the day you stop getting nervous, there’s a day you might stop working, because that’s when you maybe you’ve lost that sort of feeling, that connection. So it’s important to have that human side about you. [Ferhan]Yeah, absolutely. Absolutely. The response, you know, I will never lose something. And that’s the trust that patients put in me every day to inject them, to cut them open, to drill away the bone, to start drilling into their bone, to screw in metal screws into there. That’s a hell of a lot of trust. And it’s easy to forget that, really easy to forget that because we’re just getting to this circle, and we’re just on repeat all the time. But it’s a big thing for a patient to come in, sit down, open their mouth, and go. That’s fine. You know, Dr. Ahmed, you just crack on. The big, big responsibility that we have as clinicians when patients do that, and we must never never forget that. And it’s an honor. It really is when patients trust us like that. And I think that’s something that we need to step back and think about on a regular basis. So yeah, so and sort of going back to the nerves and even when I’m doing sort of straightforward treatment, I still am like right here, I’ve got to perform, I’ve got to do my best. And I will often often say that to the team in the morning, if we’ve got a busy day of surgery ahead, Said, You know what, I’m not doing this on my own, we all need to perform here, we’re going to do our absolute best. And so we start the day with a team huddled, discussing this. And often talking about actually how lucky we are to be doing this type of work, and the trust that patients have with us. And it’s not just me, it’s the whole team. And then at the end of the day, reflecting on the work, and a meeting to the team, you know, thanks a lot for everything, because I couldn’t have done it without you. And we’ve done a lot of good work today. And if I go back to, I did a couple of cases with a colleague in London on Saturday. And the first patient was a denture wearer, 90 year old denture wearer. And she came in, and what is the flap, putting four implants, give her a fixed set of teeth and we changed her life. The second patient came in with a filling dentition, we took out our teeth, we put in four implants, we give her fixed teeth. And we changed our life. And I said at the end of the day to the two girls, the nurses that were working with us, I said, you know, we’ve done some immense work today. And you too, should be really proud, we’ve changed lives. And don’t forget that this is not anything taken lightly. This is life changing treatment, and you had a big partners. So thank you [Jaz] That’s a really good way to put it. [Ferhan] And I’m very fortunate. I’m fortunate for the people that taught me to be able to do the work I do. And I’m feel fortunate that I can do it now and teach others. And I hope I never forget that. Because it’s a privileged position to be in. So if onto books, I manage myself in my audible. But but so I’ll give two books that actually I talk about on a regular basis. The first one is ‘Atomic Habits’ by James Clear. Phenomenal book, because it’s our habits that really set the tone for who we are and who we become. And it’s having good habits. And James Clear, does it present it beautifully in his book Atomic Habits. I also encourage you to subscribe to his newsletter, which comes out every week. And it’s 3-2-1. 3 thoughts and from himself. 2 thoughts from others. And one question he asks you, it’s phenomenal. I always look forward to every week. And it’s all based on his book Atomic Habits, and really helps you sort of create these good habits into your life and the best way to go about it. And these habits, absolutely then lead to the hopefully the life that you want to create for yourself. The other book that I wish I’d read when I was 15, is Rich Dad, Poor Dad, and it is Robert Kiyosaki, and the importance of being financially aware and financially conscious. And he talks about passive income investing. And I’ve I read this is two years ago, and it’s been immensely rewarding. It’s been the best sort of 799 I’ve ever spent. [Jaz]Yeah, I read that in my late teens. And you’re right. It’s a huge impact that book has [Ferhan]Well, I read right into my late 30s. And I honestly read that book and thought, Where have you been? It’s been out for like, 20 years. I was like, where’s this book being widened? I read it before. I wish I’d read it earlier. I really feel like be set. And you know, I’m very comfortable. I’m not complaining. But I’d be really set financially if I’d read this book earlier. And so for young clinicians out there I think it’s important to be a financially savvy, a plan for the future, invest and save. And that book, Rich Dad, Poor Dad was instrumental in me changing my a financial [Jaz]I might have to read it again. I know you inspired me to read it again, I think. [Ferhan]Yeah, it was brilliant. It was brilliant. And so two books, but yeah, I’m an absolute junkie for books and always looking for recommendations. And I follow you know, sort of podcast wise. I’m a big fan of podcasts. Yours of course number one, but then there’s a podcast by a Tim Ferriss, Srinivas Rao. There’s Shane Parrish, Gary Vee. I mean, these guys are ?? I listened to religiously on a weekly basis. [Jaz]We would so much commuting you have the luxury of having so many different podcasts and stuff and books it listen to. That’s awesome. [Ferhan]Yeah. And it’s had an immense impact on my life on these these podcasts listening to these individuals and learning from them, and back to a book and the power of a book. It’s amazing. The value you can, you get from a book that’s maybe 1099, 1299 or 799 an audible, it’s the best [Jaz] How much is yours? [Ferhan] I think it’s 1399 on Amazon, [Jaz]Man, that’s so. If you’re a young dentist or any dentist, you should definitely check it out. [Ferhan]Yeah, all the profits, go to Dan, do nothing, all that comes away from the 1399 is the cost of printing the book, the rest all goes to to building this dental clinic in Kashmir hopefully. So yeah. [Jaz]I hope you all have success with that. And that, guys, f you’re listening, and you’ve been inspired by finance tips, and you want to check out the book, I hope you bring it out an audio book, man, I think you should because you listen to so much audio, but you should totally bring it out an audio book. [Ferhan]Yeah. So that’s in process, I will bring it an audio but it’s available [Jaz] Amazing. [Ferhan] It’s going to be available on Kindle. And then I’ll bring out an audiobook where you get to hear my Scottish accent and I will read the book out. [Jaz]Excellent. Well, mate, thanks so much for coming on. And I wish you all the best with that because it’s a great little thing for us, you know clinicians to have someone to look up to like you to share those similar themes that you might have heard before, but in a way that’s so relevant to us and like even reading about your background and your ups and downs, medical school and how you come out the other side, what inspired you, your family and stuff. So again, thanks so much for sending that over. And great for you to share so many gems yo say on this episode, and I look forward to meeting in real life one day. [Ferhan]Yes, I hope so. I look forward to it. Thank you so much. Thank you for your time. Thank you for having me on. Jaz’s Outro: Thank you so much for listening all the way to the end. Hoped you found some value from that. Ferhan, thanks so much buddy for coming on. This book ‘Being Unstoppable’ is something they should totally get because it’s a so much charity. And also there’s a lot of great stuff in here for all clinicians that we can learn from and implement. This episode was just a small flavor of what you can get from this book. Please do share it with a friend if you found it helpful, and I’ll catch you in the next episode. Same time, same place

We’ve now come to the last bit of this 3-part Oral Surgery Complication series with Dr. Chris Waith. I’m going to be honest, I have a lot of concerns about Tuberosity Fractures – they scare the bejeebers out of me! We all know that it can be a really nasty complication. Fear not! Dr Waith will teach you how to prevent and manage maxillary tuberosity fracture. https://youtu.be/ZQuDeViQiX4 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “If there’s a really tight contact between those three molars, the two teeth you’re extracting, just spend a minute skimming the contact points.“ – Dr Chris Waith In this episode, we discussed about: Risk factors of tuberosity fractures 1:40 How to manage when you hear the crack of the tuberosity 3:57 High risks patients 6:35 Leaving a loose bone as a space filler in soft tissue 9:07 Join us in our Telegram group! Let us help each other out! If you loved this episode, be sure to check out the first part! Dry Sockets – How to Prevent and Manage Them? Click below for full episode transcript: Opening Snippet: Welcome to group function, where the Protruserati worked together to find good solutions to worthy problems in dentistry with your host, Jaz Gulati... Jaz’s Introduction: Tuberosity fractures are super scary, like, you know, when we did the first group function with Chris Waith about dry sockets, dry sockets don’t worry me, okay? When it comes to OACs, Yeah, a little bit concerning, but after that episode, I feel much more confident. But when it comes to Tuberosity Fractures, man, I have to tell you, I’m really worried about causing them. And I’ve seen on social media people posting these photos, you know, I try to take out the upper left molar, and then the whole premolars and all the molars came out with it. And that is a scary sight. So in this group function, we’re going to ask Chris Waith, how to prevent and how to manage that dreaded tuberosity fracture. Let’s hit it. Main Interview: [Jaz]Then the next one is and the last one is tuberosity fractures. Like, this is scary when you see on social media, some you know, sometimes a big group of people posting their tuberosity fractures, and you see the first molar, the second molar and a third molar, come out with this massive chunk of maxilla. I do not want to ever be in that position that must be so stressful and like how do you even begin to have that conversation like you know, we always warn our patients before doing an extraction, maxillary extraction about these kinds of things. But Never Have I Ever warned a patient that look me taking out this wisdom tooth, I might also take out three other teeth while I’m doing this, for example, it’s just so rare, unfortunate. So what are the risk factors? How can we manage it when you hear that crack, and so on and so forth. [Chris]So, I’ve been in that scenario of having a big unit, I think, if ever, you’re taking out an upper six, or upper seven. And if there’s a really tight contact between those three molars, the two tooth you’re extracting, just spend a minute skimming the contact points out. So drill the contact points, make a physical space in between that tooth and the two neighboring teeth. Because then when you’re Elevate, you’re much less likely to engage the your neighbor and hopefully less likely to put stress on a wider area of alveolus. I think if you just take in the wisdom tooth out, look for the risk factors. And you know, I sometimes go on when I’m teaching that I say I feel bad now about how we used to teach the undergraduates because there was definitely this mentality where you gave them some notes and just said take that. I’m probably didn’t spend long enough saying this is how you should take that type. And I think of parades is one of those where depending where you went, somebody would have put a cryers in your hand or a coupland and would have just said just push back, actually, that that’s a good way to fracture tuberosity because you’ve got two really powerful instruments, you can deliver a real large amount of energy and in the wrong patient, it will be energy in an area that’s very vulnerable. So low sinus, thin alveolar bone, difficult root morphology, elderly patient, long standing molar, existing Perio pathology, the more of those you tick, the more likely it is to happen. I think if you start to tick those, change your technique that will be the main thing. So instead of just trying to push it back, think do I use like a small luxator and try and push the buccal plates off the tooth so that there maybe I could get my bayonets and forceps in and just try and take it buccally instead of pushing it backwards. I think one easy thing to do, whether you use a mitchells or a flat plastic or something, just push the buccal gingiva off the tooth, push the distal gingiva off the tooth, push the palatal gingiva off the tooth. And then the logic is if you hear that dreaded crack, what you want is to just crack the bone and not tone all of the soft tissues. And like, if you’re mid extraction, the place you want to watch is the palatal side of your upper eight and seven. So as you’re pushing, in the bone, you’ll be causing little micro fractures, and then that big crack, that’s the macro fracture where you’ve got an actual break. The micro fractures you’ll see it in the palate and the palate will be pulsing, it will just be bulging a little bit and if you’re palate bulging in your head, you’ve got to think, right, so what I’m doing now, I need to not do that. I’ve got to change whatever energy I’m putting on there. Now if the tooth’s not moving and you see that, that might be the one that you say you know what let’s stop before some damage. [Jaz]And maybe in that case, you’re gonna go, you’re gonna follow the trauma guidelines. You’re gonna put like a stainless steel like a splint wire on and composite bonded like, right? [Chris]Splint it if you can. Get your High speed, drill the cusps off the eight. So it’s out occlusion, so that it’s not going to hurt when you keep biting on it, and refer it on, then wait 6, 7, 8 weeks, let all those micro fractures repair themselves. And they’ll approach the tooth a different way. So I take that, buccally if I could, or may even raise a flap and take some bone away to try and take it buccally. If it’s gone too far, if you hear the crack, tooth is loose, and it’s got to come out. The reason we’ve pushed those tissues away is to try and make sure that they’re intact, so that as you deliver the tooth, the tooth and the tuberosity, or is all that you’ve got a not like palatal gingiva, buccal gingiva. So the idea is, then once the tooth is out, hopefully, you’ve got gingiva either side of your socket, that you might just put a couple of stitches and then just pull those edges together. So that if there’s any airway see in there as well. Or if you want to put collagen cube, and if it’s bleeding, you’ve got proper kind of soft tissue support over the top. I think if you don’t look after the soft tissues, you chasing your tail a little bit then because then you really struggling to suture it, and you’ll already be shaking because of what’s happened. So it all starts to get a bit messy. And then I think tuberosity wise, even, I’d like, I think I’m uber-cautious when it comes to surgery. And I always expect the worst things happen. And even though I do, I still fracture tuberosity not loads, but you know, twice, three times a year. [Jaz]You’re seeing the most difficult patients, you’re in a referral practice, you are seeing the, you know, if any GDP suspects it could happen. They’re probably sending it to you. [Chris]Yeah. So my clientele probably is a prerequisite [Jaz] Higher risk [Chris] Yeah those. The tuberosity fractures differentiate quite a bit, there’s an article in dental update a few months ago, which was trying to classify them and I kind of get the logic, there’s, you know, there’s small bits of almost gristle stuck to the tooth, which is almost here and there. And then there will be the gristle and then a larger bit of bone. And then there’s the huge unit of bone. And it’s the huge unit of bone. And it’s really, it’s not so much that the bone is gone. And that’s the problem. It’s the fact that behind that, you’ve got things like your pterygoid plexus, and these bits of blood vessel, that if they traumatized in a big tuberosity fracture, it’s the bleeding that is the concern, because actually [Jaz] Hematomas and internal bleeding [Chris] We’re gonna really struggle to control that. So if ever it happens, I think, you know, do what I said try and preserve the soft tissue, you take the tooth out, before you do anything, just stop and just spend half a minute staring into the socket, and actually just see how it’s bleeding. And if it’s normal kind of socket, it is great, collagen cube, suture over the top of it, review the patient and just make sure they’re okay. If it’s bleeding heavily, just have in your mind side that that might be something behind the tuberosity, which we don’t want to bleed. So then, you know, you may even put Surgicel in but put something in, suture it tightly. But I think that’s the patient that you get on the phone to your local hospital and just say, can you see this patient? Touchwood, I’ve never seen that. But that’s the thing that we’re where we debate when they say fractured tuberosities. I think, you know, much like we’ve just said about OACs, most tuberosity fractures are relatively simple. It’s just the complicated ones that would be cautious about [Jaz]I mean, the whenever I see a high risk patient, I do exactly what you say, the very first place I start is just dissecting the soft tissue away, you know, buccal, distal, palatal for that reason, what you don’t want is the bony complication or the fracture compounded with an inability for you to tidy that up because now everything looks like a massive soft tissue mess. So that is a great point. And the other thing is that let’s say you hear that crack, and now you’ve got a mobile fragment, your soft tissues are okay, but actually, it’s a fair chunk of bone, maybe not, you know, many teeth, just the wisdom tooth or the second molar and a chunk of bone distal to it, the tuberosity. At that point, I think you’re pretty much committed to just remove the entire portion of that loose bit, or would you say there’s any merit in now? Maybe a bit too late now, ie go back and listen to section and elevating because maybe that’s one way that we can prevent these things is like, okay, yeah, you did section and elevate, now the tooth is loose. And the bit of bone is loose, is it then worth carefully sectioning the roots where drilling the tooth away so that you leave that bone as some sort of, I guess, a space filler in the soft tissue? [Chris]I don’t think so. I think even moving away from tuberosities, just bone in general in a socket. If you have some socket bone that is firmly attached to periosteum. And if you suture the socket and that bone is more or less where it started, then it’s got a reasonable chance to survive and as long as you’ve not traumatized it too much. I think as soon as a trauma increases, or if that bit of bone is actually quite loose within the socket, you may as well take that because it’s not got the constant support and keep in still that it needs for the bones. And the worst thing is that if while things are healing, it peels off, either it starts to poke through the gingiva, or it just floats around in the socket and gets infected then. I think in the tuberosity situation, of all the areas in your mouth, I think that’s the most difficult to stick your drilling. So if you’re in that scenario, your soft tissues are probably already torn, you’re having to raise a flap in an area where you don’t really want to raise the flap and use a drill in an area, you don’t really want to use a drill. So it’s another kind of avoidance is better than cure. I think if you’ve got that scenario, make sure all your soft tissues are well out of the way because potentially what’s on the end of that tooth is going to be bigger than the socket opening. And then very carefully, get it out of the socket. Watch it for the, sorry, watch it that to see if it’s bleeding and then suture across there and follow up. I think always always with those patients, give them sinus instructions, because there’s that chance that there might be a communication as well. Call them the next day and just make sure they’re okay. Call them a week later, make sure they’re still okay. I think if you’ve done that, you’ve at least shown the patient that you care, and you’ve acknowledged everything. But if there’s any complication you don’t see you can deal with, nip it in the bud early. [Jaz]Amazing. Chris, you’ve answered all my oral surgery complication questions. These are main ones that we had from our telegram group. Are you on Telegram, Chris? [Chris]No, I don’t even know what that is. [Jaz]Okay, so you have WhatsApp? Right? [Chris] Yeah [Jaz] Okay, so telegram is like, the wiser, sexier cousin of WhatsApp. And you know, when there was a massive outage yesterday, you know, guess what our telegram group was on fire. Right? So, I’ll say you a download it. It’d be great to have you on, you know, those of is like, over 400 of us Protruserati on there. And there we’ve got Pav on there giving implant advice. We’ve got loads of great dentists on there. To have like an oral surgeon on there just to give us advice will be amazing. But I understand if you’re too busy, but if you want to join our telegram group, if anyone wants to join our telegram group, it’s for the Protruserati, it’s protrusive.co.uk/telegram and as long as you had the telegram app it will take you to your, to our group. So I’ll send you the invite Chris and by the way, see you in a few days in Brighton for the Tubules Congress and thanks so much for doing this really appreciate all those group function. [Chris]No problem. It’s been a pleasure. Jaz’s Outro: Well, there we have it. I hope you enjoyed this group function series all about oral surgery complications. Please do email me jaz@protrusive.co.uk, if you have any suggestions for future episodes, always love hearing from you guys. And of course, please give the show a five star rating if you’re listening on Apple. Thanks so much, guys. I’ll catch you in the next episode.

“Wait, Dentists still carry out Equilibration?!”, that was the reply in our recent discussion on the Protrusive Telegram group when I announced this episode. Yes, Saranga, they still do! The topic of occlusal equilibration is a very controversial one. In this episode you’ll realise the WHY and HOW an equilibration is carried out by one of the best Dentists I ever had a pleasure of shadowing (and also one of the most precise and OCD Dentists I know!) Dr Koray Feran. https://www.youtube.com/watch?v=0CjKu24R5GU Check out the full episode on the Protrusive YouTube Channel! Need to Read it? Check out the Full Episode Transcript below! Let us learn more about the potential benefits and challenges of equilibration with Dr. Koray Feran, who is a wet fingered practitioner of the highest calibre. Protrusive Dental Pearl: When you have a patient who has a crowding and they want veneers, and you want to convince them to have some orthodontics first….. Instead of saying, “Oh, I have to remove this part of the tooth.” You could instead say “I don’t want to have to remove your healthy body parts to be able to achieve this goal.” Language is powerful! “Equilibration is one bit of the pie, it’s a tool. It’s not a magical process. It’s to resolve a situation that you’ve diagnosed.” – Dr. Koray Feran In this episode, we talked about, Does equilibration matter? 9:38 What is equilibration? 11:59 What are we trying to achieve in equilibration? 21:12 When should finding centric relation be a part of examination protocol? 29:18 We discuss full mouth comprehensive dentistry and preventing failure 33:32 Orthodontics is full mouth rehab! 49:26 Risks and Benefits of Equilibration 46:00 Fundamental rules of Occlusal Equilibration 52:33 Protocol after equilibration 57:09 Why is equilibration not routinely practiced by Dentists?  1:02:12 To learn more about equilibration, check out Dr. Koray’s occlusion course! If you loved this episode, you will definitely like If You’re Not In CR, You Will Die with Dr Kushal Gadhia! Click below for full episode transcript: Opening Snippet: And then suddenly you're through the enamel. Ouch that hurts. Equilibration should never be, never go through the enamel, never. Okay? If the equilibration has to go through that enamel you finally have to chop a large amount of a tooth. You should consider orthodontics or you should consider additive reconstruction to the whole occlusion. You shouldn't need to adjust three, four millimeters off a tooth. It's ridiculous... Jaz’s Introduction: Equilibration is just one of those really controversial topics within occlusion and within dentistry in general, right? It can really split a room. Like the other day on Facebook and on the telegram group when I asked you guys which episode Do you want next? And I suggested we could have one about a Equilibration. My buddy Saranga said, Hey, we still do a Equilibration? I thought we didn’t do equilibration anymore? And I remember attending a BDA event. I think I was maybe one year qualified. And Professor, actually I was a dental student, and Professor Robert Ibbotson, who was there, you know, very experience towards the end of his career, restorative consult at that time, he said he hadn’t done an equilibration since 1984. And he thought it was pointless. Whereas I know other great clinicians who I really respect who carry out equilibration, a fair amount because they’re doing bigger cases, and they see it as a really vital tool, a really vital step as part of their reconstruction. So which is the right answer? Hopefully in today’s episode, you’ll get a bit more information about equilibration, which is actually really difficult to find if you open your textbooks or if you search online, it’s not much out there about equilibration, which is why I’m so excited to bring on an absolute superstar guest today. His name is Dr. Koray Feran, an absolute legend. I saw him lecture when I was just two months qualified, and I am pretty sure he is the guy that put me on the path towards really loving my dentistry and really wanting to improve bit by bit. He taught me that the two pillars of restorative dentistry are illumination and magnification, and I will never forget that lecture that inspired me and amazingly, eight years later, here we are, I’m now interviewing my hero, Koray Feran. I remember shadowing him actually, so I went to that lecture, then I shadowed him in his clinic, I think, it’s near Harley Street. It’s Wimpole Street. It was the first time I’d been somewhere where there were two nurses working for one dentist, so I’d heard of 4-handed dentistry, but I had just seen for the first time 6-handed dentistry and this beautiful screen in front of me where he was showing me the sinus lifts as he was doing it. It was just a crazy experience for a recent grad. The Protrusive Dental Pearl I have for you is a bit tongue in cheek in a way because I know we’re talking about equilibration, which is essentially the removal or the balancing of teeth via removal of tooth structure right? That’s equilibration. But the Protrusive Dental Pearl I’m giving you is a communication one. And it is this, it’s something that Ed McClaren taught me at the Tubules Congress as he was lecturing, when you have a patient who has a crowding, and you want to convince them to have some orthodontics because you think that by prepping for veneers, you will be too aggressive and you’re in root canal territory, which you never want to be you know, you never want to be in dentine for your veneers. So to get the point across a really good communication tip that Ed McClaren shared was you tell the patient, you don’t say Oh, I have to remove this part of the tooth. You say I don’t want to have to remove your healthy body parts to be able to achieve this goal. I don’t want to remove these healthy body parts. What’s a great way to communicate that? So I just wanted to pass it on to you and it’s really tongue in cheek in this episode, because you’re thinking okay, Jaz, you’re being really cheeky here because we’re talking about equilibration. But actually the other way to think about equilibration so it just ties in nicely is that there are some dentists who think that ‘Oh, I’m not going to do equilibration because I don’t believe in equilibration but I will prepare the 28 crowns, what’s going to be less invasive? An equilibration to get some balance or to get the “correct bite”, or 28 crown preps? So just think about where an equilibration come in. And sometimes equilibration is like partial equilibration. So you’re doing partly additive on one side, maybe and you’re equilibrating just a little bit so the overall you’re having to place less restrictions, but you know, this is everything that we’re gonna talk about with Koray Feran in terms of the workflow, the protocols, the whys, the why nots so hope you enjoy this episode. And yes, we have Zak Kara again. So you know, it’s gonna be a fun one. I’ll catch you in the outro. Main Interview: [Jaz]Koray Feran and Zak Kara, welcome back to the Protrusive Dental podcast. I hope you both well. Today we’re talking about equilibration and I just want to do a little bit of introduction for you Koray before you take it away. I’ve said this before on this podcast maybe two or three times now, but when I was in DF1 it was 2013 November, I think. And you did a lecture, I still remember the title of it is called excellence in restorative dentistry. And that two hour lecture you did was such a huge inspiring moment in my career that I just didn’t know you could practice like that at all like coming from like a dental school and then early on DF1, that was a huge needle mover for me. So it’s an absolute honor to have you on today. For those very few people because you are global, my friend, you are global, you’re well versed with the BARD and also European societies. And I know I think you’ve done some work in with Megan as well as that they’re pretty International. So please tell us a bit about yourself for those listening all around the world. [Koray]Okay, so I’m a general dental practitioner, I haven’t got a specialty. I did Perio Msc, but I’ve been restorative and implants and everything related. For me, generalism is a specialty. Because I think the kind of patients that I have seen over the years, don’t come in neat packages, they come with a whole host of problems. And unless you know how to put all them together and diagnose them and put them on, you know, the treatment together, you come across. And the thing I’ve learned is, as I’ve been a GDP or you know, all this time, I might be known for implants, but I’m actually probably getting more better known for treatment planning, we’re doing something big with Tubules, as well, with regards to treatment planning and consent and communication. But for me, today’s topic is an integral part of dentistry. And I think it’s not very well taught. And it’s really not something I was into or understood in the first decade of my practicing career either. So I’m now principal of a four surgery practice in the West End, I’ve been on the West End for close to 20 years. And you kind of gradually make mistakes, everyone makes mistakes, everyone misses stuff. And my practicing protocol is basically the case of the rule of incremental improvement is every time we do something wrong, you learn from it, and you make sure you’re incorporated into your next bit of protocol, which makes me really anal. And it makes me really [Zak] Surely not [Koray] It’s just a bit OCD, but it means the people who come to it fresh, sometimes find it overwhelming, you know, sure as Khan has joined me a year and a bit ago, and when he sort of first arrived he sort of said, ‘I get this. I get this. I guess but this isn’t you’ and he’s gradually sort of come to me says like, ‘Okay, what do I do here then?’ It’s like, ‘Well, you know, you’ve done all the right things, then all you got to do is this.’ I was like, ‘Okay, I get it.’ Okay, so as you learn gradually as you make the mistakes, which are often expensive, not just financially but reputationally, and relationship wise on patients, you learn to work in a certain way where you don’t leave any holes in the safety net. And that’s kind of probably what I’m known for more than anything I don’t cut corners. [Jaz]I can definitely vouch for that after having shadowed you and seeing you do a sinus lift at that time, I was very newly qualified dentists. So I mean, if I had a been an implant based dentist, done some sinus lifts, what you were doing was gold I’m sure but for me just being in your presence and the way you communicated and just your, the way you work 6-handed Dentistry that was something cool to see. I never seen that before. That was amazing. Zak, Welcome back to the podcast, my friend always welcome guests. Tell us, Zak, before we actually pick Koray’s brain, have you had much experience with this dark art of equilirations? [Zak]So some of my backstory, my historic stuff in dentistry comes from the Pankey Institute in Miami in Florida. And actually, you know, along those lines, I’ve got a real interesting question for you, Koray. And both of you actually, because both of you are proper occlusion. That’s right. Kois’ really, really interesting. And I’ve shattered Kois as well. By the way, this isn’t some sort of plug for just keep knocking on Kois. I’m sure he doesn’t just want to be watched everyday. 300 emails about to land in your inbox. However, just to say, you hit the nail on the head with something a second ago you said that generalist, being a generalist is a specialty of its own. I think that’s beautiful. Why is it then that both of you have drawn yourselves to occlusion? Why does that seem to be some sort of key to becoming a generalist who really gets it? A comprehensive thinking, generalist. Why does that matter so much? [Koray]Well, for me, it’s a little bit like if you’re going to build a block of flats, you just got to make sure the ground is level, right? So equilibration and occlusion isn’t a dark art. It’s a set of very simple basic diagnostic steps. That if you get right will mean that your dentistry is much simpler and much more predictable, and if you get wrong, can be a nightmare. So all it is, is it’s just checking that, you know, a lot of dentist think about teeth. But really what you need to think about is the dynamics of how those teeth relate to each other statically and in function. And that, to me is occlusion. But it’s a combination not only of tooth positions and tooth contacts, but it’s also about where your temporomandibular joint is, where your discs are, how stable it is, how the muscles are acting on them, how the patient is adapting to those relationships. So it’s actually just a chain of you’re looking for the right things. And once you’ve seen them, and once you understand what those signs and symptoms mean, you start your restorative dentistry in a much safer position. So essentially, it’s just leveling the playing field before you start building. That’s all it is. It’s nothing. It’s not a dark art. It’s just good anatomy good physiology, good dentistry. [Jaz]But the reason I call it a dark art at beginning, equilibration is twofold, okay? One is a lecture attended by Professor Richard Ibbetson. I believe his name is at the BDA and he literally poo pooed it, he said I haven’t done any equilibrations in 1984 and he was like this is a mumbo jumbo stuff and it’s really teeth fiddler need to stop, that was his sort of thing. And then in my hospital years in restorative both at Guys and at Sheffield and I’m happy to be challenging this but I’m pretty sure very few of those many consultants like 20 plus consultants have ever even done an equilibration, so why there’s something about the UK and UK-trained dentistry and certainly the restorative consults who are friends of mine, dear friends of mine, they don’t practice equilibration, have never done it so they’re obviously somehow work their way around it or whatever but maybe they are approaching it just in a complete different way. So let’s go back to the very beginnings what, how would you define as an equilibration? And then let’s just go from there and then we’ll get Zak’s input what Pankey perhaps for him [Koray]Okay, so my first thing is that the tooth Fiddler reference, you shouldn’t be tooth fiddling. Okay? Equilibration is should be something done quite precisely. Okay, my first Golden Rule, equilibration should not be done in somebody that has an unstable temporomandibular joint relationship. If you have TMJ disease, you diagnose what that disease is, you diagnosed clinically, if necessary, mean you if necessary, if you take an MRI, if there is a disc issue, if there’s a disc displacement, if there is protracted muscular problems, you have to resolve that first and that’s the other dark art of deprogramming of using splints and stents. And when do you use what design of stent and splint you know, I only use anterior deprogram as well, okay, you probably not doing your serve patients the best service then. ‘I only use this, I only use that.’ No, if you make a diagnosis is where your TMJs are, what your discs are doing, if you’re not sure, then MRI them, I think we’re under utilizing MRI, we had a very interesting chap called Kevin Lotzof lecturing with us on our recent TMJ course, he’s probably the preeminent guy who understands not only how to take a proper open and closed TMJ MRI, but how to decipher what’s going on. And he’s actually saying, guys, you’re under utilizing icy stuff every day that you guys are missing, and you are building your dentistry on unstable foundations. So the first thing is are the TMJs functioning correctly? Are your discs in a reproducible or stable position? And is the new musculature that controls your joint movements and your jaw movements? Healthy. If it is, okay, then you diagnose where your occlusal problems are. And then you decide whether you need to equilibrate, whether the patient is already adapting it is, it’s an occlusal premature contact, does it have to be equilibrated? Or has the patient adapted? If you don’t diagnose it, then you don’t know what you’re treating. And you find that out when you start the treatment dentally and you suddenly find that your jaw relationships change, or the patient can’t tolerate what you’ve put in, or things start breaking for no apparent reason. And when you’ve lived it, you understand. So then you have to trace your way back and say, ‘Well, why is this happening?’ So for me, equilibration is a tool to level your ground before you start, but the TMJ diagnosis must come first. You don’t equilibrate until you’ve made a TMJ diagnosis and a functional diagnosis. [Zak]Can you elaborate a little further on the assessment side of things, but specifically you said neuromusculature, this is something that’s sounds very specific, but actually in reality, you hear about different methods of diagnosis, including all sorts of things including, you need to get a stethoscope out, you need to get all sorts of stuff that’s going to help you in different ways, and I think would that becomes, that becomes one of the barriers to entry to this seemingly dark art which is not that dark and art actually, because you’re absolutely, Would you agree with that, Koray? You made a face there as if you’re not sure. [Koray]I think the stethoscope might be overkill though I can understand why people might say I can use a stethoscope, you know the best telescope we’ve got really is just the pads of our fingers. And if you actually just get a patient to open and close and jiggle their jaw, you can see exactly what that joint head is doing or not doing. Sometimes it moves cleanly and it moves back, there’s no noise. Sometimes one side moves, the other side doesn’t. Sometimes it rotates, but it doesn’t move. Sometimes it locks, sometimes it opens but it can’t close. All of those are diagnostic. And there are five stages generally of TMJ disease from healthy, mild problem, more advanced problem, more advanced problem and joint totally buggered. And the question is [Zak] Did you read that on your notes? [Koray] Yes, dude. I mean, as a pointing fact, I’ve just got a patient at the moment and literally, I’ve just had an MRI before we came back. With diagnose, she’s got a vascular necrosis of the entire condyle, there’s no blood supply to it, it’s just black, you look on an MRI, it’s gone, it’s not there. And you know, and yet, if you don’t take an MRI, you won’t see this her disc is, you know, relatively normal position. So the, what I’m trying to say is that that is in its in a start diagnosing where the disc is, and what the likely cause of that is now it could be an injury, it could be occlusally related. It could be accompanied by muscular dysfunction, so the mandible can’t open very wide, it can’t go to one side, very wide, patient gets pain, there’s a whole routine, I mean, we run a whole two day occlusion course. And there’s a whole list of things that you look for, you know, they’re not multi, you know, they’re not hundreds of things, but there’s, you know, 5 to 10 things that you really need to have a look at. And then when you put all those together, and if you know if this is positive, this is positive, this is negative, this is negative, then you come to a diagnosis. And then from that diagnosis, you say, well, is the cause occlusal? you know, is the patient has the patient got muscular symptoms, and difficulty opening on pain because they’ve got a premature contact somewhere? Well, How’d you find that out, you put in a deprogrammer, you get rid of the contact, if the pain goes, and then when you take the deprogrammer out, the pain comes back, it’s a pretty good chance that it’s going to be occlusal. But you then still have to make sure that the TMJ is healthy, and the muscular spasm is gone. And the jaw could be put into a centric relation and the discs in the right place before you decide what to equilibrate. And if an equilibration is required, and it’s all step by step, there’s no magic to it, it’s just have I got the information. And this is like anything, if you if every single one of us had exactly the same information from a patient. In other words, you know, if adequate time is spent looking, recording and diagnosing and thinking, we should all come up with the same diagnosis, we may all have different treatment plans, but the diagnosis should be the same. Okay? 10 dentists don’t come up with the same diagnosis, then either there is inadequate information, or there is inadequate knowledge. Okay, so for me, if like if I know what’s going on with TMJs, and it looks like there’s a tooth involved, that’s a problem, or a patient comes in with me and says, Look, my front tooth keeps falling out, can you make a stronger post, and the dentist goes Yeah, I can, I can drill a bigger hole, I can put a bigger post in and what happens is that falls out too or the tooth starts drifting, or the root fractures, it’s nothing to do with the post, it’s got to do with how the occlusion is. So unless you diagnose all of these and see all of these, you’re gonna end up doing, not doing the patient the best service. Equilibration is one bit of the pie it’s a tool. It’s not a magical process. It’s to resolve a situation that you’ve diagnosed. It’s a resolver problem. [Zak]I can imagine so many people driving their car right now or chopping the onions or doing their gardening or whatever they’re doing listening to this thinking Ah, that’ll be why the front tooth, Do you know there comes a point in everyone’s career doesn’t it, you know that tipping point between I didn’t know what I didn’t know and oh my goodness, that must be why. Because a lot of times in dentistry, particularly as an undergraduate taught restoratively and you’re taught procedures on you. And you’re taught that if you miss that particularly important step in the bonding of this very technique sensitive system. If you get that wrong, then you must have done something wrong. But actually, we don’t think about the bigger picture enough for you until you become more comprehensively minded and usually through failure of your own. You stop looking at a single tooth and you start looking multi tooth in a segment or in an arch or in a quadrant but then you start looking whole mouth and go Crap I got to look around the mouth now. I’ve got to look at the jaw joints and their ligaments and I go. Look at my human in front of me, how about the shape of their face? [Koray]Just give him a bit of chewing gum and chew, sit in front of them and see what their jaw does. You know, people said ‘Oh, how should I restore this upper premolar when the palatal cusp was fractured off?, Oh it should be done in gold, Oh no, it should be done an amalgam, Oh no it should be done in composite. No. What should we done as you look at the contralateral canine first to see if the guidance has worn away and that’s why that tooth is, has got you know, it’s got an interference in the occlusion that’s why I fractured. You know, if the guidance isn’t correct, then whatever material you put in there is going to break or wear [Zak]Yep. And then you go Okay, so why would you restore the canine at that particular angle? Well, you need to look at the contralateral [Koray] condylar angle Right. [Zak] The thing is, Isn’t this thing brilliant when you think about the whole picture? [Koray]When you put it all together, it’s really not that difficult. It’s, I mean, it’s like you don’t you take a bite wing and you see caries, and you put a probe on it, and it’s soft, and it’s brown. And there you go, it’s caries. You know, you stick a probe into a pocket and it’s nine millimeters and pus comes out, that’s perio disease. It’s the same thing with occlusion, if you don’t look for the signs, you’re not going to diagnose the disease. And occlusal diagnosis is just as important as caries and periodontal disease. [Jaz]With you mentioning that the equilibration is a tool. What are the, what is the end goal? So let’s talk about what are a few example scenarios where you think, okay, here’s my diagnosis. Therefore, as part of their management, one step of their process will be equilibration. Now, what is it that you’re trying to achieve with that equilibration? And what alternatives could there be? Or adjunctive therapies that you could have as part of the equilibration? [Koray]Perfect, good. All right, great question. So the first question is, what are we actually trying to achieve? What we’re trying to achieve is comfort and health and stability. All right, you can have patience with all sorts of malocclusions. Okay, I have a clicky jaw. But I’ve had a clicky jaw for 30 years. And my dentition isn’t deteriorating, I’m not fracturing bits of. I’m not in pain, and I can function, Do I need to be equilibrated? I have premature contacts and a slide on my premolars. I don’t. Because they’re not in the way of my function. Alright? So I have occlusal disease, but it’s not destructive occlusal disease, I have to diagnose it, I have to show the patient and I have to then say to them, it probably doesn’t need treating, as long as you know about it. But if somebody comes into me says, look, you know, I had a root filled tooth up here that broke and then I’ve got another root filled down here that’s broken as well and now my front tooth here is broken and ever since that broke my left joints been really painful. I’ve got you know, I have a patient who has occlusal disease just the same way as a patient who has periodontal disease with caries, that person has not got a stable occlusion. So the ultimate aim of any occlusal diagnosis and procedure or source of work is to ensure that the temporomandibular joints sit in a stable position where they’re not doing damage to the discs with a disc sign in a stable position on the condyles, you want the condyle to be on the disc, not on one edge of it, not off it, you want it on the disc, you want it to move with the disc, and you want the muscles around the joint to all move harmoniously without giving pain and allowing full functional movement. That’s the end result. Now, if what is preventing that is a dental contact, then equilibration is to eliminate that dental contact in a controlled fashion. So you do it on models first with the patient articulated in centric relation. And you look at what happens if you adjust that contact. If you adjust that contact, then another contact is going to need adjusting and then another and then another and then another. And equilibration is seeing which contacts, which tooth contacts need to be adjusted to allow the condyles to fully seat, for the occlusion to be then fully stable without interferences in any dynamic position. Now, to be able to do that, you have to get the patient into centric relation reproducibly. If you can’t do that, you have to use a deprogrammer first. The deprogrammer will have two effects, it will relax the musculature and allowed mandibular repositioning. But it also diagnosed whether the problem is occlusal. It could be traumatic, somebody might have fallen off their bite. Somebody might have got into a fight. Some people you know might have just had their jaw held open too long when they’re having their wisdom teeth out. If it’s traumatic, it has a different diagnosis, it’s a traumatic temporomandibular joint disorder. But if it’s occlusal, the equilibration is to eliminate the problem that is causing the dysfunction. That’s all it is. [Zak]One of Jaz’s favorite catchphrases at the moment, by the way is can we make this a little more tangible? Can we make this tangible, Koray? I just want to slow this down for some people who might be listening to this and I love how fluidly by the way that you talk about this. This is obviously in your heart and soul is like part of using it and I love listening to a lot yeah, you can just tell right away and you can tell the passion that Koray has about his subjects, which is brilliant. The thing that I’ve found in my first two or three years out of university, is that I didn’t because I hadn’t had enough experience in seeing enough hundreds and thousands of mouths yet. I hadn’t been there and done that and seeing the negative end results of if you don’t catch these things early enough. So can we make it a little more tangible? What happens if let’s say, we’ve got a premature contact on a tip to lower pre molar, which is not axially loaded. And you can see other signs of tooth surface loss elsewhere. And you can see that this person potentially has a heavy set mandible, let’s say big, strong masseter muscles and all the rest of it. What are you thinking? [Koray]Okay, first of all, before we do, I mean, when a patient comes in for a consultation with me, you know, they fill out a whole load of paperwork, which, you know, is very onerous. And they, you know, they fill out the medical history [Zak]Very onerous, by the way you choose. But isn’t that also just a subtle thing? By the way? Isn’t that also on purpose? Because you’re trying to select an audience for a reason? [Koray]I want somebody to realize that we’re asking questions for a reason. So they come in, and we sit for the first 10 or 15 minutes, just get to know them. What can we do for you? Why are you here? How did you get here? You know, what do you hope for us to achieve today? The first thing I do clinically, I obviously sit, I sit them up, and I look at them whole symmetrically, the first thing I do is I stand behind them. And palpate everything. I put my fingers on their TMJ. And I say can you open as wide as you can for me, and I look to see what the mandible and the condyles do, and you can shut your eyes and do it because you can feel the way the condyles move, or don’t move. You can see which way the mandible deviates, you can see if one side moves better or worse than the other. Now the next thing I do before the patient gets tired, I lie them fully back. So I tell them, I’m gonna lie you almost tilt your head down. I lie them fully back, I extend, I adjust the headrest, so that I can extend their neck right back, making sure they don’t have any ankylosing spondylitis or neck problems that prevent this, obviously, medical history. But as long as I just tell them, are you okay, lie back, are you okay lying flat? And tell them I’m going to extend your head as much as possible, I didn’t get them to almost just kind of look, you know, try to almost arch their neck, I ask them to get open a little, just a little, I then get them to roll the tip of their tongue to the back of the roof of their mouth. And I get them to slowly close and I say, Where do you first hit Left or right? And they say, right or left they point. So then get a piece of articulating paper in millers forceps, dry the teeth, and getting to repeat it, just tap, tap, tap it. And the first photograph of the patient we take is that single point of contact where they hit that is their centric relation contact position, or whatever you want to call it, since [Jaz]That’s my preferred term as well as CRCP [Koray]Centric Relation. So is the first contact point in the centric relation. In other words, their, mandible origin. Now, here’s where the first point of diagnosis is, can they actually get into centric relation? If you ask them to tip their head back, roll their tongue back, and their mandible is out here. And they can’t get back. I already know I have a muscular problem. That person, the first thing I’m thinking is this person is going to need some deprogramming, okay? Now, but if they can get into centric relation, and I have the same dot on two separate attempts, that’s my CRCP. I record it photographically on every patient. At the same time, what I record is in that point of contact, I record the incisal relationship. And then I ask them to clench together until they’re fully in intercuspation. So centric occlusion, or maximum intercuspation, or ICP or position, or whatever you call it. And I then see what the mandible does, and where it slips to. So I have two photographs, one with them slightly open and one with them close. And that’s the difference between your CRCP and your CO. [Zak]Can I just say if you’re listening to this, rewind, rewind, rewind or listen to the last five minutes, 20 times, go and listen to it 20 times that is gold. [Koray]That slide is going to, if you don’t diagnose it, it’s going to be the bane of your life. If you’re doing something extensive on that patient. [Jaz]I just want to put the context for those listening correct is they have to understand that you are treating patients who are often being referred to you or self referred, and they’re not coming in for that denplan check with you, right, they’re coming for a thorough assessment. It can be done quickly, but this I want people to understand that what you’re doing is I know you’re not specialist but you do is very specialist in nature. And you’re treating full mouth, very comprehensively. And that is the cornerstone, the very foundation of it. So a young dentist who’s a few years out being 10 minute checkups. Yes, it might not be part of your protocol, but you need to know when it should be protocol if you’re doing anything more ambitious, full mouth, and that’s the kind of time you definitely want be checking because just like you’ve said, [Zak]Jaz, I’m gonna counterbalance that. And always like always, yeah. [Jaz]I’m not saying always. I’m saying if you’re doing big full mouth dentistry, then I think that’s where you begin? [overlapping conversation] [Koray]I think this is something I would actually slightly disagree with. I think you need to do it on every patient. [Jaz]You should. But that dentist 10 minutes examination, they’ve got their BPE, the jackets got be taken off by Mrs. Smith. By time she walks in sit downs. I’m just trying to make it real world for the majority of clinicians. [Koray]Then you come to the other bit of the philosophy. Why is your consultation 10 minutes? [Jaz]Oh, 100%. No, I’m with you there. I’m with you there hallway. Everyone deserves a comprehensive exam. I’m totally with you in there. [Koray]Here’s the issue. If I take a photograph of a patient who’s got an MOD restoration on an upper four, and that first point of contact is on the palatal cusp, and I don’t see it, I don’t record it. And I don’t tell them. And three weeks later, they come in with that cusp fractured, whose fault is it? [Jaz] Absolutely. [Zak]Well, you can wiggle your way out of it in several ways. It was probably, it was probably the Rolling Stone everyone [Jaz] It was a soft bread. It was a soft bread [Zak] Soft bread cheese sandwich. [Koray]No, he came up with the soft bread that he broke while you were grinding on it [Zak ] You’re absolutely right. [Koray] So you don’t diagnose that. To me, that’s as big a miss as missing caries into the pulp. It’s a diagnosis of occlusal disease and instead of seeing as occlusion as a peripheral thing, we have to see occlusion as a fundamental part of the examination. Now, if you spot it, and you tell the patient is they look really what we need to do is get some occlusal Records. See what would happen if we equilibrated you and then once you’ve equilibrated you take the load off that cusp, you may prevent a fracture just by doing and invariably what happens is patients who aren’t even aware that they’ve got an occlusal interference, once you go through the procedure which is completely non invasive, by the way you you take records, you take centric relation records, you put them on an articulator, you do it on the articulator first, you show them what the adjustment requires, they then consent or not. Okay? It consent to it and you adjust them. They will almost 99.9% of the time say, Blimey that feels so much more comfortable. They didn’t know they were uncomfortable, right? Now I’m not saying every patient needs a equilibration but if you see a premature contact causing damage, crack lines, history of a fractured cusp, TMJ, muscular problems, displacement of the joint when they’re occluding. You have to tell them. If you don’t spot it, it’s a missed or a maldiagnosis or misdiagnosis [Jaz]I like that example. I like the example you gave cuz I think that makes it very tangible with premolars, that was a fantastic example I think. Zak, you’re challenging me, Zak, I said so that busy guy with 10 minute checkup that he can’t be, he or she can’t be doing in the real world, the bigger problem is why are they doing 10 minute checkup? Now I’m completely appreciate that. [Zak]No. We’ve covered this previously, right? We it’s all about designing your own life. If you’re in a scenario where you’re listening to a podcast of this type of nature, well actually you’re clearly interested in something along the lines of advancing your career or learning more about what’s out there in your working world. You’re not just sitting listening to the same nonsense at lunchtime with you around some, around the normal people you do. [Koray]Let’s rewind a little bit. You say your 10 minute checkup. This shouldn’t be spotted at a checkup. This should be spotted at an initial consultation. [Jaz]Comprehensive Exam. No, this is so true. [Zak]And so what you plant in this as the seeds of thoughts in the minds of our patient base becomes your working world becomes your own destiny. What you’ve then done is you’ve designed yourself a future where you’re gonna have a diary filled with emergencies. Now, Koray, can I just put something to you? I’m sure during complicated rehabilitations and work that you do, full mouth comprehensive dentistry, once in a while something will happen, something will debond or something as a temporary that was intended to come off at some point will come off and it needs to be receipted but how often is it that you have somebody who has let’s say completed their all encompassing course of treatment whose mounds fail? [Koray]Luckily it’s rare. I couldn’t afford it to fail regularly but we do get them, we do get enamel chip, you know we do get chips, we get porcelain chips just like everybody else’s. You reconstruct somebody top and bottom in ceramic, you’d get it i’m not saying we don’t. [Zak]Do you have a diary space every day allocated for one, two, three people’s teeth bust? [Koray ] Absolutely not. [Zak] You don’t need it right? And so if you’re listening to this thinking, Oh no, that’s normal to me. I always have something squeezed in that something happened where something happened. Well ask yourself why you don’t like [Jaz] Get the GIC out [Zak] It’s plastic, isn’t it? But it’s self perpetuating the problem, Jaz isn’t it? Because as soon as you start slapping Fuji 9 on everything, then everything becomes a Fuji 9 and then you do single tooth dentistry. No wonder [Jaz]The nurses got it ready with every emergency that the trays have been set up for it, right? And I’ve joined a practice now where the dentist for, bless his heart he’s just retired, amazing dentist, great at diagnosing caries, great diagnosing perio but not having those discussion about wear, mobility, fremitus, crack lines, so missing the whole occlusal disease element and now I’m coming in, I’m having those you know, this practice went from doing zero deprogrammers to like several factors of them and having those bigger mouth discussions and now converting these cases to go more comprehensive dentistry. But that is exactly we have these emergency spaces in everyday and most common emergency we get is a broken tooth, a cusp fracture. And it goes back to what Koray says you need to examine that at the initial consult, not a terminal examination. But Zak, when I did suggest that, Hey, if you are that dentist who’s has to pick and choose who you can and can’t, unfortunately, give a comprehensive exam to and you’re going to be now treating someone like a young dentist, typically their foray into or their entrance into treating bigger cases would be a dahl technique, okay? Whether you love it or hate it, I truly believe that the young dentist in the UK, when they’re starting to think bigger, they’re taught the dahl technique. That’s the thing that they’re all undergrads are taught. And that’s what they might do. Now, even in that case, you still need to check your centric relation contact point. But Zak, you were saying perhaps that’s not necessary, right? [Zak]Well, no, no, I was, you were making the point that your CRCP isn’t always possible within a 10 minute checkup. So when we said that CRCP can be identified for everybody. I completely agree that that is actually a cornerstone of identifying the things that can go wrong. And it’s usually for me, a start point in a conversation about how things can progress inside people’s mouths. So one of the problems with every single unique individual, individual that you look after, is they don’t have the benefit of the all encompassing nature of the general public’s mouths that we’ve seen. They haven’t seen the way that mouths progress over the course of people’s lives. They haven’t seen the 20 year 30 year 40 year saga that I’m in unfolds before us. Now you don’t have to be and by the way, it’s encouraged definitely that, that you stick around in one practice for several years, because seeing your failures and seeing the way things go wrong is ultimately the best learning method, right? But you can see people in your patient base even within a year period, let’s say who were in their 20s, their 30s, their 40s, their 50s. Put your Sherlock Holmes hat on and ask yourself, let’s be a detective today. Why did that person in their 60s, end up that way? Now let’s find somebody in their 20s who might be going that way. And let’s see if we can identify that pattern spotting and dentistry for me is quite a lot of pattern spotting. You spot these things all day, every day that you there aren’t that many variables in the head and neck and mouth. There’s quite a few but there’s not as many in the whole body as in the whole body. We’ve got to be doing as looking and using your eyes and one of the best things that you taught me, Koray, is that you need screens. So I have so many screens in my office now I was [Jaz]Overboard. [Zak]I mean, for me, I now have a 34 inch ultra wide and I have a 27 on top of it and I’m like that’s about as far as it goes as far as my missus will take let me take it but the fact for me is if you see stuff because you’ve taken the time to take that photo to step back to look at the big picture and discover exactly what’s happening. You focus proper attention on people and I tell you it comes back to pay you dividends that’s fine. [Koray]That was going to be my next point I said the person that you can’t afford the time to spot this is the person that you’re going to spend hours on sorting out later. Spend 15 minutes diagnosing it and save yourself 10 hours, seriously. You know the caries, I’ve just busted the lingual cusp off my lower 7, Oh we’ll just do it online for that Mrs. Jones. Come in, do the prep, turn back, no space. Come back to suddenly you have no occlusal height left. Oh, and now there’s an anterior open bite. What? What happened? What happened was you didn’t diagnose the CRCP was on that seven. And as a result of that instead of equilibrating everything first and then coming to restore the tooth. You then have already launched into restoring the tooth and then have to equilibrate everything in retrospect as an excuse [Jaz]Or Koray having that discussion with them that actually orthodontics might be needed here before you then do it and then suggest the orthodontic space and then yeah 100% when I learned that and I started to use a leaf gauge to screen for these things and whatnot or whatever tool you want to use and your way, Koray, I haven’t heard of that way before, that’s amazing about their posture and you described it really well and how quick and easy you made it. That is so that’s how you can do it in maybe 10 minutes but my argument, Zak, was busy clinicians who are based on single tooth dentistry. They will not see the value of it yet until this [Koray]It takes 60 seconds. Doesn’t take 10 minutes, take 60 and also, I find that I’m not a big fan of manipulation [inaudible] Well, people just push it out. If you can, if you’ve got relaxed TMJs, you can get back yourself. So to me, letting the patient do themselves just by posture and tongue rolling, for me is still the best way of seeing whether they can achieve CRCP. We try to [Zak]For everybody else you basically saying every other time that, that’s not possible or not reproducible, then there’s a muscular issue and you’re going to be deprogramming. [Koray]Basically, that’s the flowchart. Correct. [Zak]Jaz, the designing your own life thing really comes into this comprehensive minded dentistry, doesn’t it? We’ve talked about it previously and equilibrating. And maybe you know, there may be aspects of some people listening to this thinking, equilibration is just drilling bits off teeth, isn’t it? Well, you hit another nail on head a second ago, which is that orthodontics can be a huge part of what we do. And so it’s very possible to really just step back from the average single tooth dentistry mindset for a minute and listen, because this stuff is, there’s more to it. Then I’m just gonna tickle and fiddle about with a few teeth. And I’ve heard that that’s a dark art on that what will go on. [Koray]How many orthodontists use articulators? [Jaz]The face group, two in the UK. [Zak]There are many orthodontists who think they do but then when you ask them, ‘Do you know how what happens if you can’t reproduce that position? Or what happens if you’ve got a particular let’s say a brachyfacial type of patients, somebody with very strong masseters and somebody who’s obviously going to resist manipulation’ ‘I will just use a leaf gauge.’ ‘Well, what happens if you push back onto retrodiscal tissue?’ ‘Well, no, that will be fine.’ And so people think they’re doing things, exactly. What happens next? So this is the thing until you become an all encompassing comprehensive minded dentist, no matter if you’re in one specialism or another, you’re not really doing all of your patient base the best service in my opinion. [Koray]I mean orthodontics has been called full mouth rehab with teeth [Jaz] in enamel. [Koray] So basically, if you moving teeth around, you got to make sure they mesh together your teeth to settle in, if you like, but you need to have healthy TMJs for that to happen. And you need to have a decent relationship between your final arch and yes, you will get micro movements and things settling in and over erupting a little bit and tilting a little bit yeah. You know, you need a really good orthodontics for me is 80-20. It’s it takes 20% of the time to gauge the result. But the real tweaking occurs at the end. And that’s very, very difficult and most orthodontists and most patients lose the patients at the end to carry on and get the tweaks right. For me, if ever I refer somebody to an orthodontist I work with Moira Wong and Asif Chattoo. The patients know that at the end of their orthodontics, they’re going to come back and have a full occlusal analysis and equilibration, that’s part of it. The orthodontics doesn’t end when the braces come off. So for me, that’s part and parcel. Now, they may need a equilibration? They may not need equilibration, the level of a equilibration may be such that it’s actually better to do additive. So this is where the diagnosis comes in. If you find that your equilibration, you know, chops everything off every tooth to get the mandible in the right position, then the correct solution is to raise the vertical dimension and add not take away. So it’s not chopping bits of teeth. It is repositioning teeth and it has to be made very clear to the patient equilibration does involve the irreversible destruction of some enamel [Jaz] And you say that you use the word destruction [Koray] I use destruction. I’m gonna remove parts of the enamel of your teeth [inaudible] back but it’s being done with a diagnose, the diagnosis and a therapeutic goal and is to prevent bigger problems in the future. And basically instead of you spending years wearing the thing away and causing yourself TMJ problems, I’m going to do it for you in a way that allows you to settle and this is how much I need to do. And one of the things I do when I equilibrate is I have the equilibrated models and I photograph every step of my equilibration. So it’s literally this is where the contact is. This is what adjust, photograph [Zak] Of course he does. [Jaz]Do you still write in your notebook? You just tell me you used to write like this. [Koray]No. I just have a sequence of photographs. And I know where the dots are and I know wherever equilibrated and every single dot in the mouth during a equilibration must have a corresponding contact on the models if they diverged at any stage. I know the mandible has moved back and my initial record was not correct. [Jaz]Wow. So what you’re suggesting is that when you’re doing equilibration it actually, it is the beauty of it. What’s happened on the articulator is more or less happening in the mouth which is just the point of articulators, right? Which is amazing. [Koray]If your centric relation is correct. If your centric relation is out, you’ll find out very quickly because what’s in the mouth will not be what’s on the articulator and you will know at that stage that your equilibration was incorrect. Now even if the first point of contact was correct, it may be that there’s a slight rotation. And then the next point, the contact isn’t the same in the mouth. If that’s the case, then you deprogram them further, you then retake the lower impression against the upper, the record against the upper, rearticulate the lower cast, repeat the process. You have to be honest with yourself. If you’re good at what you do, if you get used to taking records and you see the reproducibility, it’s really rare, I need to do that. It’s maybe happens once a year. But I see between 50 and 70 new patients a year roughly, of those I would recommend, I would probably recommend between a third and a half, go through a full occlusal analysis, and at least a partial equilibration process. It doesn’t need to be much. It might be one tooth, it might be a couple of teeth. But invariably, when you do it, virtually all of them will immediately report that they’re more comfortable. They didn’t realize they were uncomfortable until they have it. [Zak]Koray, I just briefly add to that, is it also worth adding? What do you tell people? The main benefit of this is or what’s the risk of not doing this? Is it that you’re straight to the point and you explain that root fractures and mobile teeth and those types of things may be possible. Very good question. Future outcomes. [Koray]So basically, what I say to them is this dot is the stone in your shoe, okay? It’s the thing that stops your lower jaw from relating to your upper jaw, the way your muscles wanted to relate. Basically, it’s something that’s stopping your door closing properly. Now you can push the door, and it’ll be fine. You’ve got no TMJ symptoms, you’ve got no crack lines in the teeth. You know, you’ve got no drift in, no history of breakages. And you’ve been like this for 20 years, you probably don’t need to treat it. But if you do find that things start to deteriorate, I’m going to recommend a full occlusal analysis. Would you like to go through a full occlusal analysis to see and see what would happen if we adjusted this? You know, the risk is you can get a spontaneous tooth fracture, things can drift, things can crack. But you know, I will say actually, you’re probably pretty low risk or I’ll say, you know, what, can you see that crack line? And can you see that, that tooth has now started to wear and the one that was behind it was the one that you broke two years ago and had a crown? And now that crown is out of occlusion and this tube is taken abruptly. And then it’s important, I’ve got one lady at the moment who’s lost a tooth, keeps losing the crown on a lower six, can I just make a bigger crown for her? No, her centric relation when she closes her anterior open bite is five and a half mil. So it’s like she has a major, a major discrepancy in every axis, anteroposterior, transverse and vertical. She’s basically pivoting around her sevens. And, you know, you speak with a maxillofacial surgeons, well actually, this needs to be a forward rotation, not the full error, mandibular osteotomy. And yet, the patient is ‘I’m not having surgery on my jaw just for this, I just want to have this crown replaced.’ No, this is the diagnosis. And if I can replace your crown, and you will break it, or you will break the tooth, and then the next tooth and then the next tooth. But when they see it, they understand. It doesn’t always mean that they will go ahead with what you’re recommending. But they will understand why things are deteriorating, and then they’ll start working with you. As opposed to you having to give them an excuse as to why something’s failed. [Zak]That’s key. That’s absolutely key. I would love that door on hinge analogy in the stone in order something in the way the snack in the way and [Koray]Not be able to tolerate it. But it might be giving you back ache. [Zak]I specifically like the door on hinge analogy, because as soon as you start saying, Well, I can push the door closed, and I can really force it. But what might be I would probably at this point, if I was to sort of think through this, in my mind, I would probably expect somebody to push back. Or I’d ask somebody, what would you expect to happen next? And they go Well, you know, they’d be probably the hinge wouldn’t there, right? Okay, there is the hinge but where’s the hinge in the mouth? There. And that’s probably one of the most fragile and potentially damaging outcomes of this type of condition [Jaz]Of the most used joint in the body. And patients can relate to that very much and when you make it relatable to their daily issues, that chewing and their function, that’s how to get the patient on board. So these analogies were brilliant guys, I really appreciate. Now just want to pick on the nitty gritty details. Now we can’t explore every single indication in the scenario. And I would you know people ask me all the time, can you recommend an occlusion course. At the end, please do tell us where you teach Koray because you know I’m a big fan of your work and the amount of equilibrations you have done. I don’t know anyone in the UK who has done as many as that basically. So there’s that’s why I’m so excited to have you on today and learn these little details that you share. In that case with that premolar as we said that premolar of the first contact which may be at higher risk at fracturing. If you take that patient, you’ve taken their scan or your models, you’ve taken a Facebow record and I correct me if I’m wrong here, [Koray] Absolutely [Jaz] you mounted it on [Koray] you must [Jaz] of semi adjustable articulator [Koray]Just a semi adjustable articulator, you don’t need I mean we do run a two day occlusion course which you can find a LCI, the academy but the thing is you don’t need hugely advanced you know, you don’t need to look at lateral shifts and things like this, it just needs to be a status centric relation position is a skeletal position and it should be reproducible, it is reproducible if you get it correctly. And the key to this is to look at the anatomy not of the lateral pole of the joint or not the outside bits of the joint, but the inside, the medial aspects, because that’s actually where the anatomy doesn’t allow the condyle to move anywhere else. We look from the side you think Well, we know this condyle can be anywhere inside this socket. But actually when you look at the fact that it’s a football and it’s the medial aspect of your jaw joints, of the actual socket that guides where your mandible is, you can see what centric relation really means. And if you can reproduce centric relation, your equilibration should be a doddle way and once you’ve done it, that becomes your backstop that the mandible is stable there. You can then go forward laterally, you can decide what your guidance is going to be, you can decide where the interferences are if you need to add the teeth or adjust teeth. So the the equilibration is really just to get them into centric occlusion in a reproducible way. From there, you’re then going to look at their protrusion, you they’re going to look at their lateral excursions and you’re gonna look at their outside in and inside out function. So that’s another thing you know, we get people to bite on stuff and slide sideways. That’s not how people chew. Remembering if you slide sideways you’re using basically using medial pterygoid which is a slightly weaker muscle. When you’re closing and you’re grinding from the outside in using all of your major closing muscles, your temporalis and your masseter so the outside in force you apply to an occlusal guidance contact is higher than the one you use when you ask the patient to slide sideways. So always also test them from the outside and getting to chew on articulating paper and see the marks [Jaz]When you’re actually assessing those marks on the models and then you’re [Koray]I don’t do those on the models. I actually do the guidance in the mouth [Jaz]Yes but when you’re actually doing the trial equilibration on the models [Koray] Yes [Jaz] When you doing the trial and then you’re going to take that to the mouth. Now what are the fundamental rules of equilibration in the sense of where to adjust. So for example, what you don’t want to be doing is just hacking off cusps making everything flat, so how can you do it in a safe way anatomically driven way? [Koray]Slopes not tips. Slopes not tips. And which aspect of a slope you adjust will decide which direction of tip travels, okay? So if you’re in a cusp to cusp relationship and you don’t want to know which way to go, what basically what you do is you adjust one aspect of one cusp and the other aspect to the other and you get the tips to move in relation to each other without losing hunt. So slopes not tips is the primary one and the second one is go for the bigger cusp rather than the thinner cusp okay? So don’t overthin a narrow cusp take a little bit more of a thicker cusp. It’s the usual way it goes. But when you look in the mouth, you kind of gradually get a feel for where which aspect of the cusp is best to adjust. Depends where you want to move the tip, you would ideally want your cusp to meet in fossi and not on marginal ridges and not edge to edge and not tip to tip. So as he say well actually you know I’ve got this kind of relationship you know where do I adjust? I don’t want to adjust the tip I want to kind of adjust this aspect to this one that aspect of the other and then to mesh together. So it’s a little bit of thought but the general rule is adjust slopes not tips. That’s the main rule [Jaz]I did an equilibration this morning so it’s fresh in my head. What do you do and this is me in so at the very beginning stages and I’ll tell you the rationale of why I did an equilibration on my patient, I’ve down the moment but the thing I remember the most the biggest challenge I had was being confused or not confused but being a bit like whoa all these red marks and then having to rub away and then go again. So any hack you can give us? And obviously that if you’ve never done the equilibration before, go on a course and I don’t know many courses that teach equilibration so I would recommend Koray’s. At the time at the Dawson, I got taught by Dawson but I don’t know if that none of the other occlusion courses I’ve been on actually teach a equilibration so definitely check out Koray’s but how can you help us to be more clinically efficient with the marks because otherwise all you see is a sea of black and red. [Koray]Correct. So what I do is I actually get the laboratory to paint a very thin dye relief all over my occlusal surfaces and my incisal edges. So it’s, the models come back with a red surface, I then use a dark blue articulating paper, and I held it in my hand, I don’t actually hold it in millers forceps. And what I do is I just make sure the pin is up so that the pin isn’t stopping the teeth from coming down. So the pin has to be up. And then what you do is you just close and just give a little tug. Close, just give a little tug. It’ll either pull through or it won’t. Where it doesn’t pull through should be a bullseye, not a streak, not a mark. But a bull’s eye. The bull’s eye indicates that the cusp tip has gone through the paper and contacted. The bull’s eye is what you adjust, okay? And the bull’s eye on the model, the first one should correspond with your CRCP that you took your first consultation, or after deprogramming if you’ve had to deprogram first before you equilibrate. So the corresponding mark on the model should be exactly the same, then you will notice that when you pull, if it pulls through, ignore the marks. If it doesn’t pull through, and it’s bull’s eye, that’s your first one. And you should get to the point where eventually as you equilibrate the number of bull’s eyes, it gets more and more and more, until every contact has a bull’s eye, then you fully equilibrate. Now in the mouth, it’s interesting, you end up actually doing more on the casts normally. But in the mouth, you get there a little bit quicker, you don’t need to do all the fine control, because there’s a level of vertical movement, obviously within ligament of the tooth. So on the casts, you’ve got to account for the fact that they are totally immobile. And sometimes there’s a couple of false positives, but it’s actually a safe thing because you know, you end up actually doing less in the mouth than you do on the, on guard. Also, once a equilibrated, I think invariably you get a little bit of shift of mandible, it’s a little bit more relaxation that you maybe didn’t have with the deprogrammer, and I get them back in a couple of weeks later, and I just fine tune them and make sure they’re back. [Jaz]I was just gonna ask about that. What’s the protocol for afterwards? [Koray]Provided all the dots correspond to what you’ve got on the models. And then you just fine tune it and make sure and invariably and you must repolish things, don’t leave them rough. I do it with the red diamond, then I just go with some brownies or some greenies and just just polish the enamel. [Zak]Can we add a little bit more context for somebody who’s maybe never seen, maybe even never have definitely never done one of these equilibrations, but never even seen one of them happen. How do you guys make sure that, that person is in CRCP every time that they close together? [Koray]They have to be in CR, okay? So the same way where you do the equilibration with them lying back in the same position as you took the centric relation record, okay? And you got to make sure that when they touched teeth together, that you can feel that their mandible is doing this consistently not swinging around, okay? If they still not doing, if it’s still not in the right position, then [Zak] It’s still not deprogramed [Koray] You’re premature. You have to keep deprogram. Now with the deprogrammer, what you’ll find is if you make let’s say, a Michigan appliance, which is the most common one that I’d prefer to use, you’ll find that when you first fit the deprogrammer, as soon as you fit it, their muscle do a bit of relaxation during that appointment. And the first thing that happens is that, you fit the deprogrammer, and you immediately find that your heavier contacts are towards the back of the deprogrammer, and you do a little bit of adjustment there. And then when you get them in for a review, you find that it’s still heavy on the back and you do a little bit more adjustment. And then gradually what happens is the deprogrammer, you do more adjustment at the back than you do at the front and then everything stops moving, nothing else moves, it becomes stable, or the anteriors and the posteriors all hit at the same time. You fully deprogram, the have muscles of relaxed, the condyles have moved back. And they are now stable in their centric relation positions. There is no further movement backwards. And that then when you start getting even contacts on your deprogrammer with no more of the anteriors being lifted off slightly while the posterior is then you know that you’re fully seated. You know, from there, you can equilibrate. [Jaz] Have you seen an equilibration gone wrong, Koray? [Koray] By assuming the equilibration are wrong? No. I’ll tell you why. Because there are two things that can happen. The first thing that can happen is that your lower cast is not articulated properly, you’re unlikely to get your facebow record majorly wrong. You know, there are only two ears, you know, but you can sometimes find that when you’re taking the centric relation record, the patient posture slightly and you don’t quite get. So what you then find is that what you do on the models is completely unrepresentative of what you see in the mouth and you think this is wrong. So all I do there is I retake the records. Again, rearticulate the lower cast. Alright, it’s that simple. And then I come back. So that’s the first thing. So the first one is an error of recording before you do anything. Yes, it costs time and money to do it again. But that’s just the way it is. Once you do the equilibration on the models, you then look and see how much equilibration is required, okay? Now if you need an inordinate amount, don’t start. The correct procedure for that is probably additive. And to probably reconstruct an occlusion rather than adjusted away [Jaz] Plus or minus ortho [Koray] plus or minus ortho, plus or minus orthognathic surgery, sometimes. A big transverse relationship especially, but once you have seen on what you got it, you know, if you’ve got a reasonable amount of adjustment that you’ve done on the casts, and it’s totally reproducible at the mouth right down to the last dot, then invariably, the equilibration is successful, the patient is more comfortable, the occlusion is more stable. You would, but that’s the first starting point, that is where you get the maxillomandibular relationship stable. On there, you still have to check your protrusive and laterals and make sure that you’re not got any non working side or working side interferences. Then you have to play with your canine guidance, new insight or guidance and if you have got those and you still got interferences, then you may need to orthodontically move teeth or you may need to adjust posterior cuspal slopes as well. That’s slightly more advanced as you get on but the main thing is to get that maxillomandibular relationship stable so that if you adjust any tooth, if you do a crown prep on a tooth, it’s completely stable. What you start off with is what you end up with. So you don’t have any mandibular movement in relation. If you don’t diagnose it, and you start adjusting the tooth that is the first point of contact. It’s like starting an equilibration and not knowing where it’s gonna go. [Jaz]Zak, this is your cue for Am I naughty if? Zak’s ‘am I naughty if?’ So am I naughty if? And sometimes not just him. It’s just like he might be speaking the mind of a young dentist. Am I naughty if I do this? [Zak]I’m Baron on Am I naughty ifs for equilibration? Because Do you know what I think the thing that most people will have with this is a complete blank. They think, Jaz, that actually most people in dentistry in the UK will have kind of no real concept of this. Why does this not radar of most dentists, Koray? [Koray]I think it’s just not given sufficient. It’s just not given sufficient coverage, maybe in dental school. [Jaz]I think was not mentioned. Not the word of equilibration and all occlusion [Koray]When you get back to Richie Davidson and said, Oh, you know, I’ve never equilibrated anybody. Okay, I’m gonna I’m going to qualify that. It may be that he’s treating full mouth rehab cases where he’s doing all of his equilibration through restorative work. [Jaz] Yes. [Koray] Now, he’s getting his centric relation and then it’s what is it easily gold surfaces everywhere and gold palatals. And he’s done his equilibration by rehabilitation, [Zak] and you’ve equilibrated in temporaries at that point [Koray] but I bet my bottom dollar that he gets his central relation record right. Okay? But he can’t say to me if somebody’s got temporomandibular joint dysfunction, and their muscles aren’t working and they’ve got an immobile joint, and they’ve got pain on the other side, and they can’t open more than 25 millimeters, that you can restore that patient and they’re going to be comfortable. There was no way that’s going to happen. And anybody who says that that person doesn’t need occlusal analysis, and deprogramming and getting their neuromusculature and the TMJ is healthy before they go into a restoration. For me it’s irresponsible. I don’t believe them. I don’t believe them. I don’t think you can do it. If you want the lucky ones, but he won’t happen consistently. [Jaz]Yeah, absolutely. Well, I’m gonna ask this am I naughty if because I just want because I know the answer gonna get and I think a really important message to say safe is, am I naughty if I’ve got someone with occlusal trauma and some fremitus and I started just making some marks and I start drilling away to reduce the loads on these teeth with occlusal trauma. [Koray]Very naughty, very naughty. [Jaz]What is the correct protocol? [Koray]Because to two reasons, first of all, you have no idea where it’s going to end, okay? And you may find this somebody becomes much more uncomfortable. If you remove them from there, if you remove that reference point that they used to, and suddenly they can’t relate and suddenly, yes, their muscles might relax, but then they have no occlusion, because you know, I used to meet here. Now if you just adjust that and then suddenly you’re through the enamel, Ouch, that hurts. Equilibration should never be never go through the enamel, never. Okay? If the equilibration has to go through that enamel you finally have to chop a large amount of a tooth. You should consider orthodontics. Or you should consider additive reconstruction to the whole occlusion. You shouldn’t need to adjust three, four millimeters of a tooth. It’s ridiculous. Sometimes you might need to be heavy, you know you’ve got an over erupted upper seven that’s hitting the distal of a lower seven. And you might need to adjust quite a bit off the anterior plane of that tooth. Because intruding orthodontic is very difficult, you know, you can’t easily intrude a single posterior molar, you can put, you know, TADS, palatally and buccally and try to put elastics and things but actually, it’s not practical. So sometimes you do need to adjust quite a lot, you just have to say to the base, you know what, I actually need to remove four millimeters off this tooth and devitalize it about a two millimeter crown on it to get your occlusion correct. But if that’s the diagnosis you come to, it’s inescapable, you know, what, extract the tooth and put implant or you know, if you want to eliminate the contact, and that’s the only choice you have. That’s the diagnosis. [Zak]And actually, if they’ve decided on balance, that the negative potential consequence of not doing that outweighs the treatment itself, then that’s consensual, that’s an absolutely valid treatment. [Koray]They can say, I don’t want to have equilibration, I don’t want to have this, I don’t want you to do that. And then you say, okay, it’s fine. But I think that like the hinge principle, if you’ve got something in the way of the door, and you keep trying to slam it, you’re going to break something, it’s like, then I would recommend that you perpetually wear a night guard, then you make them a proper Michigan appliance that allows them into centric relation, but it’s been adjusted properly and so and then get a couple of duplicates made I mean with CAD CAM now you can just, you know, just get three of them made all identical [Jaz] milled [Koray] milled, or you know, and then just say, I really would recommend you wear this II don’t wear this, the chances are that you’re going to do something like this. Now 90% of the patients may never fracture their upper four. But the ones that do and they come back with a fractured, you say I did say and then you can play you know, smuggling like let’s do what I recommended the first time shall? [Zak]At that point, it becomes their responsibility at that point rather than [Koray] They’re fully entitled [Zak] That’s the really big deal. It’s not your excuse. At that point. It’s their responsibility [Koray]Exactly that. It is entirely down to their level of concern. If they don’t consent to you doing it, you can’t do it. What you can’t do is not diagnose it and then try to gloss it over when they come back and say you know, why did my tooth break? You know, why did mention? Breaking teeth is quite difficult. You need a lot of force. [Jaz]Well, you’ve answered all my questions, Koray. Zak, do you have any questions about equilibration? [Zak]I want to add one thing. I wanted to hasn’t if we were obviously enjoying ourselves, like Uber nerds on a Saturday night. I, you said something, right in the beginning of this podcast, which I think is golden, very, very important. By the way, there were segments of this that I’m not gonna listen back to myself and go tonight that you summarize that incredibly well there. Sometimes you just pick up those nuggets and gems where you go, I’m gonna Nick that I say this a lot, don’t I that we add these things to a patchwork quilt. And you’ve no doubt Koray become a product of some of your mentors and some of the things you’ve learned over the years and some of your colleagues, no doubt. You said something, incremental improvement. Incremental improvement to me is a progressive movement in the right direction. Let’s hope always for the progression of our careers, but your it also made me echo. I know a good friend of yours and a mentor of mine too, Basil Mizrahi. It made me think of Basil’s way of thinking about incremental improvements and incremental steps in the right direction of our patients treatments, psyche and treatment acceptance and treatment outcomes. So Basil’s approach no doubt and same with yours is that you always make small changes in the right direction. And in order to achieve the end outcome, you cannot go from zero to hero, you have to take one step up the ladder, one step up the ladder, and so on. So what your equilibration might become part of it. Is there anything? Would you echo that And is there anything to add to that? [Koray]I do. I mean, one of the things I lecture about is what I call stepping stone dentistry. So you know, you got to get from one bank to the other without falling in the water. And you know, every single one of these things we do is a stepping stone that makes the next step more predictable. Now the interesting thing is that even after you’ve done all of this and you rehabilitate somebody new, you know, you put implants in in your bone graft and you do that perio and you do their endo and you know get their jaw relations correct, you provisionalise them, you provisionalise them again you just the provisionally everything for them. And then three years later, they come back, their jaw relationships have changed again, things change. So then at your checkup, you must again look to see whether anything new has developed. How do I go to new premature contact? Have the teeth worn and my implant crown remained unworn? So that my implant crown is now my crcp. Why did my screw fracture? Why did my implant crown break? Why did it loosen? The chances are that your tooth contacts may have been fine five years ago, the patient hasn’t been back for five years because they’ve been fine. And then suddenly, the implant crowns come loose, or the abutments fractured. And you look to see and the photographs show that actually, the teeth in front and behind have worn. These patients have [Zak] Materials haven’t worn at equal rates. [Koray] The materials haven’t worn on equal rates and suddenly the implant crown has become proud. There’s no periodontal ligament, suddenly the entire occlusion is pivoting on this implant crown. So as after you’ve done all of this and you’ve restored the patient, it doesn’t end there. Every single checkup must also incorporate is the occlusion still stable as the temporomandibular joint still in the right place? Can you still get centric relation? Have you still got even contacts around the arch? Have you still got guidance that allows posterior, instant posterior disclusion? Have you still got the balance and function that you built in? You know when you did the rehab. For this reason we don’t get we only guarantee our work if the patient is coming back at least once a year. Usually, we said we will depending on their level, we set it when I write the letter and it’s usually twice a year for checkups and four times a year by hygiene. But it can go up and down based on that patient’s level of stability or instability in the past. If they don’t conform with that, and they come back to me three years later and say, Well, this crowd is now broken and I’ve got a five year guarantee on it. Well actually, you don’t have a five year guarantee on it if you haven’t come back for checkups [Jaz] 100% [Koray] because things change. Patients change. Patients’ functions change. Somebody was very calm person may have started a new job where they’re highly stressed. And there’s suddenly started bruxing and clenching. And yet, you didn’t have that two, three years ago. So you’ve got to keep the observation that they got new carie,s they’ve got new periodontal disease. Have they got new occlusal disease? Have they got stability? [Zak]What you’re talking about is the thing, that’s key with this is like we always say, Jaz, it’s relationships, isn’t it? It’s about keeping consistent relationships, because you can’t step into doing dentistry, by the way, something I’m going to steal off of you, I’m going to quote that to my patients, because I think that’s very, very important that you instill it in their minds that they cannot go from zero to hero, they have to take every single step at this appropriate. But you’re also doing something very key along this the same time, which is that you’re building a relationship and mutual trust and respect with that person, so that you get to know what they’re about. And you’re never going beyond your competence level. And you’re never taking them into something which you don’t in your heart of hearts think is right for them. So you can kind of as long as it’s a safe stepping stone to stop on, you don’t offer the rehab. Do you see what I mean? Is that fair to say? [Koray] I agree. [Jaz]Koray, I’m gonna get bombarded by the end this episode where people want to know about your occlusion course. Is it just in London or multiple locations and can you just give us some details about that? [Koray]At the moment it is just in London, obviously, because we’ve come out of lockdown, we’ve not really had anything concrete laid down. And the only times we’ve managed to is at the practice, and somewhere close to the practice where we do the lectures. But we need hands on for the scene, it needs to be out of practice. So I run it with Shiraz Khan. We run it together because there’s obviously a lot of elements involved in especially patients who are sort of doing general practitioner orthodontics and aesthetics and lengthening anterior teeth and this sort of thing really needs to have a good foundation and occlusion. But the bottom line to end all of this off is diagnose it, see how you treat it is another matter but if you don’t diagnose it, you’re doing yourself and the patient a disservice and when you’ve diagnosed it or you feel much better in yourself, you sleep better at night, but also the process of going through this is also an it’s a lucrative treatment option. It’s like you know, Oh I make more and more implant you know, people say Oh, I do implants because I make more money. No, it’s not like that. This is a valid treatment diagnostic and treatment process that also will fill your book and allow you a stability of your patient base. That means your book isn’t filled with emergency with Mrs. Smith from crown has come up again and Mr. Smith fractures as lower six again after the third time. This actually gives you control over your entire patient population. I mean I do full mouth rehabs but I do a lot of General Dentistry that’s why I get patients coming in for composites and an endo and one crown, you know, that’s fine, but they still go through the same you know, they still go through the same occlusal analysis process. [Jaz]But for me, Koray, dentistry becomes fun when you’re moving away from single tooth dentistry. And having the comprehensive exam and the knowledge of working knowledge of occlusion is the basis for you to have more fun because it allows you to move away from single tooth dentistry. And that’s why I got into learning about occlusion. So please do send me the date and the website, I’m gonna love to stick in the show notes. Because I’m sure people love learn from you. [Koray]The website is, is www.lciadacademy.co.uk. [Jaz]Perfect. [Koray] We also we also run photography, so I think photography is an integral part of this, we run a separate course with Shiraz, and also a an occlusion course with Shiraz. And I think the two of them, those two courses, actually will, I want, I gave a lecture to the Scandinavian Academy on this over a one day period. And I actually stood up in front of that, say what I’m going to say today is going to change your life, right? And I did it with tongue in cheek. But it really did, because people said I’m now going to look at my patients in a different way. I’m going to see stuff I didn’t see before. I’m not going to fall into holes I fell in before. And I’m going to have far more control over the work I do than I did before. And the genuine, the genuine, you know, I got bought a lot of beers at the end of the night. Because some of them said, No one’s ever, I’ve been in practice 10 years, no one’s ever told me this before. And I see all the stuff you showed, I know which patient. You showed me that, you know, Mrs. So and so has that you showed me this. I know why Mr. So and so’s crowns failed. You showed me that I know why that implant, you know, crown broke. And suddenly they get it and when they get it, this little light comes on and suddenly run back to the practices and they start seeing these they didn’t see before. And that to me is the epitome of teaching. It’s about showing people something that was never seen before. [Jaz]Amazing. Brilliant. Koray, thank you so much for giving up your time today. I know how busy you are and on holiday as well. It’s so great to have you on and you’re a fountain of knowledge and it’s great to share your passion. Just like you inspired me in 2013 I’m sure you inspired hundreds others now listening, Protruserati about this very [Koray][overlapping converation] and you’ve been fantastic. Both of you. [Jaz]Zak you as well, my friend. Thanks so much, buddy. [Zak]Likewise, buddy. Well play. Thank you, Koray. [Koray]Thanks, guys. Jaz’s Outro: So there we have it, guys, thank you so much for listening all the way to the end, you now know about that dark evil side of a equilibration. I mean, I can count on one hand how many equilibratio I’ve done, because in my previous working experience, I’ve been influenced by hospital based dentistry. And a lot of the TMD literature which is made in hospitals is very much like controversial, like, Hey, don’t do equilibration because this is not effective according to the studies, but the studies themselves are not very high quality. So I do think there is a role like in everything we have to you know, keep our mind open. Everything has this place. Okay? Although it’s not mainstream, I do think a equilibration has a role. In fact, I’m investing at T scan I’ve just bought a T scan. And I can see equilibration becoming more and more into my practice, especially as I take on bigger cases. And as much of a controversial area it is, you have to keep an open mind to it. So that’s my philosophy anyway, you know, I like to listen to everyone and make up my own mind and my own practice. And I think it would be great to contribute to practice or to research one day, I was actually emailing Riaz Yar, Then I said Listen, I want to contribute to research. How can I test my splint theories? How can I produce some TMD data? How can I produce some outcomes based on Hey, can equilibration help? Or can this serve this type of splint be proven for this diagnosis eg myofacial pain. so I’m always thinking about it. So if anyone out there actually I’m just this is my plea to you. If anyone out there is involved in research and practice, I would love to do some of that. So please get in touch with me. Anyway, I hope you enjoyed that. The next episode will be on planning your CPD and not burning out. So you know it’s going to be a cracker. I’ll catch you then.

After the last group function where a juicy bit of dry socket has been tackled, I was again surprised by Dr. Chris Waith that managing OACs was such a simple matter of using your existing tools – there is some super real-world GDP-friendly advice in this episode. https://youtu.be/aHV15R0SNaw Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “If the OAC is bigger than 5mm, you really get into the point where I don’t necessarily think we should be expecting GDPs to do something super courageous at that point.” – Dr. Chris Waith In this group function we talked about: The Classic OAC regimen  1:31 Oro-Antral Communication Management 6:37 Medications for an OAC 8:55 If you loved this episode, be sure to check out the first part! Dry Sockets – How to Prevent and Manage Them? Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome back to another group function again, Oral Surgery, we're doing a three part for surgery with Chris Waith, we already covered dry sockets. And his answer was very surprising to me. This one OACs was a bit more of what I expected to hear. And so we're gonna jump straight in, right? You are now very familiar with these group functions. So how do you prevent and manage an OAC? Shall we move on to now?... Main Interview: [Jaz]OACs. Okay, so, OACs, I was taught at dental school that a lot of times when we take tooth out, we probably make an OAC without even realizing. And it’s a very common thing. And actually the probably heals up, especially when it’s less than x millimeters, maybe that’s four millimeters or whatever it might be. I was also taught and here’s why I’ve been a little bit naughty. So let’s play Zak’s stuff ‘Am I naughty, I get my, if I’m really not sure if there’s an OAC and then I want to start them on the regimen, which we’ll talk about shortly and see if our regimens are the same. But if I’m really not sure, then am I naughty if I get them to pinch their nose and try and blow out the nose aka the Valsalva maneuver, because I was taught not to but a few times, I’m really not sure whether I’m about to start this patient on the regimen. I have done it. What do you think? [Chris]I’d say yes, you are naughty. I mean, my logic is that I think we must close OACs all the time. But 99% plus they just heal. Some of the time will be because the membranes completely intact. And the whole, the communication is actually it’s just a bony break. Sometimes the hole in the membrane will be so small that your body can heal it. If you’ve got a small hole, and you squeeze your nose and blow. Essentially, what we’ve just got them to do is what we’re about to instruct them not to do for the next two weeks, because we know it might open up the OAC. So I would say if you got, if you’re going to check and grab your suction off of your Nurse (so that she’s not tempted to put it down to the bottom of the socket), just get your suction over the top of the socket, either get the light from your loupes or your chair light in a decent position. And just look. And I think if you can’t see anything obvious, it’s not to say it’s not there. But if you can’t see it, that’s good. Because I usually teach five millimeters, I say less than five millimeters, I think you can kind of sit on that. Give them the instructions. And I try and make myself feel better – I put some collagen cubes in the coronal portion of the socket. [Jaz] So do I [Chris] If it’s bigger than five millimeters, you really get into the point where I don’t necessarily think we should be expecting GDPs to do something super courageous at that point. If you were thinking that that actually needs some kind of physical closure. I think if you’re the GDP, the quickest, simplest thing you could do is just take an alginate, take an alginate send it to the lab, just say to the lab this needs to be kind of processed now. So we need a bit of a favor. And you want to clear blowdown, so clear blowdown all of the teeth but also [Jaz] Like an Essix retainer? [Chris] Yeah, Essix. Yeah, so an Essix that grips the socket. So it’s got to be tight over the socket. And the logic is then you put that in and you say to the patient, you wear this 100% of the time with the section of taking it out to brush your teeth while they’re eating and drinking. They haven’t got food and drink going up into the sinus so that you’re trying to prevent them getting a sinusitis. And really you can go two ways with it. One is it definitely needs closing. That’s great refer them but they were that until they see the surgeon or you might say Do I still try and treat this conservatively. So the last one I saw was last summer when one of our associates took a tooth out. About a week later the clot broke down and they started to get some nasal regurgitation and numbed him up and cleaned the socket out but when I looked, the hole was so small that I just thought if I take this tooth out now I wouldn’t close this. So I thought you know what, I’ll put some collagen cubes and then I’ll suture it like I would do but I’ll take the alginate and I got him a blowdown and he wore it for three weeks and three weeks we took it out and everything was fine. Everything that healed over so I think that just protect the socket. Don’t jump into thinking I need to advance a flap or something like that. I think leave that to your Oral Surgery friend down the road and then just give the patient directions. [Jaz]I think that’s very fair. [Chris]I think the thing we’ve closed in OAC when it does need close in most half decent dentists, I think will be able to advance a flap specially if they place implants and things. So incise the periosteum do a buccal advancement flap, but actually there are times when that’s the wrong thing to do. So, you know, the anatomy might be difficult, like they might have a prominent buttress, the sulcus might be shallow, might be seen Symbiotype, it might be a big defect, but all of those things and you starting to think right buccal flap, or palatal finger or you know, something else, and the thing you like, I still don’t see them often enough to make this a really slick process where I kind of sit and think, oh, right, let me just do this. So I think for a general dental practitioner, it’s like, you don’t need to make that kind of decision. Your job is just protect the socket. So get that splint in, speak to your colleague, and then you call the consultant, everything else. And I mean, even going back a step, I think just preempted everything we said last podcast about sectioning the tooth looks after the socket loads more, you’re much more or less likely to cause an OAC or certainly a big OAC. And then even when it does happen, either leave the socket and supports it or collagen cubes and suture it. And if it’s a big OAC that needs closing, fine, take your alginate put your splinting, refer it on. And I think then you’ve got Touchwood all bases covered. [Jaz]I think that’s such great real world GDP friendly advice because you’re right man, you even you don’t see these regularly enough as an oral surgeon to make this like a autopilot kind of thing for you. So yeah, why should GDP is be expected even with implant training to know exactly which is the best route in that scenario definitely sent to an oral surgeon. Makes good sense to me. But it’s a real gem there to take that Alginate impression, get that Essix retrainer made. And then as part of the pharmacological care, obviously, the instruction you give to a patient is not to blow your nose. And now I remember taking out an upper molar at Guys hospital as a DCT. And unfortunately and see the patient when he came back, but I think he sneeze and he held his sneezing. And apparently, like it was an absolute sight, the anchor lining herniated into the mouth. And that I mean, how does he even heal from that, I mean, obviously, the body is remarkable, but that’s not a pretty sign. [Chris]I’ve still never seen a proper antral polyp like that. But I’ve seen some big holes, and I’ve seen some long standing fistulas and particularly the fistulas. If it’s been open for a long time, and they’ve had food and drink going into the sinus, it’s horrible. You know, it’s really full of anaerobes, really smelly. Like, I’ve listened to an ENT surgeon not so long ago. And his advice I can completely get on board with which is if they get to that point, you’re actually, they need to go and see ENT to properly have a sinus cleaned out and have some drainage before they have the OAF close. So from our point of view, you want to avoid all of that just by taking care of the communication and not letting it become a fistula. And my instructions would be just like yours so dubbing the nose instead of blowing it. If they’re sneezing they’ve got to let it out. Rather than squeezing the nostrils. A little bit funny like there are obvious pressure differences like not to go dive in for a few weeks. But also plane travel and I’m bit dubious about. So somebody who’s got a maxillary tooth that’s close to the sinus. I like to know that they’re not flying in the next kind of week or two just in case. [Jaz] It’s good point. [Chris] Then, I don’t massively go into chemicals. Normal analgesic regime, I wouldn’t bother with any antibiotics. You might give them something like Beconase. And like I think I don’t know what yours was like. But when we were undergraduates, we often got told to give them Ephedrine. So Ephedrine nasal drops. Now, Jerry, the ENT surgeon that I was talking about, we chatted a lot about this because he’s very anti Ephedrine. And his logic is that you stifle the blood supply to the nasal epithelium. And in trying to treat one thing you actually create another that you get a rebound disease in the nasal epithelium. So he said for us Ephedrine is either short term, it’s just two or three days or avoid it and go steroids so just go Beconase over the counter stuff. [Jaz]And that’s something that you prescribe. Can we get Beconase over the counter? Is it like [Chris]Any chemist Yeah, or supermarket. [Jaz]How about Sterimar? Are those saline rinses just to keep your nasal passage patent? [Chris]I probably wouldn’t bother. I mean, my question would be what you’re trying to do it for. And really, that’s why I wouldn’t jump on antibiotics. Because really missing there is infected, [Jaz]Even if you’re giving them a suck down, right? Even if it’s like a big enough that you’re gonna go to the suck down and send it to oral surgeon. [Chris]Yeah, I think I still wouldn’t, we might be dubious of an infection, but those antibiotics that we gave them straight off, they’re probably not going to stop that. It’s going to be the physically treating it and closing everything that will prevent the infection. And also if you get to the point where you’re teetering into our way out and they have got some kind of sinusitis, the way that ENT treat that with antibiotics will be very different to our way of treating it. Jerry’s regime, he said, You know, it’s not unusual for him to give people four or five weeks worth of antibiotics, because he says the absorption so poor, that actually they need a sustained dose over a long time. Now, none of us would ever do something like that. [Jaz]So that five days of amoxicillin that we usually give is really not doing anything! [Chris]I mean, I wouldn’t give him amoxcillin, the use of it be something like doxycycline, something like that. [Jaz]Well, there we are, again, you surprised me again, I’m pleased to hear it. I think that’s one less reason to reach for the prescription pad. Amazing. [Chris]I think this is the kind of prevention is better than cure one. It’s like look after the small communication. Bigger one, sit down, splint, refer it on, closer early, it means closing and then try and stop those patients getting away and sinusitis. [Jaz]Perfect, very happy with that. So that’s how you manage OACs. Amazing. Jaz’s Outro: Well, there we have it, guys. Thanks for listening all the way to the end. Listen, if you’re listening on Apple, please give this show a five star rating leave a comment. I love reading them. That’s how this podcast grows. So if you’re watching on YouTube, hit that like button, give us a comment. And I really appreciate that. We’ll see you in the next group function where we cover the dreaded tuberosity fracture like this is the scary one, right? Like this is the kind of thing that you see on social media and the dentist has removed a molar but actually he’s removed like the maxilla with. So this is like the scary one, so let’s wait for that juicy one. Hope you never experienced a tuberosity fracture, but if you do, you’ll be well equipped from this next episode coming. So I’ll catch you in that one.