Protrusive Dental Podcast

When did they change the ingredients of Alvogyl?! It’s the return of Oral Surgery Specialty Dentist and sensible man Dr. Chris Waith – this time to answer our Oral Surgery Complication questions starting with Dry Socket prevention and management! https://youtu.be/QiOJAwxAZE8 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “It will be better no matter what we do, whether we dress it or not, it’s just whether you can live with that timeframe.” – Dr Chris Waith In this group function we discuss: How can we prevent dry sockets? 3:54 Can suturing help in preventing dry socket? 10:43 How to manage patients in pain with dry socket 15:39 Does Irrigation and Alvogyl actually help in managing dry sockets? 19:09 Click for ->Chris Waith’s Oral Surgery Course If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth 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: Hello, Protruserati. I’m Jaz Gulati and welcome back to another group function this time with all surgeons specialists, Chris Waith. Yes from that epic episode on how to section and elevate teeth. Listen, if you haven’t listened to Episode 85, it is huge, because it just gives so much. I wish I had that when I was just one or two years qualified. In fact, let me tell you a story. Kamila. Kamila, you posted on YouTube when you watch the video which got like over 1000 views now, which is awesome. Guys, I appreciate it very much. Now, Kamila posted on one of the comments saying that, ‘Thanks for you know, I discovered your podcast. And thanks for this episode. I was able to on my last day in dental foundation training, I was able to section and elevate a tooth with confidence, and is only possible due to this episode.’ So thanks for epic episode with Chris Waith, she was able to do that, which is just amazing. That’s the kind of feedback I absolutely love. And that’s the reason I keep this podcast growing. So thanks so much guys who always comment and like on the YouTube or if you listen on your commute, I really appreciate it. Now, this episode is very fundamental, right? Like dry sockets. Such a huge thing. Actually, Lucky you. I’ve got Chris Waith to talk about three things over three group functions. We’re talking dry sockets, OACs, and those dreaded tuberosity fractures. So let’s listen to what Chris Waith has say about what’s the best way to prevent a dry socket. And if you are unlucky enough to have a patient’s who’ve got dry socket, how can you manage it? And I’ll be honest with you, I don’t think I’ll be doing what Chris says like on reflection. I don’t think I’ll be doing what he says because it’s a very interesting approach. It surprised me and it will might surprise you. And you may or may not do what he says. So let me know, you know, reach out to me the protrusive Instagram pages @protrusivedental, so it’d be great to connect on there. But let me know what you think about Chris’s advice. Main Interview: [Jaz] Chris Waith, a man who needs no introduction after that podcast episode we did about extractions and how to section and elevate. Chris, how you doing, mate? [Chris]I’m really good. Thanks, man. [Jaz]I’m brilliant. And we were just chatting before I hit the record button. I asked you have had you seen the comments that we got on our YouTube video. And it’s had like over you know, 1.2k views on it, which is great. But overall, over 4000 dentists over the world have listened to that episode. And I sometimes thinking why do I do this? Why do I do what I do. And when I get comments, like I saw, it was amazing. It was young lady, foundation dentist who said that, on my last day of FD, I was able to tackle a difficult molar and I had the confidence to section and elevate and help this patient. And I wouldn’t have done it if it were if I didn’t listen to this episode. So just that was like, wow [Chris] A remote appointment isn’t? [Jaz] Absolutely and I know you’ve been doing some you’ve been a busy boy teaching these skills to everyone. You’re doing like a countrywide tour. I’ll be seeing you in Brighton in a few days time for the Tubules Congress, very much looking forward to that. But today’s group function, I’m probably gonna split it into three, three little bite sized chunks, okay? We’re going to cover in these three chunks. We’re going to cover dry socket, we’re going to cover OACs, and we’re going to cover that dreaded tuberosity fracture. So Chris, I’m gonna hit you straight away because people have heard your intro and yours interesting oral surgery. And how awesome you are, we know already from that episode. If you haven’t listened to that episode that we did with myself, Chris and Zak, all about sectioning and elevating that is going to profoundly improve your extractions come Monday morning, do go back and listen to that. But now hit me, Chris. Dry sockets is an annoying complication. It’s an annoying complication. And over the years, I like to say it’s happened less and less to me. But I couldn’t honestly tell you whether it is just me getting quicker, better, cleaner extractions? Or are there other things at play? How can we prevent dry sockets? [Chris]It is a really a tough one, I think not to beat ourselves up too much. We’ll never prevent it completely. It’s just one of those things that you’ve got an open wound healing in a difficult environment. And some of those patients, they’re always going to have the risk factors that make them more prone to it, which we can’t do anything about. I love having lunch across the road. And watching my last patient walk out and light up after I’ve just spent two minutes telling them not to smoke for as long as possible, just little things like that. But I think going back to the last podcast that the thing that we can do is look after your extraction so make it I mean reduce that trauma as much as you can. Sectioning a tooth rather than just putting your forceps on will always mean that the patient starting off on the right foot. I think once you finish your extraction, just spend a minute with a currette or a Mitchell’s or a dental excavator. Just something in the socket. Get rid of all the little bone chippings, filling chippings, tooth chippings. If there’s some pathology there, get rid of the pathology. And then after you’ve got that point, you’ve got to just think about the blood clot, anything you can do to support that blood clots. We were talking about this on the course this weekend that I just think I’m going to have to pick a month or two, where I just suture every single socket that I put in, because I want to know what my incident rate of dry socket will be compared to when I don’t suture it. [Jaz] And you did this little experiment? Yeah? [Chris] No, this is what I think I’m gonna have to do, because we talk about it all the time. And it’s like when people are saying how to prevent it, I just think really, the only things we can do is make our extractions less traumatic, and support the blood clot. And not necessarily put a sponge in or surgicel or something like that. But actually just suture the socket, bring the side in, try and make sure that the clot stay in there. I think that’s probably all we can do. There’s no evidence for antibiotics or mouthwashes, or anything like that. They’re all hearsay, I think with the exception of wisdom teeth, where there’s a tiny little bit of evidence about pre op ABs, but not enough that I think it’s ever changed how everyone behaves. [Jaz]Two behaviors. I’m going to share with you Chris, that some of my colleagues have suggested. One by the time this episode comes out last week, we had Nekky Jamal from Canada talking just exclusive about wisdom teeth, and I’ve done his little course and whatnot on wisdom teeth, and he’s a huge fan of PRF, right? Platelet-Rich fibrin. Obviously not every GDP, they have access to able to do venipuncture and actually made the good stuff and then put in the socket. A) you do that? B) Any evidence you aware of that, that is a beneficial thing to do? [Chris]I don’t do it. But I don’t do it because there’s not enough evidence for it, to prove to me that it’s worth it. And PRF are really interesting one because the breadth of how people have engaged with it is huge, really, from that kind of scenario, just simple just placing it into a socket to the other end of the scale where you’ve gotten MRONJ patients where they’re trying to use it in disease sockets, and to implant work where people put them in sinuses, across grafts in all sort. It is what is one of those regimes where I think the evidence hopefully will come and it will build up and it might be that we’re sitting on the cusp of something new. Purely if we’re talking about dry sockets and socket so I think the cost and the techniques and the time of committing to venipuncture putting it in the centrifuge [Jaz]and the degree of invasiveness like you know everyone’s not going to have easy veins. [Chris]Yeah, it puts that barrier up that I think it will probably never just work into general practice. [Jaz]I mean I think my colleague, Nekky, he all he does is wisdom teeth, right? Surgical. So for him that surgical background implant stuff. He’s got the kit already, and he’s a big believer in it. Early Adopter. And so it makes sense. I mean, for those who are listening who don’t know what this is, I guess a crude explanation will be taking out the patient’s blood, putting in a spinny centrifuge machine and extracting the Platelet Rich fibrin hence the term and looks like this yellow jelly, doesn’t it? [Chris]Yeah. Like for sockets. But PRF make sense, it’s like, biologically, it’s that slightly M rich version of the factors that we want to promote healing. If we’re just talking about simple extraction sockets, I think Well, we’ve got hopefully, platelet plug in the socket, with or without PRF. So on a simple level, and for the simple level for the gdps out there, I think you know, sometimes don’t get sucked in by equipment, fancy techniques. It might be that your wisdom teeth and your implants and your sinuses benefit from it, but actually basic extractions, I’m all for keeping it simple, I think. Get your suture technique, perfected suture a little bit more, keep that clot stable. Give all your instructions that you can to the patient. And as certain as I can be, I think that’s enough to bring your incidents down. I always think such word that I don’t get a massive amount of dry socket. You’d expect particularly the type of extractions that I sometimes have to take on that my incidence might be a little bit higher because the probably a bit more traumatic [Jaz]Any percentage to go by? You know, if I was saying at 1%, 5% anything you can give in that regard? [Chris]So I always say that if you look at all the journals, you’d have it in your head that about 1 in 20 is right. I don’t think ours is that high. I think mine is probably like 1 in 75, when I look at it. Now, it’s difficult for me because I’m referral base, I know that I probably missed some of my follow up. So it might be a little bit higher than that, because they may go back to their GDP for it. But we try and call our patients, so we call a day later and a week later. So we’re trying to make sure that we mock up anything that’s happened that we might not have known about. But think about 1 in 75. And I don’t do anything too special for that. I just clean the socket, make sure it’s cluttered and when it needs it, suture it. [Jaz]So let’s talk about the suturing in this as a wrap up this prevention side about you know, what, what is it potentially that we can do. Suturing, once the principal who is very much like really pro like after you take out a tooth, turn that secondary healing into primary healing, like he was really going chasing the primary closure to the extent that he was actually releasing the periosteum and trying to cover over. Is there a real massive benefit of doing that? Or should we just let the sockets heal by secondary intention, which they do quite routinely? [Chris]Yeah, I wouldn’t go as far as that. I think if you go to that extreme, what you’re trying to gain to get your socket to heal. I think you’re losing by disturbing your normal anatomy. And if you’re advanced in the flat, really you may be obliterating the sulcus and making your prosthetics more difficult down the line. I’ve all before, I’d be all for trying to keep it as natural as you can. But I think I’d be suturing, it’s not so much that you’re going for primary closure, you’re just going for stability. So something like a horizontal mattress across the middle of your socket, actually bring the edges of your socket together, just so there’s something physical to hold the clot on, I wouldn’t be going for anything more than that, I don’t think. [Jaz]I think you summed up well to get that stability. So you haven’t got something that’s too floppy or moving, you know, any moving parts just want to secure the area. So that’s covered it perfectly in terms of what we can do in our best intentions, prevention. But like you said, it’s one of those things that can’t be avoided and do what we can in terms of a clean surgical technique to to maximize our chance of not getting that dreaded phone call. Now, when we do get that dreaded phone call, and your patient has got dry socket, Our duty is to help them and I want to really help this patient, you see these patients in absolute agony. So what is the the gold standard way? And what is I mean, is what we’re doing okay, I’ll just tell you what we usually do a lot of me and my colleagues, you know, patient comes in, sometimes we’ll just rinse it out with the saline, and then just stick some good Alvogyl in it. And that’s it, should we be doing more? Because I read some colleagues saying that, ‘Hey, you got it, you’ve got to make it bleed.’ But I’m thinking if I’ve got to make it bleed, already they’re in pain, then are we supposed to be numbing out these patients to actually, you know, produce a new blood clot? [Chris]Yeah, it’s a really difficult one, I mean, my way of approaching it, I’d go two ways, I’d look at what you do beforehand, to get the patient prepared, your instructions afterwards, and then what you do when the patient’s in the surgery. So I think beforehand, the most sensible thing is as long as they’re okay, taking them, get the Brufen, their NSAIDs on board before the extraction makes loads of sense because it helps your anaesthetic work better. But also, it means that pain levels controlled as the anesthetics wearing off, which is loads more comfortable for their body, rather than letting them get a big blip of pain that they then have to try and blast to control. So pre emptive NSAIDs, great, get those on board if you can, after your extraction, and particularly if that patient ticks a few of the boxes. So longer, more difficult extraction mandibular, ladies more than man, oral contraceptive, the pre existing infection, all of those that I’m ticking, I think, right, just spend a couple of minutes now with this patient and just say ‘So this is what I think is normal. This is what I think might be abnormal. And so two, three days down the line, any increase of pain, struggling more with your analgesia give us a call. ‘ But I’ll try and hammer home. How important it is for them to respect taking the full dose of analgesia so the paracetamol and ibuprofen for a few days, so that when they call if they’re not doing actually I might just hammer that home again and say, ‘Right, so this is the important that you need to take your paracetamol and your ibuprofen regularly.’ Because a lot of the patients just get in that analgesic regime correct will be what they need without me putting my hands in the mouth or doing anything. [Jaz]I think that’s so true because a lot of people are like me I’m like really anti painkillers. I have to be like literally having the worst man who ever or the worst tangle ever before I even reach for a paracetamol more but a lot of our patients you know they’re the same so for whenever I you know when I have done on my shoulder and I literally was on painkillers for one day, but I’m pretty sure my orthopedic guy probably wanted me to take it for longer. So you’re right, you’re totally right just to reinforce that and the regimen I like to recommend is 600, Ibuprofen 600 milligrams Ibuprofen and a gram of paracetamol and then to even taper that ibuprofen up if needs be in his worst case, and I’m thinking more in irreversible pulpitis to 800 milligrams, but make sure you eat something beforehand. But then obviously don’t exceed the four grams during the day for paracetamol. Any comments on this regimen? [Chris]Yeah, I mean, there are two things. One is just from a pure effectiveness point of view, but one psychological for the patient. Like from an effectiveness point of view, if you’ve got a dry socket, and that severe pain with it, you do need to up the game with the analgesics, I think at least 400 milligrams of ibuprofen, but probably 600, 4 times a day, just make sure they’re having some food later on in the evening if you’re taking some before bed. I think as well as that, if you start to get to 600 milligrams, which is a dose really that we can prescribe rather than saying to them go to the counter, psychologically, a lot of patients are tuned in to come in to you for a prescription because in the past, they will have just been given some antibiotics, which is wrong. But you can still give them the prescription to say well actually you do need a stronger medicine and this is it. But it’s analgesics and we have loads of patients that come in for it. And I mean, there is a little bit of evidence that there’s some kind of bacterial component, but a dry socket isn’t an infection. So it’s trying to say to somebody, and I mean using your analogy, but not so much shoulder, I just say twisted ankle slightly. If you’ve twisted your ankle, it’s really sore. But it’s very hard not to aggravate it because you’ve got to walk on it. So you’ll be taking painkillers for a few days, and then you’re rested a little bit more when you come. If I gave you antibiotics on that day, when you twisted it, a week down the line, your ankle would feel better, but it’s not the antibiotics. It’s just the fact that your soreness and swelling is gone and you’ve not been walking on it and this is the same in your mouth. The difficulty is that every time you speak, every time you eat, you’re aggravating the socket, you’ve just got to respect the fact that it takes some time for those analgesics to work. But if I gave you antibiotics on day one, and you’re better in a week, it’s not the antibiotics that have done that, it’s just Mother Nature, it’s just nature taking care of socket and you getting over that kind of severe spell. The other thing I say is about picking scabs. It’s like I mean, our youngest right now has a massive sore on his knee because he’s had this scab for about five weeks and he just keeps picking it and you know you try and say to them Just stop it, it won’t heal properly. And that’s dry socket and it’s like, you know your scabs got in, your clots going into the socket. So now you’ve got that horrible sore spot underneath which isn’t fully healed, only it’s worse for you because it’s in your jaw, it’s not even your skin so that’s why it’s so sore. So that if they’re coming and you know people talk about dressings, I wouldn’t necessarily jump into dressing something unless they were really struggling you know, quality of life struggling to sleep, struggling to function, and they just need something to break that pain cycle so that then their analgesics are working better. I think for that patient that’s we’re not irrigate with some saline and put some Alvogyl in. I think for everybody else I would try if they’re on board just to say you know what, you’re going to need your analgesics for a little longer but in you know, 7 to 14 days it will be better no matter what we do, whether we dress it or not, it’s just whether you can live with that timeframe. [Jaz]This is when they’re in the chair, so this is when they’ve come to see you so you’re telling me that patients come to see you and for dry socket you’re not always reaching for that Alvogyl and the rinse, is that what you’re saying? [Chris] Yeah [Jaz] Wow, that’s another shock to me. Just like you shocked me the last episode about you know using the fast handpiece to section teeth, this is another shock because it’s so engrained in what we were taught and the way all my colleagues practice is like you know, okay dry socket equals and even the nurses are primed for it. Oh, we got a dry socket. Let me get the Alvogyl ready you know. [Chris]And don’t get me wrong. It’s definitely got its place but I won’t necessarily jump on it straightaway. I don’t want to sound too heartless with it. But like my old maxfacts consultant used to say he was like you know, in two weeks, your dry socket will be healed whether you’ve dressed it or not [Jaz] Very true [Chris] It’s just which path you take to get there. So if they’re analgesic controls doable, and if they can live with it actually just let Mother Nature take care of that one. It’s when their analgesics aren’t really recovering it. And the suffering, we just need to break that pain cycle before it gets too bad. Those are the ones that I’ll irrigating dressing like, I mean, what you said, for the people who aren’t already in saline instead of Corsodyl. Shouldn’t be putting Corsodyl in sockets because there’s been a couple of anaphylactic deaths with off license use of chlorhexidine. So irrigate them with saline, part of my reason for changing as well as that alvogyl years ago, change to alveogyl which isn’t, I don’t think, as effective because they’ve taken out the butamben and the iodoform. And those are kind of local anesthetic components, which we definitely used to see a big difference almost straightaway, when you applied it. My take on it is, if they really need that help it’s there for them. If they don’t, though, we’re just putting a foreign body into the socket, while it’s trying to heal. And I’m all for trying to avoid doing that. Because I think sometimes you actually, you delaying the healing a little bit more. And we’re really, we’re trying to speed it up, I can see why people say about trying to promote some bleeding and getting it. I don’t do that, but I can see the logic with it. And I think it probably comes down to your patient again. These patients with mandibular teeth who smoke, you take the tooth out, and the socket doesn’t bleed. There that first time while they’re anesthetise, that’s when you make it bleed, go to down on the socket little bit and try and encourage, then I’ll suture it and keep the clock there. I think if you don’t do that, and then then they come back with dry socket, well, that was almost inevitable for you to have to numb them up again, and then go to down on the socket I think, oh, we could have maybe done that last time. But there’s also, there’s a little thing in the back of my head that I think you know, we don’t completely understand the pathogenesis of this. There were all these little elements that we think play a factor. And I think the worst thing that could happen, I mean, I’ve been treated if anybody does do this routinely, I’d love to know how many of those people come back with a second dry socket because that clot breaks down. Because I just think it’s the same person and the same risk factors. The same socket and or, you know, whatever we change put in that second clotting. I can see why they because there’s a physical, a physical barrier to the socket, and it’s the one that’s supposed to be there rather than Alvogyl or something like that. And I think even for alvogyl, we still sometimes have to anesthetize the patient because it’s so sore to irrigate and place it, so it might be that every anesthesize does it make more sense to try and make it bleed again? I don’t think there’s a wrong or a right answer there but I’m much more in favor of natural healing than unnatural healing. And like I said, I’m not trying to be mean to my patients. I’m just trying to get them on board with my way of thinking. And I think whenever we see see on the groups there are loads of people or I think numb people up and currette the sockets and make it bleed again. And I think you do that unless you’ve been doing it for a long time and it worked for you. They that’s certainly anecdotal. I’d love to light no fingers on it. But I think if people do that they must know that for them it works. For me doing nothing, works a lot. [Jaz]I’ve definitely learned something that and even about the whole Alvogyl versus Alveogyl like Wow, I didn’t even realize that they took away the good stuff, that iodoform and butamben. This is news to me, you know, I didn’t get that memo. Jaz’s Outro: So there we are. I definitely have less faith in stuff that’s in our drawers at the moment now. And maybe now I think I might do the same thing as you and just give them comforting advice. Make sure you’re on the correct analgesic regimen and some reassurance so that is very useful, and I’ll catch you in the next couple of group functions coming very soon.

I think we owe it to our patients to a know some fundamentals of full arch implant Dentistry, even if you do not currently place or restore implants. Make a big cup of coffee because this is one of those longer episodes! I am joined by Restorative Specialist Dr. Harpal Chana to breakdown FP1 to RP5 and exactly what GDPs should know about full arch implant prostheses. https://youtu.be/QY_3SZKdc0U Check out this full episode on YouTube Protrusive Dental Pearl: Instead of booking patients for a ‘fit appointment’ for crowns or bridges, rebrand it to ‘try-in appointment’. This takes the pressure off of you and your technician – in the small chance that things are not perfect, you can correct it and book their fit. If everything is good at the ‘try-in’ you can go ahead and fit your work definitively. It’s just a good way to manage expectations and reduce the chance of disappointments and surprises. Need to Read it? Check out the Full Episode Transcript below! As Promised! Infographic summarising FP1 – RP5 classification In this episode we talked about: Dr Harpal Chana’s journey to full arch dentistry 8:19 The initial stages of full arch complex implant reconstruction 15:18 What determines a terminal dentition? 23:52 Implant Reconstruction Options for GDPs to know + Classification 31:03 Difference between Implant retained and Implant Supported 37:10 How many implants? 40:56 Research about the quality of life that impacts clinician’s decisions 48:40 Learning how to place the first implant 56:56 Advice for dentists who wants to learn implants 1:08:00 If you liked this episode, you will love to listen and learn about Implant Assessment for GDPs: from Space Requirement to Ridge Preservation Implant Overdenture and All-on-4 course Sponsored by Nobel Biocare 12-13th March 2022 at Elmfield House Dental Education, Teddington, London. Hosted by – Harpal Chana, Harjot Bansal, Pynadath George, Manish Patel, George Xirogiannis, Hannah YoungSummary: Beginners course for fixed and removable implant retained and supported bridges and dentures. Cover implant planning, bone grafting, prosthetic planning and execution, dealing with failures and maintenance of appliances and implants. Register your interest by emailing: info@elmfieldhousedental.co.uk Click below for full episode transcript: Opening Snippet: And one of the procedures they always used to make me do was to do a workup make them a new set of dentures. And it was interesting that half the patients I made new dentures for say, thank you very much. I don't need implants now. I'm actually quite happy with these. And they're much better than they were before. I really don't think I want implants. So okay, maybe a lot of these patients don't always need implants. They just need to have well fabricated dentures... Jaz’s Introduction: FP1, FP2, FP3. Do you know what I’m talking about? No, I’m not talking about filtering facepieces ie FFP3 masks like we’re all experts now on FFP2 masks and FFP3 masks, unfortunately, due to the COVID pandemic, but do you know what I mean, when in the context of implant restorations, what I mean by FP2 and FP3. Well, I’m embarrassed to say I had zero idea when it came to talking to our guest, Dr. Harpal Chana, who’s a consultant restorative dentist, and the pinnacle of full arch implant prosthesis like this guy does some most complex work. The kind of work Harpal Chana does is based on referral work, complex full arch prosthesis work. So it’s a great honor to have him on the show today. He is someone who I’ve looked up to for many years, like all the clinicians that I have on the show, I had a impromptu lunch with him in Pizza Express actually just behind his practice in Denton, when I was absolutely starstruck. I was like one year qualified, and that then I knew who he was and I knew he was about and I went to a few more of his study clubs in the local area, and he just has a brilliant clinician. What he has to share today is all about the classifications like basically his implant classifications, and we’re gonna delve deeper into what a GDP, what the average GDP ought to know about full arch prosthesis like okay, fine, you may or may not be placing implants, you may or may not be restoring full arch implant dentistry, however, do we owe it to our patients to understand what FP1,FP2, FP3 means, what the surgery might involve, and to basically be able to give our patients more information rather than just take a massive step back and say, ‘You know what, I don’t know speak to the specialist. I don’t know, you just speak to a specialist.’ I think we can do better. So I’m hoping this episode will benefit you as much as it benefited me. Sometimes you have to just be straight up honest about what you do and what you don’t know about. So I know a fair bit about occlusal appliances, resin bonded bridges, managing tooth wear, occlusal design, what I don’t know much about is implants. Okay? So this is like my big weakness area because I don’t place but I think like I said before, I owe it to my patients to learn more. So this is part of my journey. And I hope I’m sharing that journey with you and you will find benefit from. For those of you who are listening on high quality speakers or headphones, you probably realize that my voice sounds a little bit hoarse at the moment, this is because I just recently I was at the Tubules Congress, that’s called the Dentinal Tubules Congress. It’s the best dental event of the year. There was Ed McClaren, Marco Veneziani and some of the Great Bridge lectures that I absolutely adore the specialist which actually inspired me so much. And you guys, so many of the Protruserati were there, it was so great to see you. I’m not going to begin to name all of you people that I met for the first time and we’re reunited with for many times over. It genuinely felt like we used to have these events called the BDSA as a student with the British Dental Students Association. And they were the best nights out like we’d go to like a dental school, maybe like Manchester, and we’d all meet up and it’d be the best thing ever having dental students from every uni around the country, it really had that great positive, inclusive vibe that only a Tubules Congress can offer. So save the date in your diary for sixth and seventh of October next year. Location to be confirmed we’re thinking maybe Midlands, so we’ll keep you updated on that but it was so great to see and speak with every one of you. Thanks for saying hi for those of you who listen to podcasts and it was just, it was actually really weird people coming up to me, dentists coming up to me and you know you are guys thanks so much, saying, ‘Let’s take a selfie.’ I was like ‘Yeah, cool. Let’s take a selfie.’ Or some of you coming up saying ‘Oh, I’m just a massive fan girl or whatever.’ That was really weird for me but it was just absolutely amazing. It’s such a great time. It was lovely to see every one of you and I hope that we can continue to meet up in face to face events. My next one will be the BACD, Pascal Magne, 12th of November, that sort of the next so if you’re there and you listen to the podcast please do say hello. The Protrusive Dental Pearl I have for you today is non implant because I can’t teach you anything implant related but what I can teach you or share with you based on what _ birth shared to me many years ago there’s probably a BAAD, British Academy of Anesthetic Dentistry meeting about four, maybe three four years ago now. And a really cool thing he shared with me about the protocol for placing a crown or placing indirect restorations. He encouraged me to stop booking my patients in for a fit appointment because that puts a lot of pressure on you as a dentist and on your technician especially when you start doing more complex cases so what I mean by that is sometimes you may have had it before where you sit the crown on and the either the occlusion is way off or there’s an open contact or there’s an aesthetic compromise and the patient is not happy. So in those scenarios, it’s like ‘Oh I’m so sorry we have to remake this now.’ Whereas, the better way to do it what _ taught me and I’m happy to share with you is to tell your patient that ‘Hey, this is not a fit we’re going to do a try in, so it’s a try in appointment. It’s just a change of name it’s really as a fit appointment but you’re changing, you’re framing it as a try-in appointment, and if everything goes well the aesthetic’s good, the fit’s good, the contacts are good and you’re happy with the level of work, then you will go on to cemented that day, but if there’s anything that you’re not happy with or if anything the patient not happy with that’s a perfect opportunity to say ‘Okay, this is what we learned from today’s try in, let me get this corrected for you at the next appointment we will do another try or a fit.’ So 19 out of 20 times you’d probably go ahead and fit anyway at that appointment but it’s just the labeling of the appointment which I quite like. So sometimes I have a tricky case or a complex patient and I think I will brand it as a try in I know some dentists who always brand it as a try in. It’s about the way that the patient perceives that to be but I think there’s merit in using that terminology for your appointments. So I hope that communication gem was useful. Hat tip to give him the birth of sharing that one with me some years ago. So let’s join Harpal Chana and learn all about full arch implant dentistry. Main Interview: [Jaz]Harpal Chana, welcome to the Protrusive Dental podcast. How are you? [Harpal]Very well. Thank you, Jaz. Very kind of you ask, I’m fine. I hope you’re well as well. [Jaz]Yeah, absolutely brilliant. We just had a little chat before we started the recording about how COVID has affected our different worlds. And, you know, it’s been tough and we’re still you know, while we’re recording now, it’s still ongoing and the extreme pressures, [Harpal] Absolutely [Jaz] but I think we are, you know that we’re getting vaccinated and stuff. Hopefully the end is in sight. And we’re having a little chat about that. But yeah, health is wealth as you know. And that’s the main mantra. I wanted to do a small introduction for you for those dentists around the world listening, and then I’m going to get you to introduce yourself. So Harpal, we met at a Pizza Express many years ago, outside. [Harpal]I’m not a cheapskate I would have taken you somewhere else. Honestly. [Jaz]It was geographical convenience. I’m sure if it was mentioned it was still gonna take that. [Harpal] Absolutely [Jaz] You practice in Teddington, where you practice. I always go Teddington. Now when I go to the Nando’s I always see your practice and say yeah, Harpal works there. So that’s your sort of claim to fame for me as well. But you know, you’re a well known restorative consultant, you do a lot of advanced cases, when I think of zygomatic implants, I think of you. Now, I don’t know much about zygomatic implants. And you can help us a little bit with that. But even more, we’re going to dumb it down even more to just fixed or full arch cases for the GDP, right? So GDP is that aren’t doing them or are starting to dabble to give us some insight so we can better inform our patients. That’s the point of today. And I can’t think of anyone better than you who’s so vast experience in all forms of full arch cases. So tell us how did you get involved with full arch cases, a little bit about your sort of history as a you know, restorative consultant, how much of that, how much time you spent in hospital now versus practice? Give us a flavor of that kind of stuff? [Harpal]Oh, yeah, thank you, Jaz. Well, my experience really is from a general practice perspective. I started life as a general practitioner, I worked in general practice pretty good four years actually, but I was very keen and hungry to learn. I was very much keen on fixed and removable prosthodontics. I sort of one area I decided to sort of focus on really and a little dabble in the early days of orthodontics and although I thought that was my chosen career pathway, I soon learned to actually do to relapse problems that it just didn’t tickle my fancy so it was a big awakening and I, you know you’re finding your path in your early careers as to what you like and I’ve always enjoyed fixed and removable prosthodontics but there’s always something about it that I didn’t quite understand and I was very keen to do the MSc in fixed prosthodontics at the Eastman so actually a year or so after qualifying I started to apply to Guys and the Eastman and no surprises I didn’t get in straightaway because you know the competition is quite high. I hadn’t had fellowship and my background is very much general practice but I’ve played it on and I continued applying and third time round I managed to get in and thanks very much to great mentors actually at that time I was mentored by people like Martin Sein, Kash Uhbi as well. Kash, I’m sure you know off as well a great guy and Martin Kelleher actually who was my local consultant to Kings and I used to take a lot of cases over to him. Just to discuss how to manage them because it was like a great Enigma to me, I didn’t know how to do a full mouth reconstruction. So a lot of wear patients and I wasn’t quite sure how to manage these cases. So I have a great rapport [Jaz]Harpal, I just want to sort of interject now actually. You actually pass the baton along yourself. You mentioned Martin Kelleher, Kash Uhbi, people who inspired you and whatnot. But some episodes ago I had Richard Porter on and he mentioned you as a mentor that you inspired. So you know, it’s great that you were inspired, but it’s also wonderful to know that you have also mentored and inspired other great clinicians. So you know, it’s, you receive and you gave. It’s fantastic. [Harpal]Absolutely, I you know, I think what Martin’s always taught me is actually education is one of those things that it’s a never ending sort of curve of learning basically. And half the education is actually getting people around you to discuss things in an open fashion so that you can clarify things in your own mind. And I think Martin has great at that and he still is I know he’s retired but I still have contact with him and he’s still quite inspirational on that front. So I’m glad other people are taking on board what I’ve learned basically over the years and you know, the baton gets passed on from generation to generation from that sense, but yeah, now going back to the Eastman, I finished my course there and you know, it’s one of those things I finished now for I still have all these questions, you’ve learned a huge amount, but it actually just opens more pages for you that you don’t really understand or don’t really get clear in your mind at the end of it. And so the hunger was there to get more and more information. And, thankfully, actually, I managed to carry on at the Eastman for about six to nine months as a registrar so I was able to complete more cases. And thankfully, an opportunity opened up as a specialist registrar at that time in restorative and I thought, Well, yeah, why not? Let’s give it a go. It’s not something I intended to do. But thankfully, it was the right pathway for me, I think, and it just opened a whole new avenue of further doors to explore and improve my education and understanding of fixed and removable prosthetics. So yeah, I get the StRs in restorative dentistry, and I credited over 20 years ago now. And, again, soon as I got appointed as a consultant in restorative dentistry, one of my links used to be queen Mary’s Roehampton, which is now closed, so you probably never heard of it, which is not a million miles away from Kingston, but it used to be quite an epicenter actually, for maxfacts prosthodontics since the Second World War and a lot of research was done there. And that’s when I first came across Peter Blenkinsopp who’s one of the maxfact consultants, and Professor Bonemark, who used to come over roughly once a month and help do these rather large reconstructions. And that was my first ever experience [Jaz]And you had exposure directly to Prof Banemark. [Harpal]We were in theaters with him and an operating it was you and he was a very open guy. I mean, you know, you were half the time mesmerized by his presence. But he was actually a very down to earth clinician as well though he was not a dentist, actually, or even a maxfacts surgeon. He could relate things very, very easily to the maxfacts field and dental field. And I never quite understood that I never had the chance to really ask him either. Why did he explore a dental route? It’s, for an orthopedic surgeon, you would have thought someone would have been thinking more along his specialty lines. But just shows you how great a man he was. He was very interested in dental alveolar defects and hence the relationship with Peter Blenkinsopp and he had an honorary fellowship appointed for him as well so that he could actually work in the department. And he brought a great amount of experience and wealth to our department. So much so I actually got the plaque and I put it on my wall actually at the practice when we sadly closed down because like most great things in the NHS, things move on. And the services got pushed elsewhere basically and we ended up fragmenting some of that service in the end. So that’s really where my interest in implant reconstructions sort of came from mostly cancer patients, atients who have large maxillofacial defects, missing half their face, basically I’m working with some great prosthodontist Martin Kelleher was there. He’s one of the first people who just threw me in at the deep end. There you go, you know, get on with it. And it was a sharp learning curve basically, at that period of time, and zygomatics at that time. [Jaz]And What percent of your work now is full arch complex implant reconstruction and what percentage of it is, is the more initial stages of your, you know, full mouth traditional reconstructions? [Harpal]Yeah. At the practice, I spend roughly sort of 60 70% of my time at Haddonfield house where I take on a lot of referrals basically, on patients who have miserable time with dentures, or they present with a lot of tooth wear I don’t actually have a lot of clinical time available now for true restorative dentistry, I have to say, hence why I know you asked me initially whether I talk about gold onlays, because that was my baby, you know, 20 odd years ago. But actually, I do very little of it now. And so much so that actually I’ve got great people like Harjot and Manish at the practice, who are also at the Eastman. And they’re pretty much at the forefront. So if a patient comes in with a lot of tooth wear and need a full mouth reconstruction, I still assess the patient, I still see the patients jointly with Harj and Manish and we jointly plan it together so that I don’t lose touch and that sort of thing. But by and large, a lot of that work on teeth anyways, is managed by the prosthodontist at the practice. My sort of interest is when they’re missing teeth, and having a debate, we have lots of debates at times, you know, when is it the end of the road for those patients with failing teeth? What is a terminal dentition? And that’s quite a difficult question to answer sometimes. And hencewhile we do like having joint consultations, because I may have my own views. Manish may have his and as well as Harj and we sometimes see the patient join me just to work out what is save-able and what needs to go. [Jaz]I don’t think that happens enough in private practice, because I can see it happening more, certainly meetings in a hospital based setting. But in a private setting, I don’t think it happens enough. And I think we need more of that it’d be great to do that. It’s just, you know how it is the way the business works, the way the diaries work, it can be difficult to arrange it. So I know I’m going off tangent, I just love to know, a couple of minutes on how do you actually zone everything so that you have these opportunities to have multi disciplinary sort of a meeting about a patient? [Harpal]Well, as you say, it’s extremely difficult everyone’s part time, you have to make time available for it to be honest. And the interesting thing is, even with referring dentists, I do try and encourage them to come along, I’ll try and fit around them to some degree. For example, you know, we get quite a few patients referred from Nick Charter as practicing stains. And he always wants to be there at the consultation, I say ‘Absolutely right, it’s essential that you are because often you’re doing the prosthodontic working in tandem with us.’ So it is difficult at times, and we have to sort of throw around our diaries and you know, patient has to accommodate us as well. But we normally make it work, you know, may have to work in an evening some time with it, or late nine o’clock, to see a patient join me. But that time is so valuable, because you can iron out so many problems actually, and we’re all on the same page. And that we all know what each other’s roles on. Ultimately the patient gets, I think a better service by and large. So they will often accommodate that sort of wish. If there are patients that are need to be seen at a particular time, that’s you know, that’s the only time available. If I can’t make myself available to do it for whatever reason I’m doing an NHS clinic, then we just have to impress upon the patient that actually if they want the best outcome, they have to work around us to some degree. And more often than not, they will accommodate to our desires. But really, it’s about given [Jaz]Especially in the nature of the complex work you’re doing I guess these patients are a different beast to your normal patient who doesn’t have as many problems though the scale their problems are not as big and the type of treatment will be a bit more simple. I think these patients that you see, I have seen many dentists many specialist in the past and they need a major reconstruction Henceforth, the importance of having that team approach arises more. Now, Harpla, you mentioned the terminal dentition. Now I was actually going to ask you this as the last question, but I think it will flow so nice if you don’t mind me asking you this. When I was a couple years qualified, I went to an implant based lecture in Sheffield and I was absolutely shocked and at that time because of my lack of experience I was disgusted by what I saw, because what I saw was photos of patients. And when you know, their full face photos, when they smile, they had teeth in their own teeth as ‘Oh, brilliant, they’ve got their own teeth.’ Okay, I’m in my head, I’m treatment planning, you know, a bridge here, a bit of periodontal stabilisation, obviously, in the reverse order, maybe a partial denture here, and the patient will be happy or a couple of implants. But then what I saw was a full clearance and then a full arch, a beautiful, full arch reconstruction implants. And at the time, I just couldn’t fathom it. I didn’t understand, right, it didn’t make sense to me. But later, it made more more sense to actually and you can correct me if I’m wrong and elaborate on this, that if you have someone who’s got severe periodontal bone loss, and if you just let that continue and continue and continue, you’ll get to a point where implants may not be a possible option anymore. So I can see why it’s such a tough decision to deem someone as a terminal dentition and decide that actually, we need to start fresh by extracting all the teeth so I there was a huge shock to me. So can you expand a little bit more about that, for dentists who, to help them decide where at what point is someone terminal that they should be considering a reconstruction like that? [Harpal]Well, you know, Jaz, that’s a really good question, but it’s actually a really difficult answer at times as well because you, I can get 10 people in a room and I can show them radiographs and put a clinical scenario together. And you can ask 10 dentists, including specialist periodontist, and you can ask them, you know what stages this patient terminal and you will get 10 different answers, because no one really fully understands and grasp what a true terminal dentition is. For a periodontist, for example, they might be hanging on for sort of three to four millimeters of bone. And then there may be others who in fact, I had an interesting patient only last week actually who came to me for our third opinion. And he was missing his posterior premolar and molars in the maxilla. And he had six remaining upper anterior teeth, which had about 20 to 30% horizontal bone loss actually and he’d been around the houses and he said you know, I’ve come to the conclusion I’ve got very little bone in the posterior it makes it I’ve been told I just don’t have enough to consider implants. And I’ve been told that sinus lifts are all you know are possible, but I might have to wait a year or two before I can have the final reconstruction. I’ve decided I really want my front six teeth out. And I’d like to have this all on full type of reconstruction. And I have to say I this is a patient telling me that he felt his teeth were terminal. They were quite rigid, they were quite firm. And I said well, like you know, I don’t agree with you. I don’t whoever’s told you, that is certainly an option. But you know, there’s mileage in those teeth, there’s possibility that those front teeth could give you another 20 years of service with good maintenance. Your problem is at the back, you know we can fix that by ever means. But the criteria for terminal dentition is so variable and I can, I certainly have had joint consultations with periodontist to I’ve got very upset when I’ve said you know the patient’s not happy with the teeth are loose, you know, they’ve got 70% attachment loss, there’s not much bone remaining back in the maxilla now, you know, this is probably the time to deal with it. And sadly, my suggestion may be to take some of those teeth out now. And while they still have bone to consider implants. Before it gets more complicated. It’s never, they can always consider [Jaz]Well, Harpal like with anything, I thought you’d give me a magic number. Well, I know I didn’t think that I was secretly hoping you’d say okay, the rule is if there’s 70% bone loss and you got X number of teeth, the formula suggests that you should remove all the teeth and head for implants, it’s never ever in dentistry ever going to be as simple as that. And I think you’ve just summarized it well, that actually it’s a gray area. And this is where you need multiple inputs inside, along with the patient’s values as well. But what determines a terminal dentition. So I don’t envy you at all in these decisions. You have to make such a tough decisions. [Harpal]Oh yeah, it can be tough. And sometimes we have real arguments with it, which is actually why I like having joint consultations because I’d like to argue my case. It’s nice to hear from other people’s opinions, you know, Harj just coming along the scene and training quite nicely and he sort of exposed to some of this times and he asks pretty simple questions as well as Why are you taking them out? And why is somebody else the periodontist wanting to save them. And I said a lot of it is subjective experience of how we’ve dealt with things in the past. And there is no magic cure for a lot of these patients. You know, if the patient may have terminal periodontitis, they may well end up with, you know, Peri-implantitis in the future. And that’s something else to bear in mind. It’s not as if the problem stops there. So, you know, it’s really understanding the patient’s perspective and what their goals and objectives are. And sometimes if they’re a complete tangent to yourself It can be a real challenge. I certainly remember presenting a case years ago which actually Simon Sharda I’m sure you know, used to work in our practice and we sort of jointly soar together and she had quite much periodontal disease. Lots of consultation was about three or four consultations with only decided the interpretation of very gummy smile, high lip line, you know, short upper 70-80% bone loss teeth that are loose, ex smoker. And she wanted to avoid wearing dentures. And you know, it really took a very radical decision, we took everything out and put implants in and gave her what I considered a fantastic result. And so, so did she, she thought was a brilliant result. And I presented this at a local PDA lecture group. And I have to say I was quite shocked the amount of attacks from periodontists, you know, periodontist said I could have kept those teeth going for another 5-10 years, you know, you just needed to section some of those teeth and keep some of the roots out and the bone. And you could have spent the others and I said, Sure, you absolutely could have been, but we wouldn’t have been wrong. But a lot of this is discussion and debate. And ultimately, the patient would still have a poor aesthetic result with a high lip line. And once you start getting recession andn the horrible black triangle spaces, the patient can live with that, that’s it, there’s no harm in going down that avenue. But once you show patients photographs of what their teeth are going to look like, once you’ve had a extensive course of periodontal treatment, and all the horrible gummy, black triangle spaces, I said they may not want that. So it’s really part of your consent process. And if the patient says to me, I don’t mind. You know, I’d rather keep my teeth going for as long as possible. You’re not gonna accept the fact that there won’t be pretty, but they’re my own, that’s absolutely fine as well. There’s no hard and fast rules about it’s about tailoring the treatment plan to what your patient’s wishes and desires once they fully understand all the options. And I think that’s the crucial take home point really, for general dentist, this is actually understanding all those options yourself and laying it on the table for the patient. So these are all the various treatment plans that we could consider. There are pros and cons of each. You may not be the right person to do the full arch reconstruction. That’s why we think mentoring is a good thing so that your patients can still have a course of treatment. And we work jointly with the dentist as well so that they understand the reconstruction element. And often do it jointly with us [Jaz]Harpal, I’m just imagining the how thick your patient letters are like they probably like a each patient gets a book a volume of all the options, explanation. [Harpal]I’m trying not to make it too thick to be honest, because like most things, you know, I probably write fewer notes than most dentists, surprisingly. And the reason as I want to give it to succinct points, I’ve tried to just highlight really what the discussions were with the patient and what have been used with discuss. And my general rule is try not to make it more than two sides of A4. Because most patients can’t take more than that in and if you provide them with a dossier, which I’ve certainly seen, and I’ve noticed some of my colleagues do that as well. You know, the ability of the patient to retain a lot of that information, although you might be very comprehensive, it might confuse them so much that actually they don’t really understand the nuances of the treatment plan at all, because you’ve given too many, too much information overload basically. So is the same if you ever get a letter from me from the NHS I, my rule there is one side of A4 paper, if you can send on one side of A4, then you may miss out some of the salient features. And if somebody wants to elaborate in what more information, I don’t have a problem in going back and giving them further information as long as you’ve got detailed notes, right. But really, I’ve tried to give a summary sort of option. If somebody else is carrying out a treatment plan, of course and you’re giving them advice, clearly you need to give the dentist a lot more information at that point. But when it comes to to patients and writing to them, I try not to overload them with information actually, I’d rather give them a few pointers and actually get them back in and discuss again with them because that time is so valuable talking to them face to face. And understanding their concerns and fears and what their desires are because as I say if you write them a huge letter, I guarantee you, you’ll end up probably scaring the life out of them and probably not seeing them again. So it’s always better to have a good follow up appointment, write to them with, in my view no more than two a4 sides of paper and getting them back in and discuss it again to make sure that they understand what the options are and why they want to choose what they want to choose. [Jaz]Brilliant, I’m not going to if you don’t mind I’m gonna go back onto the implant theme because we’re going on some tangents it does a very valuable tangent I have to say. So we talked about the gray area of deciding if someone’s a terminal dentition or not, I think you covered that beautifully. I think the last part of when you summarize that was just phenomenal about the way you pitch it to patients. And that’s fantastic. We then talk about obviously, I joked about your, the letters to patients but now I want to bring it back to edentulous patient so if you’re a GDP and you have edentulous patient in front of you, and they’re struggling with their denture, and then you want to say okay, I’m gonna I can refer you to someone who might be able to help or maybe you’re the dentist who can place some implants, What are the usual options that people can explore in terms of you know, either you know, there are fixed implant reconstructions there are removable, there are a hybrid, can you just break it down for the GDP, the newly qualified dentist who doesn’t really know where to begin with classification and what’s available? [Harpal]Yeah, that’s a good question. I actually before we even go down the implant Avenue, I think the most important part, as you say, is unsuccessful dentures, just try to understand why they’re unsuccessful. If a patient comes in with a whole bag of dentures, and says they’re being trying 20 different dentists, etc, and I can’t seem to find one that works. But this set and that set mixed together seem to be the best. You know, those usually are a big warning signs that perhaps those patients are going to struggle. But equally I recall, when I was a registrar, I used to have to work up cases for full arch reconstructions with Professor Roger Watson, I don’t know if you recall him at Kings and David Davis. And one of the procedures they always used to make me do was to do a workup, make them a new set of dentures. And it was interesting that half the patients are made new dentures would say thank you very much. I don’t need implants now. I’m actually quite happy with these. And they’re much better than they were before. I really don’t think I want implants. So I’m like okay, maybe a lot of these patients don’t always need implants, they just need to have well fabricated dentures. And making good full dentures is, you know, it can be extremely challenging as well. But a good prosthodontist should be able to make them, a good general dentist should be able to make them if they spend time and effort. And that’s always the first port of call, I would always say because if a patient is struggling, you need to work out whether the those concerns are really genuine either actually technical problems in the denture, as the patient actually just one of those that can’t tolerate dentures. And that’s what you’re trying to ascertain in the early stages. And you’ll be surprised how many patients actually would be satisfied with just that alone. I certainly was. And these were patients on a waiting list for implants so that and they were getting it free. So it was no financial incentive for them not to say no at a particular point. So it was certainly an eye opener. And it is a very valuable exercises because it taught you how to plan for the implants as well. Space creation and half the technical and restorative problems you could pick up actually in the wax try in stage of how much interocclusal room that you have. So all of the basic stuff which you think, you know, probably not that important for implants is actually crucial for implants because it sets the footing for when you go down the implant Avenue, what type of treatment avenues you may be considering for a patient. So there’s one very good article by Carl Misch who sadly passed away on implant reconstruction designed from FP1 to RP5 now that’s you may come across there are some dentists who may not have come across it. And it’s very much to do with whether you give a patient a fixed reconstruction or removable and an FP1, So FP, fixed prosthesis usually graded into 1, 2 and 3 with FP1 just replacing the white part I should say, of a patient’s dentition, so the crown part. So if there hasn’t been a huge amount of volume loss and periodontal disease or trauma and all those things, then that patient may be suitable for what we call an FP1 type of design. But if there’s been a bit of recession, or sunburn loss, if you have this thing called an FP2, which is also a slightly more complicated sort of a gradation, so slightly more recession, so you’re replacing not just the white part of the crown you’d be possibly replacing part of the small part of the root form as well. If the patients lip liners quite low, they don’t show it too much, then it probably doesn’t matter if those teeth are slightly clinically longer than their appearance because the patient never shows it. Then you have the FP3 which is actually replacing not just the white part of the tooth but the pink stuff as well so you you can understand there’s been quite a lot of volumetric bone loss in these cases. So you are trying to replace both hard and soft tissues of the bone structure. Now that then leads on to the removeable, RP4 and RP5. Now RP4 is actually going to an implant reconstruction which is purely supported by implants but it’s still removable, so you may say have four implants holder prosthesis in place so it’s replacing all of the white and a lot of the red stuff, the pink stuff, but it’s anchored by four implants in is supported by implants. And then you’ve got the other, the RP5 and in his list which is basically same sort of volume loss but it’s maybe supported by two implants or one implant for that matter. And there’s partly mucosa supported and partly Implant Supported [Jaz]If you don’t mind me asking, Harpal because I learned so much from that because because I don’t do implants myself sometimes you never get exposed to the air because I’ve seen it all you know bandied about on social media and in papers and lectures or yes I did an FP3 or whatever. And he sort of think you know, but you know, I’ve never had I’ve never done my due diligence to actually go through it. So I learned so much now I know people listening and watching would have learned a lot just basically you’ve just gone through and so from F1 to RP5, and it was crystal clear. I just remembered I was a DCT at guys hospital. And I used to work with restorative consultants, Sara who might know she taught me once that and then some of the consultants told me once that what I was making for my patients at a time they had two implants in the lower canine region. We had put some locator abutments and housings inside the dentures. But Strictly speaking, she told me that this is not an implant supported over denture and I should use the term implant retained overdenture because and is that just semantics? Or is there something in there? Is there a difference between something that’s implant retained and Implant Supported? Or can you mix and match them? [Harpal]Yeah, that’s a good word that terminology is crucial to this and understanding the detail because you’re quite right or she’s quite right I should say in the sense that the vertical load in that the implants if you just got two implants taken the full load those two implants or can we take a pretty hefty occlusal battering basically. And usually you just want to stop the denture falling out. A lot of patients problems is they can’t keep the denture in place. So, you know, many years ago, we were talking over 20 years ago, the McGill conference suggested two implants as you suggested was a brilliant way of sorting out patients lower denture problems. In fact, even one implant is satisfactory to improve denture, simply not so much support resistance to falling out. And often this was the biggest problem for patients is keeping the dentures in place. So technically you’re right and that’s the distinction between the RP4 and the RP5 because an RP4 has implants and you got to removable prosthesis, the implants are taking all the load. The RP5 implants are there just to assist so I call those important assisted dentures, stop the denture falling out. But the occlusal loads are still taken by and large by the supporting alveolar tissues, basically, the soft tissues and the bone around it. And that creates other problems as you know, because over time, that patient will get continued resorption in most regions and therefore maintenance of those cases is much greater. You often have to rely on those cases to avoid overloading the implants in the long term. But you’re quite right there is a distinction and understanding that distinction is quite important because if you expect those two implants to take all the occlusal load and they still to be there many years later. It can certainly open your eyes in terms of functional problems and implant complications. In fact, we’ve had a case recently at Kingston hospital, an oncology patients mouth opening is very very restricted. And I’ve just about managed to get two implant at a very acute angle in the mandible because his mouth opening is so poor and I thought well, you know we’re trying to extend the prosthesis as far as possible, so an RP5 design with two locators and it was a sharp rude awakening when he’s fractured. Well one of the implants is fractured and the other one actually was explanted by the denture. It literally came out with it, and I thought blimey. So maybe these situations now we’re having to redo it with further risk reduction space problems because these patients often post oncology, have very limited mouth opening have had to do quite a lot of risk reduction just to create space for the prosthesis. To try and extend the prosthesis now so that you can actually take a bit more support from the alveolar tissues. So yeah, those cases can be quite challenging as well. [Jaz]And well, since you touched on the number of implants, the next question want to ask it and just leads beautifully that is when I used to see patients at work in Oxford, and my principal was an implant placing dentist and he was happy to do full arch cases. But when I saw my own patient who had the “terminal dentition”, or were struggling with an unsuccessful denture, and they needed some help, I’d have to always meet with my principal dentist at lunch, I’m saying, here’s the photos. I don’t know what to quote because I don’t know how many implants this patient needs. And every time I take a patient photos, you get a different answer. And obviously, everyone knows, every dentist every student dentist, probably knows that the famous AO4, all on four. Right? But is that the rule of thumb that four implant solves everything? I assume not. But tell me how to even begin to fathom how many implants are going to be needed for a case and why is it sometimes very between 4, 6, 10? Is it purely financial? Or Is it much more anatomical? [Harpal]Yeah, well, there are lots of reasons there are multiple factors to be honest, and I’ve went from, you know, from my early training, I’d be trying to put as many implants in as possible. And it’s interesting how you almost come full circle. As you know, I’ve worked very closely with all on four centers as well. And you have to be very careful with the number of implants versus long term maintenance and complications. For example, as I said to you, you may have a patient who’s got an edentulous mandible and just as miserable, can’t cope with dentures, and they’re okay with the full upper denture. Surprising even a single implant in the mandible in the midline to help secure that denture is more than enough. Most people would probably put two and consider it an RP4 because it’s much easier putting two in and getting some support both sides. But if you got an 82 year old, who was struggling to, you know, eat satisfactory, a single implant to help secure a lower denture is more than adequate, believe it or not. You may choose to put too, but he sometimes find they can’t always get the prosthesis out with two because their manual skills and their dexterity may not be as good and the retention may be so good that you have to then deactivate one and then go back to one. So it’s horses for courses, you have to put so many factors in the patient’s wishes desires, the all four really sort of took off, I would say probably about 20 years ago as the base standard. We’re trying to provide a cost effective way of giving patients fixed reconstructions. Now there are certain problems and we’ve certainly seen them on our own clinic, when only four are used, especially in some patients who are susceptible to perio or their quality of bone is not so good. And it’s interesting having done that for a number of years and we’ve managed to repair and try to remedy some of the problems with patients with all on four I’ve sort of gone back and put extra implants and now on the maxilla. So I’ve taken a slightly more dim view now for the maxilla if we go for a fixed reconstruction, which is often what patients are referred to me for that I very much have the view that perhaps if I can get six in and get a good AP spread then I probably give myself a better insurance policy in the future for any potential complications. Part of the problem with four [Jaz]Can you define AP spread for some of younger dentists who may not know what that means? [Harpal]Yes, AP is really the anterior posterior spread and the cantilever design and I’ve certainly been to lectures and I’ve heard people who are very well versed in this that they don’t worry so much about the extent of the cantilever, especially in the upper jaw. Actually I do I get very paranoid about the extent of cantilevers because we know the longer the cantilever, it’s basic physics from, you know from A level physics on levers, basically, the longer the lever, the greater the force you can generate. And no surprises if you’ve got a large cantilever, especially in the maxilla, you’re going to get more prosthetic and in my view, surgical complications of bone loss around the implants. Perhaps the Peri-implantitis isn’t always Peri-implantitis, it may be overload of the implants. The difficulty is managing those cases in the long term, especially 5, 10 years down the road, the patient’s invested quite a lot of time and money need to put a lot of effort into it as well. So that if you do get complications, you know, how do you deal with it and hence why I’m sort of gone back partly to some degree what I used to do in the old days, and I try to over engineer it’s I don’t see a problem with over engineering because at the end of the day, You it depends on what kind of service and maintenance program you’ve got for that patient. So ironically, we did a case just Saturday, George Xirogiannis, my periodontist and myself did a upper and lower fixed arch reconstruction. For a patient with complete dental clearance. And the mandible went perfectly well we managed to get six. Pretty much straight implants in the mandible, great baby spread up to the first well actually the second premolar stroke small cantilever to replace the molars where there was insufficient bone. But the upper proved exceptionally difficult, we manage to get four good implants and it’s canine region. But the posterior implants were an absolute nightmare really worst. I struggled to get pterygoids in. The pterygoid bone was really quite hopeless using all the tricks, and it nearly took me three hours just try and get the additional implants in those regions. But in the end, I ended, we ended up with eight implants in the upper jaw, two of which were buried, just to wait for the bone to repair because there were another two which weren’t so great, you know, their stability, primary stability wasn’t that great. So you still walked out with fixed teeth, the same data, I didn’t plan to put a implants in the upper jaw, we were planning just to put maybe four stroke six with possibility of two zygomatic implants or pterygoids. But life doesn’t always work out like that. So you often have to go in with one expectation and you start struggling a little bit with zygomatics mouth opening wasn’t as great as I thought I couldn’t quite get the angles to get the zygomatics in I was hoping and praying that the pterygoids would go in and they proved to be absolutely you know, very well. They weren’t as good as I thought. So you often have to think outside the box. And certainly George know well, now what we’ve got four good ones at the front. But they’re only as far as the canine region, I’m not going to do a huge cantilever. Because the AP spread now and this is so large, I’ve got potentially three pontics cantilever it, you know, you’re asking for trouble, you need something further back. And sometimes you have to compromise. So I’ve managed to get additional ones in with a little bit of a compromise. [Jaz]I mean, some people might be listening right now, Harpal. And I remember the first time I came across pterygoid and zygomatic implants, you know, when you’re young dentist or you’re student and you’re thinking implants, and you know you’re looking at implant in the more traditional areas that you’d place them. And then when you first get exposed to wait, you can put implants in these really long things in, you know, your zygomatic arch areas, or your pterygoid it blows your mind as young dentist when you’re first getting exposed to those kind of stuff. So some people may have been listening to you saying that I mean, wait, what a pterygoid. And you know, some people don’t know how to spell pterygoid. So it’s just how it is. So it’s very fascinating. But is there any evidence pointing to, because but what you’ve basically alluded to is, it depends on your level of experience. It depends on your successes in the past as a clinician for anything you do in dentistry, the team that you work in your training about what kind of solutions you can offer your patients, and some dentists do full arches may not be able to extend to zygomatics, for example. But is there any evidence for quality of life studies and that search either fixed versus removal? Or a number of implants or the AP spread? How much research we have about the quality of life so that we can as clinicians inform our decisions based on that? [Harpal]That’s an excellent question, Jaz. And the answer is actually, there are lots of quality of life studies available in the dental literature on dental implants. But none of them or very few of them really deal with number of implants per se, they often are just looking at a qualitative sort of factor out as a patient, give them patient orientated outcomes, etc. You know, there isn’t that sort of study where you can evaluate quality of life for the number of implants so to speak. There are some comparing fixed versus removable and there’s a lot of studies comparing quality of life with say just a complete denture versus an implant or an RP4/5 versus an FP 1, 2, 3. And the studies are equivocal to some degree we know most of them seem to agree that most patients if you’ve made a well constructed full denture and they’re still struggling with it, that any form of an implant prosthesis, whether it be removable or fixed will improve the outcome compared with a removable denture that goes probably without saying for most studies. The question really is I don’t know how people will have evaluated outcome for the full dentures have they actually made new dentures for those patients like I used to have to do at Kings. So made a big certain questions there as well those studies are not completely foolproof from that perspective. But with regards to fixed and removable Yeah, you can find some studies or certainly been studies from 20 years ago with off top my head Saltzman it studies took about 20 years ago in university of Bern, comparing fixed versus removable. And they found actually pretty equivocal outcomes from a patient perspective, when you look at quality of life factors. Now, things have moved on a little bit, now you’ve got more assessments and a new quality of life, guided by there’s a lot more detail in terms of questions that these patients have to answer. And there are, these are very subjective questions a lot of the time, they’re sort of often patient lead, which is not a bad thing. But you know, if we want more science behind it, you have to do more of the mechanical studies, look at forces etc. And we know, if you measure forces on patients, certainly, if you look at patient if they’re their natural dentition with 100% worth of occlusal force, if someone’s given a fixed reconstruction, they’re almost 90% there to what their patient had previously, with implant retained dentures is a little bit variable, this sort of between 50 and 70% in general, compared with dentures, which can be you know, zero to, you know, to 20 to 30%, depending on how well the patient can tolerate these things. But certainly from an outcome, perspective and quality of life, it is actually very difficult to dissect whether fixed versus removeable is better. And that’s often where patients input come into and obviously their budget as well because at the end of the day, we are dictated to some degree about what our patients can afford. Hence why it’s very important to discuss all these avenues you can explain to patients the advantages and pros and cons of an implant retained denture versus a fixed prosthesis and also ease of maintenance and hygiene those are the sort of factors patients really do need to understand and depending on their age as well i mean i have a GP who’s only in his late 50s last week who have very little residual bone, his dentist to be monitoring and maintaining his teeth for last 20 years and pretty terminal actually they’re quite loose and they were about to come out and we discussed all these options with him I said you know, you’re still relatively young What would you like to have at the end of the day you know, dentures are removable, they are cleansable, they’re easy to remove and keep clean but they clearly have some coverage of the palate and you know having something removable for this doctor who still practicing and still communicating with his patients he said that’s not for me I don’t want anything removable and also there’s a psychosomatic sort of benefit for these patients because they think removable is still not part of them. It’s still a sort of, you know, a inverted commas a second hand type of problem to fix basically compared with something fixed It’s like my own. Well, that’s important to understand from patients perspectives as well. But it is very different. [Jaz]I really like that example you gave with the GP I think it really makes it more tangible. And I know some dentists listen to this, that explanation that you give to patients. That’s really valuable, actually. [Harpal]Yeah, I think you have to be honest with them. And just equally I’ve got a patient and the other age extreme I’m dealing with at the moment who’s had an FP3 fixed reconstruction with quite severe bone loss. She’s already had psychosomatic implants placed elsewhere, actually struggling to keep them clean. Her manual dexterity is not as good as perhaps they thought it was going to be. And there are a few other complications I won’t go into which has necessitated her having further treatment with us. But actually, I’ve convinced her to have something removable and I said, I think you’d be better off actually with an RP4 primarily because actually you can take it out and clean it and you can look after things and we’ve done the first preliminary step for her. And she’s over the moon already. She’s like why wasn’t this offered to me at the beginning, I’m actually really upset. So it does make you think with patient so that will maybe we should spend a little more time at the beginning explaining these avenues. And I think unfortunately, in her situation, she had very little discussion with all the treatment avenues that she could have explored in the early days and she’s now in her 80s as well so it’s not as if she’s in the younger age group and we know what tends to happen as we get older, our skills, our manuals, skills go down. So they may have had great intentions of giving her something which they consider superior, but maybe didn’t factor what the patient variable so that they’re a part of the equation is. And that’s always a learning point for me as well, just to say, well, would I have done the same? You know, would I have gone straight to a fixed reconstruction verse? And probably, you know, the sexy factor of having something fixed is the driving factor because you think I’m giving somebody something which is close to what nature gave them at the beginning. Unless you’ve got to think beyond that we’ve got to understand as a patient at the end of it, and how are they going to look after it? Does it give them all they need? Does it gives them all the function of phonetics? and more importantly, this physiological support their lips, and the ability to maintain? I think that part is actually very difficult to answer the maintenance part, which we’re not so good at explaining to patients. We assume naturally. [Jaz]That is brilliant. That is fantastic. [Harpal]How are they going to look after these things? Are they going to get underneath these prosthesis? We’ve actually just been asked one of, I don’t know if you know, Pynadath George, who is part of the department, Pynadath George, and I’ve been talking to each other about running a course at Humphrey House later this year, which were just in the final process of setting up. I’m trying to explain these differences as well to dentists, and actually how to service and maintain them. So part of the lecture course is not just that saying, This is how we put the implants in and how we restore him. But we’ve got the hygienist and George, our periodontist on board. So all of these are the problems you may encounter. How do you look after these patients? How patients expected to clean around them? And I think that’s perhaps not the told enough, if that makes sense. Because that’s the long term game that’s about keeping things going for the next 10, 15 plus years with hopefully very few complications. [Jaz]Brilliant. I just want to in interest time, I’m gonna ask you a one more question. This is a bit more dentist specific focus terms of training pathways, because you mentioned about in the course in educating dentists that you’re taking part in with Pynadath George as well. So it flows nicely to ask you, With implants, when implant education implant courses are being taught to young dentists for the first time. So let, you know dentists learning how to place their first implant. And the advice we’re taught is, you know, start with a lower molar, maybe an upper premolar away from sinus, good bone, the low lip line patient, low aesthetic expectations as your first case, and that’s what we’re taught. But then I was once speaking to Pynadath George, actually a few years ago on the phone. Before I move to Singapore, I was asking about I was at that time, I was considering getting an implant and stuff. And he was asked me, okay, what kind of implants do you want to do? Do you want to do implants, you know, to replace the old missing tooth? Or you want to full arches? I was like, Gosh, I don’t know. You know, should I start with one? And he was like, You know what, they’re completely different kettle of fish. So is there a case for dentists who, perhaps are passionate about dentures and those big changes that you give to someone from going no teeth to having lots of teeth, and really improving their lives that way, rather than someone who sees a more general population with more teeth, for that dentist, perhaps to skip straight to learning full arch? Or do you think no, every dentist who’s learning implant is better suited to learning how to restore the single tooth in a bounded saddle area? And then, then develop on to full arches? Or is there a case for someone to go straight to full arches and learn the basics of that? [Harpal]Yeah, they are totally different skill sets. I have to be honest, but like most things, in the early stages of one’s career, I think, and I certainly, you know, talk dentists around me in this fashion by getting them to restore a lot more of the simple cases. First, I think once you understand prosthodontics, the implant surgery becomes much more straightforward afterwards. Because it’s prosthodontically led, you don’t understand the prosthetics. And I think that’s where a lot of complications arise is because actually, there’s no forethought to where you’re going to end up well work backwards. So if you can understand where the outcomes supposed to be, then the implants would naturally sort of follow on from the prosthetic part of the training. So a lot of the dentists who certainly work around me I don’t let them go wild and start putting implants in straight away because I’ve seen the harm and the damage it can do for patients because they just want to get numbers in they think they’re going to get their confidence by putting lots and lots of them in and all you tend to do is create lots and lots of problems and don’t necessarily understand how to fix them. So my view is actually learned how to restore. Once you’ve restored a few, got your grasp in understanding the space in occlusion. Then move on to putting the implants in and that the natural progression. And Harjot said that point at the moment, he’s missed out a lot of the stages at the moment, with regards to what I used to do, we used to have to work on models, drill a hole in a stone, work out the prosthetic shape before we even, now we’ve got all these clever digital stuff we’ve just invested in the x guide. And he did his first x guide implant on Saturday. And that’s the next sort of progression really is to put implants in, in bounded situations, get a good outcome, understand what gives you a good outcome basically. And I certainly wouldn’t suggest jumping into fixed full arch reconstructions, because often, there are so many nuances of learning which you miss along the way with single teeth, that actually you can adapt to fix big arch reconstructions later on. It might take you a few years, I don’t expect somebody to rush into full arch reconstructions from day one and be an expert within five years, I’ve always said go and learn how to make dentures first, because once you understand how to make full dentures, actually, everything else becomes a lot more straightforward. So from the natural progression perspective, I would say, always start simple build up experience on simple cases, first put implants, and I totally agree put implants in the lower sort of 4, 5, 6 region, as long as you’ve got acres of bone, avoid sinus lifts and all that, because if you make mistakes, and they can really put you off, and I’ve certainly seen patients, or dentists who said, You know, I put an implant in this size, it all went pear shaped the implant got infected a patient and ended up wired communication. I’ve got sued, all sorts of things in it. Okay, maybe that wasn’t a great way to start. Or perhaps they didn’t have the right mentoring at that time. And I think that’s crucial. So I’m very cautious. And I certainly you know we’ve run zygomatic courses, and I’m very cautious on those as well. I certainly have had surgeons who’ve come out after doing a phantom head and said, Oh, this looks really straightforward. I’m ready to do my first case next week. And I did have that a few years ago, actually, I was quite shocked when I said, Well, actually, you know, we might make it look easy on this Amazon course. But there’s lots of technical bits, which you don’t realize until the day of surgery, and he didn’t listen to me, phoned me up Monday morning and said, I’m about to put the zygomatic implant in, can I just run through it with you over the phone and I have to say, I was pretty shocked. I said, I’m really sorry, I can’t help you any further. I did say to you need a mentor, you mustn’t put this implant in, without guidance and supervision. Because if you mess up, the consequences are quite severe. And I take no responsibility for things going wrong. So yeah, I think it’s horses for quite a while, you know, we often have over confidence in ourselves because you learn something, you’re eager to get on with it. But if you don’t understand the hiccups in the trips that are along the way that you are going to encounter, because you’re not experienced enough. And that’s where mentoring i think is crucial. So your boss is absolutely right, you know, you may, you may come up with different answers for a different number of implants, because each case is slightly different. The volume of balance is slightly different, this patient may have acres of bone, then you might say, well, I could put six, eight implants in, you know, versus the standard on four. So each case is different. And you do need a little bit of guidance for it and there’s no cast iron. You know, solution to a lot of these patients, you can often adapt techniques as you as you go along and I treat my zygomatic and pterygoid cases exactly the same way. They still need the workup at the beginning, you’ve got to work out where the final tooth position should be. Those are quite challenging even when you’re putting zygomatic and pterygoid implants in to get the right outcome. But if you do your basics and you do your groundwork, then as you gain more and more experience you’ll get more and more confident in doing things and then you move on progression wise you probably would want to do sinus lifts, etc. Get your experience in sinus lifts and zygomatics yeah, you know and pterygoids are the ultimate, it’s not something even although a lot of Dentists have trained over the years and surgeons including Maxfacts, not everyone gets it and they’re not easy to do. But the most important thing which we do try and get them to understand is not about the surgery, it’s about the outcome, it’s the prosthetic outcome is just trying to get that patient right superstructure to fulfill their needs whether it’s removable or fixed that’s down to you and we’re all have our debates about whether it’s fixed or removable and I certainly, I presented a case a few years ago in Italy actually do Professor showed him pre op studies and I asked her a group in the audience what they would do in this case and nearly all of them you know understand what it looks like an RP4 to us, you know, I can understand lower volume last patient been edentulous for 20 odd years severe bone atrophy of the maxilla and I said that’s certainly an option that’s probably what the patient would benefit from. But that’s not what she wanted, she didn’t want something removable or psychological aspects when she wanted something fixed even though there was severe bone loss, I managed to show how we managed to do a fixed reconstruction with zygomatic implants and she got basically what she desired but it was really still planning it and understanding the prosthetic stage. So even you know that the other extreme you can get professors who are very, the professor I presented this to is quite actually horrified we put zygomatic implants here for this patient that’s fullfil the patient’s needs you know she got the outcome that she wanted. I understand perhaps a removable option might have been feasible for her and certainly easy to clean but I had to deal with the psychological aspects of this patient and she was miserable with dentures and for her even anything removable wasn’t right for her. So those are the other side we have to work within our own skill set I have to say and thankfully I’m blessed with a good team around me, they’re the ones who make us look good at the end of the day and can give us the outcomes that we want you need really good excellent technical support to do these things and thankfully as I said, we’ve got Harjot and Manish who are great prosthodontist as well so they’re always teaching me things you know I never too old to learn as they say you forget certain things at certain stage and you go yeah, I forgot that. Yeah, that’s a good idea. Yeah, that’s a great solution for the patient but it’s really about being open. Having an open discussion with the patient as well I’m being frank with them and we certainly have no problems laying it on the table, telling them the pros and cons so that they can make a decision at the end of the day. They may choose you know one pathway over the other. [Jaz]Amazing and I think what I’ve gathered here is that you every time you present something to a group, especially I saw dentist Harpal, you got to have thick skin so I know you must have thick skin in this amount of controversy you must get you know, amount of attacks, amount of debates and I’m sure you’d love it and then you’re great. I can tell you’re great at it and you know, a massive respect to you for what you do. But you have to have thick skin because as you say, you know, there’s so many, I mean there’s gray areas in all dentistry, but from having this chat with you today, implant is a whole different field there was a gray areas and lots of strong opinions and subsplash out that like an oral surgeon might see something completely different to a periodontist, might see come something could be different to a prosthesis, right? And then you have those sort of arguments. So I’m gonna let you have the mic in a moment to just wrap up. But one thing I want to remind you is I think, send me some links for any dentist who wants to learn more about zygomatic, about the course later on. I want to stick it on the website before I get bombarded with messages. And also any closing comments for dentist who listened all the way to the end, and we appreciate that so much. [Harpal]Really, I think the most important part is just go over treatment planning, discuss your patient in detail, really take a detailed history from your patient, what their goals and desires are. And that’s so key to the equation, I think you miss so much sometimes if you don’t listen something. Martin Kelleher always used to tell me this at the beginning. And that one thing I do try and listen is just zip up at the beginning. Ask the patient why they’re there. And just keep your mouth shut and listen to what they have to say and write it down. That’s so important because you learned so much about what the patient wants and their expectations. And ultimately, just to spend time with them to explain that you understand their problem. So you can, you may sometimes at the end of your consultation, just say right, So just to summarize, I think you’ve said you really do not like dentures or you don’t mind dentures, you just want to have an improvement in quality of life. You know, it may well be that a fixed solution or removable solution is suitable for either of those cases. The workup in my opinion is often the same. You know, CT scans, getting them back and doing diagnostic setups. See the patient multiple times, don’t rush into it. And I think that’s the other problem. You sometimes see when patients are traveling and trying to get treatment done quickly. Sometimes you miss out on those same questions that the patient doesn’t fully understand. Certainly we’ve seen that when patients have gone for dental tourism, and they’ve come back and their expectations have never been met. We’ve actually probably no one’s listened to what their real desires are or spent time explaining things to them, and what the limitations of those treatment avenues are. And ultimately, if you haven’t got the skills, you know, there are plenty of people out there who will help you, great mentors. So we’re only just one amongst many different clinics throughout the United Kingdom who can help you so you know, I will say to dentists, just pick up the phone, ping us an email. We’ll have a chat sometimes I’ll have a discussion with, I’m over WhatsApp and just look at the scans and look at the photographs and say oh this is possible, give them an outline of likely sort of treatment plans just based on their assessments and then before you’ve even seen the patient and then I often strongly encourage a joint consultation. If the patient is happy to come for a consultation with the dentist that really I think is crucial Firstly, the patient really appreciates it that the dentist is spending the time and as part of their learning experience because they may not have as you say have ever come across zygomatic implants or pterygoid. They don’t often know what to explain to their patients and part of my role is explaining that to the dentist as well so that their patients are well informed as to the treatment options so yeah now keep [Jaz]Harpal, when these dentists come to these consultations with you, Do you take them to Pizza Express or Nando’s after? [Harpal]At the moment nowhere, I’ll have to bring them sandwiches at this particular moment due to COVID restrictions but you know we’re not averse to having a Pizza Express, I have to be honest, in fact there’s a lovely Italian place around the corner from us and occasionally we have a very nice Italian meal. I love the social environment as well actually because it’s a great way of meeting new people and new minds and you know, I think the future is always the people around you to some degree, even the youth coming up, we’ve got lots of questions and you know, make challenges on you might you think things in a different way. So now I’m always for that I’m very much open. We have an open sort of arrangement. But you know, we have no problems, there’s no wrong or right way we like to discuss things openly with patients as well as the referring dentist and I now all these sort of pros and cons in there. Usually the patient chooses the right treatment option. And more importantly, if they’ve never seen anything like that before they usually go Wow, I didn’t know you could do that. And I didn’t know my patients could have that. And I think that’s always a great reward as well because those patients you know, they thank you, they love the dentures as well, you’ve changed their life often actually in those situations. And there really can be true life changes. So yeah, by all means, you know, just remember, there are patients out there and it’s important to give them all the treatment options even if you don’t know about them yourself. There are plenty of people you can vies and guide you and at least do joint trips and [Jaz]I’m hoping this little chat today would have helped a lot of people, I guarantee you, Harpal, to you, the language of FP1, RP4 that sort of stuff is like second nature to a lot of dentists it’s not. And I think they will learn even just from that, the summary and the wonderful things that the way you explained to patients including that GP, I think today’s episode full of lots of communication gems and also, you highlighted the importance of having a support network near you, including mentors like yourself who can pick up the phone and I love the fact that you said that look, Whatsapp you know, despite all the doom and gloom I keep saying there’s never been a better time to be a dentist who’s hungry at knowledge [Harpal] Absolutely [Jaz] it’s never been that time in your life, you can connect to anyone, anywhere in the world with a click of a button WhatsApp or social media, respecting privacy and confidentiality but to gain knowledge and advice so that’s wonderful. And you know I thank you so much for giving your time from your very busy schedule for to make this episode I really appreciate it. [Harpal]Thank you for you time as well it’s great to be here. Jaz’s Outro: There we have it, Harpal Chana everyone, I hope you found that useful. I hope you were making notes. It’s kind of one of those episodes where you have to go back and maybe make notes. But hey, don’t worry if you didn’t, because I’ve got an infographic for you so I’ll finalise or summary, hit the @protrusivedental Instagram, and I put a little infographic on there, also on the protrusive.co.uk website. And some big announcements coming very soon, including, so I know many of you will listen all the way to the end, but many of you will just you know switch off at this point because it’s me blabbering on. However, if you get to listen this bit, I have a secret for you. The secret is that the Protrusive app is coming out very soon and on there I hope to make it a little home for all the different infographics, PDFs references that I share. So it’ll be an easy place for you to catch that up. Anyway, let’s keep that secret for now. And I’ll catch you in the next episode guys. Thanks so much for listening.

All of the Protruserati clan get 15% OFF the third molar experience with the code ‘protrusive‘! A brilliant course by Dr Nekky Jamal A tricky Third molar surgery can humble even the most experienced of Oral Surgeons. Surgical removal of Wisdom teeth has become somewhat of a post-graduate discipline, with many Dentists lacking the confidence or even the appetite for their removal. We have today the very enthusiastic Dr Nekky Jamal who is a GDP that lives and breathes third molar surgery. He shares with us his top tips for the planning and execution of M3Ms surgery! Protrusive Dental Pearl: When you are sectioning a mesio-angular impacted tooth, start your section 1-2 millimeters more mesial to where you think the furcation is – you will have a tendency to drift distally and therefore more likely to HIT that furcation which is when the magic begins. https://youtu.be/Cc_dp2ktt2w Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! (Regarding disto-angular third molars) “If you lose your crown, you almost lose your ability and your orientation of where that tooth is.” Dr Nekky Jamal Click Here to visit Nekky’s Third Molar Experience Course – coupon code is PROTRUSIVE. In this episode, I asked Dr Nekky about: What clinical and radiographic features suggest an easier third molar? 9:51 Main features that identify a tricky third molar worthy of referal 15:15 The two characteristics to determine the difficulty of third molar removal 16:37 Things to look out to determine a high risk of inferior alveolar nerve damage 20:15 Does CBCT help in planning tooth removal for Wisdom Teeth 24:19 When to consider a coronectomy? 26:37 Tips and Tricks on how to get cleaner flaps 30:54 The Hydraulic flap Technique 32:34 Armamentarium for wisdom tooth removal 35:30 Three magic Nekky tips 38:33 Join us in our Telegram Community, where we can always help each other out! If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth with Dr Chris Waith Click below for full episode transcript: Opening Snippet: The situations where I failed in, I noticed when the third molar roots are directly touching the second molar roots. Okay? That's what makes it difficult and if you look at at the classification of that, that's a distal angular impaction. But what makes it so difficult is you can't get your instruments between the second and the third molar. And if you break off the crown of that third molar, you can't even see the mesial root because you can't see past that second molar crown. Jaz’s Introduction: In this episode, Dr. Nekky Jamal will cover all the points you need to know as a GDP if you’re extracting wisdom teeth, and that’s surgically what makes it an easy case, what makes it complex case. What about those cases where you’re worried about nerve damage? When do you need take a CB CT? What about coronectomy? How to get cleaner flaps so you could take out wisdom teeth in a much more cleaner field, what equipment to use, and how to get cleaner flaps as well as Nekky’s main tips to improve your success rates with surgical third molars. Hello, Protruserati. I’m Jaz Gulati, my journey with wisdom teeth began when I was a DCT, a Dental Core Trainee at Guys hospital, I was doing my oral surgery post. And that’s when I started to see my consultants the way they were moving it. But when I got to do some easier cases, it felt good. And then a few times I got stuck and I needed rescuing. Now when I went to Singapore, the fascinating thing about practicing in Singapore and how that’s so different to UK when it comes to wisdom teeth is like in the UK, we have the nice guidelines and we touched on that in this episode. But in Singapore, I felt as though like the only people that wouldn’t have third molars removed is that if you actually had hypodontia, if you didn’t have a wisdom tooth, that’s the only time you weren’t having it removed like it was pretty intense and extreme as about the cases that you’d have wisdom teeth out. So I got a lot more exposure and a lot more experience of taking out wisdom teeth, but I still was staying within my comfort zone or just slightly beyond so that I can improve as a clinician. Now one thing that really helped me was a 45 degree handpiece and again, we cover a little bit about equipment and how to get the right armamentarium to improve your extractions. But when I came back to the UK, I was doing less and less. I’m doing less and less, I’m still happy to take on surgical wisdom teeth, but you see less because of the NICE guidelines, right? So we have to really careful and judgmental about when we take on these third molars. Now, my colleague John, he referred me a case recently, and I shied away from it. I looked at it and I thought, ‘Oh, this is just beyond my comfort zone.’ I’ll share that radiograph if you’re watching this, if you’re listening, it was a mesio-angular and the distal root had a little kink in it and I shied away. So then I was looking at Okay, how can I improve my wisdom teeth because I, it was kind of bugging me that I wasn’t ready to take on a case like this. So I found Nekky Jamal, his course is on course karma. So it was mine splint course and RBB masterclass. So I started to watch the reviews and some clinical videos of his and so I signed on and I’ve been really enjoying it. I mean, can you learn wisdom teeth online? Well, you know, I have to eat my hat because you can. There were so many clinical videos like when I was in Singapore, I was literally relying on YouTube videos, and there was only a handful of good ones. Now to have like a bank of 60 plus surgical extraction videos from flaps to actual elevation to closure was absolutely brilliant. So that’s what really helped me, so I invited Nekky on today to share with you the main ways that we can improve your wisdom teeth extraction, whether you’re starting out and you’re looking at Okay, how can I pick the low hanging fruit versus if you’re already extracting out third molars? I know he shares a few gems in there like the hydraulic flap technique to make your flat bracing easier and your sectioning more successful. The Protrusive Dental Pearl I have for you is very relevant to wisdom teeth and it’s actually when I listen to this episode again, it wasn’t covered in the main interview. So it’s like a another big gem that can reveal to you that I learned from Nekky’s course, which is this when you are sectioning a wisdom tooth. Now obviously we spoke about sectioning and elevating molars with Chris Waith, what a brilliant episode Chris, what great job he did for us. So if you haven’t listened to that already, or if you want us to more extraction based episodes, do check out that episode with Chris Waith. Now when it comes to wisdom teeth, let’s say you are going to be sectioning a mesio-angular tooth, right? When I have section before, sometimes the section goes off plane and you don’t get exactly to the furcation. The big tip here that Nekky taught me is that you want to go one to two millimeters more mesial than you think. So you want to start that sectioning a couple of millimeters more mesial than you think. So by time you actually get to the furcation, you probably going to be a bit more distal. If you start where you think is the middle of the tooth, you end up being a bit more distal and then we start to section the tooth, you get a chunk of the distal part of the crown, you don’t actually get to separate the roots. So that for me was a massive takeaway from the course. So I want to share that with you go one to two millimeters more mesial to where you think the furcation is when you are sectioning these mesio-angular impacted teeth. Now let’s just join Nekky for so many gems. It’s a really nice gem packed concise episode so hope you like it and I’ll catch you in the outro. Main Interview: [Jaz] Nekky Jamal, welcome to the Protrusive Dental podcast. How are you my friend? [Nekky]Dude, I’m so pumped to be here today. This is a dental dream for me. This is awesome. So thank you so much, man. [Jaz]Man, it’s an honor to have you on, man. I mean, I one thing I’m really pissed off about, right? is where the hell were you in my life in 2016? I was doing more wisdom tooth, I was doing more wisdom teeth in 2016 than I ever had, and maybe more wisdom teeth in 2016, 2017 than I ever will do my entire life. I’ll tell you why, Nekky and for those listening [Nekky] What is that? [Jaz] I was in Singapore. I don’t know how much you know about the way they work in Singapore. Probably very similar to Canada, based on what I’ve seen the videos that you post and stuff is that the only people that don’t have wisdom teeth out in Singapore is that if you had agenesis of or hypodontia of the wisdom teeth, right? If there’s a wisdom tooth in your body, they will find it and they will take it out, right? So I took advantage of that because I had a little bit of surgical experience and I was really stepping out of my comfort zone and man I was relying on like the sketchy YouTube videos like where the hell were you in my life back then, man. But I mean that just tell me what, Tell me about your journey, when did you qualify? How did you get into so much passion and experience with wisdom teeth? [Nekky]You know, that’s so complicated. I always found the hardest part about dentistry was connecting with patients so many patients were anxious, so many patients were nervous and I found that you know, by looking people in the eye, I was able to calm them down and they knew I was there to actually care for them which you know, I think is a missing part in oral surgery period. And it’s just knowing, the patient knowing that we’re here to help them and so that’s how we started getting into taking your teeth and I always had a passion for helping out so I started volunteering around the world. I’ve been on 19 Dental brigades all over Central and South America taking out teeth and helping those that don’t have access to a dentist and you know my skills just grew and grew and grew and you know what led me to this but I really you know started this without a mentor to help me I was frustrated, I failed over and over and over again. And you know, I thought why does this have to be that way so I developed systems you know, I took every single course I could, I talked to every single dentist I could pick up lots of tips and tricks, and yeah, it got me to where I am today and now it’s kind of all I do all day, every day is take care of anxious patients and take out third molars [Jaz]So you’re limited to just wisdom teeth as is that we all you do now. [Nekky]Yeah, mainly Yeah, in limited to extractions basically. Yeah, and I’ll do implants too but it’s mainly sedation and extractions and implants, but it’s mostly extractions and third molars. Yeah. [Jaz]But are you a like Board Certified Oral Surgeon or not? [Nekky]No, I’m a proud general dentist. I love being a general dentist because I get to learn everything man, I get to take Jaz’s splint course and apply those principles. I get to do restorative, I get to see kids, I get to you know, see facial traumas. And you know the same kids I get to coach in basketball, and you know, fix their teeth when they’re a kid, I’m taking out their wisdom teeth when they’re 18 years old. And so for me, I’m proud to be general dentist. [Jaz]Amazing. I love your story. And I love your enthusiasm and I love the fact that you’re a GDP flying the flag for GDPs but you know, you’re an example of someone who’s really found their calling, found their niche within general dentistry. And I love the fact that you’re not a specialist but all the videos I’ve seen them you extract I mean, you’ve taught it to me better than any specialist could could ever do. So thank you so much and for all you do for the dental community. So let’s dive right in buddy and help the GDPs who are commuting to work or sat on the beach. You know, I once I always tell my who’s listening from you know, around the world, and I love, two places that really resonate with me and really stuck in my mind forever is that in one month, two people from the Maldives listened to my podcast. So I can just imagine like these two dentists on the beach in the Maldives like, you know, they just say, I just listen to a podcast, which is amazing. And then two people from Afghanistan, listen to me, and I you know, I was born in Afghanistan, and I came as a refugee to the country so Afghanistan’s got a huge special place in connection with me. So I was amazed in one month. So wherever you are in the world listening right now, I hope that Nekky and I are gonna take you on a journey to help you to remove wisdom teeth, more proficiently, better surgical technique, and to avoid failures, just like you experienced many failures. I experienced so many failures as well. Lots of frustrations, messy flaps and stuff. We’re going to get into that, but no more after today’s episode. So first question for you Nekky is, let’s start with easy cases. Like if you’re a new grad, right? And sometimes you’re like looking at it and you’re just automatically scared because it has that label, right? Wisdom tooth. What are the features clinically and radiographically to look at that, that made that deeemed these wisdom teeth as low hanging fruit. What are the easy ones? What are the features that we should look out for? [Nekky]For sure. And you know and to your point i think it’s embarrassing that our dental education or dental schools aren’t teaching us how to safely and efficiently take out third molars and it’s almost like a letdown to us it’s a disservice to our patients. So no, I’m glad to share a bunch of secrets today and a bunch of tips and tricks but if I was gonna say a low hanging fruit for new grads, you know, you want to start with younger patients. One of the main complicating factors with third molars, especially taking out third molars, is older patients tend to have you know, more dense bone, their roots are fully developed and we know third molars, they tend to have big curvatures or dilacerated roots and you know, those older patients are gonna have more postoperative complications as well so when you’re getting into third molars maybe stay away from some of those. If you want to dive into third molars, maybe take on cases with younger patients. So my favorite time to take a third molars is anywhere between 14 and 25 years old. 14 are like you know developed already, but you want to go after conical roots you don’t want to have you know, multiple roots that are divergent and they’re just you know grabbing in there because those aren’t cases to start out with, you want to start with conical roots maybe not fully formed roots. So you know, if a tooth just isn’t coming in the right way and the roots aren’t fully formed and they still have a bit of a follicle around them. That’s a great time to get those third molars out of there because they’re only going to cause problems and so if you want to get into third molars just stick to younger patients because chances are you’re gonna have more success. [Jaz]I mean, I had flashbacks of you mentioned about conical roots and I remember being a DCT. So it’s like one or two years out of dental school I was in a Guy’s hospital and I started doing this wisdom teeth and had one on my list, one of my first ones and at the time like I wasn’t so great at assessing radiographs or what makes a simple extraction versus a complex one and I had one with conical roots and literally took the luxated to it pop right out and at that day I felt like yeah I’m a champion you know and then you see other teeth and you’re really in the depths of despair, you’re really struggling and you feel like the worst like in you know too well that difficult wisdom tooth can humble even the most experienced oral surgeon, right? So yes conical roots on young people. Now, people listening around the world right now would have heard you say you know 14-25 age and anywhere else in the world but yeah, that makes sense. But in the UK we have these NICE guidelines, right? [Nekky] I was just gonna say that totally [Jaz] They messed up, man. Nekky, you know, they’re messed up, the amount of people I see on a monthly basis who absolutely have the second molars destroyed from caries from these third molars is ridiculous. So yeah, in the UK we’re in a crappy situation which is why I said that in Singapore I was taking out more wisdom teeth than I am in UK at the moment even though I’m like far more skilled and knowledgeable now compared to how I was back then. [Nekky]Absolutely. And it comes down to caries, periodontal concerns you know association of potential cysts in tumors external root resorption like there’s so many reasons why we don’t need to have those third molars in our mouth and then you know when that patient is 40 has a bombed out second molar mesio-angular or horizontally impacted third molar, you end up taking out an extra tooth there when you know that tooth probably wouldn’t have to come out anyway. And so to do it younger, that patient heals so much faster, they don’t have the pain and you know all the associated postoperative complications of waiting so I understand the NICE guidelines and I have full respect for all the clinicians in all the parts of the world but you know here in Canada and in North America we follow the AAOMS-White Paper and that’s you know, put out to say all the reasons why third molars should stay or should or they should be removed and not every third molar needs to be removed, but the ones in certain positions may need to be so [Jaz]What does that White Paper, Nekky, say about people who are struggling to keep the area clean and they’re not necessarily getting like full blown pericoronitis but it’s a irritation, inflammation may be an episode of pericoronitis would that be good enough? [Nekky]I absolutely think so. Because you know, just because you don’t have symptoms, that doesn’t mean pathology isn’t there. And so that’s really what it comes down to and that’s the same thing for periodontal concerns just because you have a six millimeter pocket distal to the second molar and you don’t know it’s there that doesn’t mean that that’s a full breeding ground of bacteria that’s you know harboring bacteria that can go all over and so I I’m a firm believer in you know, taking out third molars as they need to be taken out, especially you know, if you consider where all the bacteria is, and pericoronitis it’s only going to get worse. And so the younger the patient is I think just the better it is to get those out of there, especially in cases like that, [Jaz]Which is why the NICE guidelines are so frustrating but let’s not, you know delve too deeply, that’s out of our control. Hopefully in the UK, we can improve that. But still we can you know we can improve our technique when the time comes to do it, but we shouldn’t fall into the trap of that really difficult one that perhaps we think okay, we should referred. So what are the main features in a radiograph or clinically, that you that help us to know that Whoa, this one’s may be really tricky. And we should refer this, [Nekky]You know, this took me years to develop, and I kind of made my own guidelines. And, you know, I read a ton of research papers. I’ve done a ton of third molars, I’ve failed on a lot of third molars. And I started to go back and see like, what about this x ray did I find so difficult? What about this patient, did I find so difficult? So honestly, let’s just break it down. Okay? So let’s look at angulation. If you’re going to take on third molars, everyone’s looking at angulation first, okay, so mesio-angular is a lot easier to take out than a disto-angular, and we’ll talk about the reason for that in a sec. And a lot of like, GDPs, they get stuck, right away, they can see a third molar, and they’re like, Oh, I can take that out. I can see it. But if that tooth is disto-angular, that’s what makes it so difficult. So that’s where a lot of GDPs get stuck. Age, right off the bat. Older patients, like we said before going to be much more difficult. Root development, is the roots fully developed? Are they partially developed? Or you know, are there any roots at all? You know, fully developed roots are going to be much more difficult. PDL space, is there, you know, a tiny PDL? Is there a PDL? Especially on older patients, no PDLs, that makes it more difficult. But these two characteristics right here, which I want to talk to you about these really set the stage for me in looking at third molars and easily being able to determine is this going to be easy? Or is this going to be hard. So the first one I want to tell you about is proximity to the second molar. And no one taught me this but experienced myself. And so I, you know, I failed over and over again. And the situations where I failed in, I noticed when the third molar roots are directly touching the second molar roots. Okay, that’s what makes it difficult. If you look at at the classification of that, that’s a disto-angular impaction. But what makes it so difficult, is you can’t get your instruments between the second and the third molar. And if you break off the crown of that third molar, you can’t even see the mesial root because you can’t see past that second molar crown. So that played a huge role for me, have you found that too? [Jaz]100% but the way you taught it to me was different or better than any other way like people would say, Oh, disto-angular is difficult. Yeah, remember DD Disto-angular Difficult. But it’s a whole, looking at the root and the lack of space that you have to put your instrument. And then when you know, when you taught me about keeping a lever, it is that term you write, the handle, sorry, keeping a handle [Nekky] keeping a handle [Jaz] mesial handle on, that was exactly. So just explain about what you mean by keeping the handle? [Nekky]Yeah, so a lot of it like to be honest, there’s multiple different ways to take out a tooth as long as the tooth comes out, that’s the right way. I like to teach keeping the mesial part of the tooth for as long as possible, especially when you have that you know, close proximity when the roots of the third molar are touching the roots of the second molar. And so keeping that mesial part of the handle gives you almost an, or gives, the mesial part of the tooth gives you almost like a map to the tooth, if you lose your crown, you almost lose your ability and your orientation of where that tooth is. And so I find by removing the distal half of the tooth, I can create space in the socket to manipulate that tooth to you know, extract the tooth but a lot of GDPs you know, they go after that mesial part because they feel like that’s what’s holding it up. And I find it’s always the distal part, you know, that’s either hitting distal bone, or it’s, you know, caught up in the soft tissue. So I tried to keep my mesial handle as much as possible. [Jaz]Okay, so proximity to the second molar, any others? [Nekky]Yeah, my last one here. And this is what I call the depth of application. So since we’re keeping the mesial portion of the tooth, we’re usually gonna be elevating on that mesial crown there at the CEJ. And so what I like to do is I like to separate the second molar roots into thirds. So we section it like the most top third here is easy, the middle third is medium difficulty and the lower third of the second molar root is difficult. And if we match the third molar up to the second molar roots and see where the mesial CEJ is of that third molar, we can almost have a guesstimate of how difficult this tooth is going to be to access. So if that depth of application is deep, and it’s you know, very apical in relation to that second molar, that’s often going to be a very difficult tooth to get to and it’s going to be a difficult tooth to remove. And so a quick and dirty way of looking at a difficult case real quick is just look at the depth of application in relation to that second molar root and you almost have a telltale sign of you know How easy it’s going to be to get to this tooth. [Jaz]Okay, brilliant. And yes, I can certainly visualize that trying to kind of put your instrument your luxator or elevator at that point, and how much less visibility you have, the deeper it is. So that’s covered nicely. The thing that really concerns most of us, when we’re starting out with wisdom teeth, as well as assessing the difficulty is the nerve right? Like we, like I want I am personally, like, I have got a phobia of being responsible, being that dentist who cause that nerve damage on a patient. So I remember in that same job role I told you about that DCT position at Guys hospital starting to get patients referred to the hospital for wisdom teeth being on the consultant clinics, and any tooth that had roots, even like close, let alone superimposed, I was like, freaking out, oh my god, oh my god, you know, the risk, the risk, but my consultant would come by and be like, you know, calm down, okay? It’s just super imposition. So what are the actual three or four things that we’re looking for, that will determine a high risk of inferior alveolar nerve damage? [Nekky]Absolutely. And really, this goes back, I think, to both of our dental education. And, you know, we see this paper by, you know, Rood and Shehab in 1990, the landmark paper of radiographical features, and you see them in dental school, the seven pictures of the tooth, and the nerve, and the pictures were almost blurry, you know what I mean, like, and that’s almost an indication of what you see in real life. Because on the panoramic X ray, the tooth looks blurry anyway. So you can even see where the nerve is in relation to the tooth. So we just weren’t educated properly. So there’s, you know, there’s four, you know, relationships between the tooth and the nerve that’s related to the tooth and three that are related to the canal. But, you know, let’s just wash our hands on all that, I want to share with you the three signs that I look at. Okay, so the first one is darkening of the roots. Okay, when I see a darkened root in relation to the mandibular canal, or the inferior alveolar canal, I know that there could be a close relationship going on. And it doesn’t mean that if you take out that tooth, they’re going to have a nerve injury or paraesthesia. But it just means that there’s a higher risk of it. And so we have to talk to our patients about that. But we’ll talk about that in a sec. The other two signs is diversion of the canal in relation to that third molar. So if that third molar like is in position, and then the canal literally goes around it, I call that diversion of the canal. And that’s a sign of a high risk association between the tooth and the nerve. And then the last one is loss of the white line of the canal. So if you see your third molar, but you can’t, you can’t really see the white line of the canal in relation to that third molar, that’s another indication that that’s a high risk tooth to come out. But what I found is, you know, we have our signs, it doesn’t mean that you know, we’re going to have, you know, nerve injury, but it’s important to talk to your patients about this. And so see, you know, you talk to your patient, and you tell them that there’s a high risk of nerve injury, and you always give it back to them and you’re like, Are you okay, with taking out this tooth? These are the reasons why I think you should take it out. These are the reasons what could happen if you don’t take it out. Okay, but it’s up to you, what do you want to do. And if you do that, and if you take your time to explain to your patients, you know, the pros and cons, risks and benefits of taking out that tooth in relation to that, you know, possible nerve injury, and they get a nerve injury, they’re more likely to work with you than against you. And so patients always do much better with explanations than with excuses after the fact. So you have to take your time to educate your patients show them you know, why this is a high risk tooth and what would happen with a possible nerve injury. [Jaz]Amazing. So darkening of the root, deviation of the canal and loss of the continuity of the cortical lines of the inferior alveolar nerve. Those are three main signs as you taught me as well. And that’s really useful to go by. Now, as I told you my fear of being that dentist who’s ultimately responsible, so my threshold for a CB CT is quite low, like if I see if definitely if I see any of those three signs, I’m thinking, Okay, CB CT, but sometimes if I don’t see those three signs, but you know, the root is superimposed with the canal, I sometimes will be like, okay, maybe we should get a CBCT because I’m a chicken. I’m practicing defensive dentistry in a way. What do you think is your threshold for CBCT? And does the CBCT change your management in any way or when you actually go to remove the tooth? [Nekky]You know, that’s a great question. First of all, I don’t think you’re a chicken I think you care about your patients. And so I think that’s a huge factor right there. If we want to be cowboys and cowgirls and just go after every single third molar we wouldn’t really care about taking a CB CT. So my threshold is quite low just like you. Why wouldn’t we want more information when we have the ability to get more information if you were gonna get your third molar out, you know, you’re 35 years old, you’ve had you know, chronic pericoronitis, but there’s a one of the close relationships like we were discussing, wouldn’t you want your dentist to have all the information possible? So we have to think about it from the patient point of view. So my threshold is quite low as well. Definitely, if I see those three indications, I’m always taking a CB CT. And what I’m looking for on the CB CT that maybe not everyone understands is if we lose cortication of the mandibular canal in relationship with that tooth. So if the tooth root and the canal are touching, and there’s no more cortication of that canal, that’s when we’re like, Okay, this is a high risk extraction, that doesn’t mean that they’re going to get a nerve injury, but there’s a higher chance of that. So I always like to take a CB CT. And the other thing that I’m looking for on a CB CT is the tooth in relation to the cortical plate. So in cases where we see darkening of the root that may indicate that we have the actual tooth roots embedded in that lingual cortical plates are actually extending beyond it. And so what if you break a root tip, you know, which may happen, and then you go fishing for that root tip. And you can push that root tip into an anatomical space because it’s already beyond the lingual plate. But if you didn’t have that CBCT you may not know that so I think the CBCT provides you invaluable information and I encourage you to take them whenever you’re unsure. [Jaz]Amazing. You’ve covered that really well now one question I also had when I told everyone on the telegram group that hey, you know when we’re talking wisdom teeth with Nekky, it’s Kameran Ali, he had this question about coronectomy, Okay? When would you and obviously you covered it in the course. But when would you consider a coronectomy which leads on quite nicely to talk about risk and CB CTs? [Nekky]Absolutely, I think coronectomy is a great option when you do have a high risk scenario. So say you have an older patient who is more likely to get a you know postoperative nerve injury in comparison to a younger patient you know with a similar relationship. Why not do a coronectomy but you have to do the coronectomy properly, you can’t just cut off the crown and then expect you know everything to be okay there’s a couple tips and tricks that maybe I can share with you here. If you’re going to do a coronectomy in a high risk, you know, nerve, possible of nerve injury situation, you want to make sure you remove all the enamel of that crown. So what I like to do is I like to cut off that tooth root or that tooth crown three millimeters below the CEJ and that way we ensure that you know all that enamel is gone because the thought of a coronectomy is if we can bury the roots we want bone to grow over time, but we know bone doesn’t grow to enamel so you have to make sure you get rid of all the enamel. So I like to make sure that my bone level is three millimeters above my actual root. Okay, so there’s a three millimeter gap there. And second you you want to make sure in my experience when I do coronectomy, I always try to get primary closure. If I don’t get primary closure I find you know it doesn’t always close up the way I want it to. And you know that could be okay but try to get primary closure. And the cool part about coronectomy is one of two things are going to happen. Either the tooth is going to you know continue to erupt away from the mandibular canal where you can take it out if the patient is having an issue or bone grows right over. I think those are two great scenarios that you can either take out the tooth without a you know risk of a mandibular nerve injury or bone grows right over and you let it be so I think your coronectomy is a phenomenal option. [Jaz]I used to work with a consultant or surgical at Guy’s hospital. And he was really like well known for coronectomies and really pioneering and championing coronectomies in London and in the UK. So I learned a lot from him. I remember being on his clinic. And you know, just as you said, that I didn’t know I didn’t realize at the time that is so important to make sure you don’t even have a single prism of enamel, you just won’t get the healing. So you’ve echoed that already. And one more thing is that, if you’re going to try this at home or in the office is just as you told me as well, make sure that if the roots do mobilize ie you’re trying to, you’re aiming to do coronectomy, but by accident, you know the roots start moving, then and you got to take it out, right? Explain a little bit more about that. [Nekky]Yeah, totally like you can’t, you can’t leave mobile roots in there because they’re not going to heal but also infected roots. You don’t want to leave an infected root. If it is in close proximity to that mandibular canal, you can’t leave infected roots in there, those aren’t going to heal over, that’s just going to continue to get infected. So you have to take those out. You know, will a coronectomy work 100% of the time? No, but I think it’s a great option to try especially in very high risk scenarios. And I think it’s a great option I do coronectomies when I have to but not every indication is a chance to do coronectomy. [Jaz]Absolutely. Now the next question I want to asked you is about flaps, right? Because I’ve been in a situation where, unfortunately, my, you know, periosteum is tearing a little bit. I have haven’t done as clean as of a flap as I’d like to. So it’s something that for me, once you get a decent flap, as you’ve shown so many times in the videos that you share, it’s so so critical to see that nice clean bone. And I love the videos of you just moving away the flaps so nicely. I wish every one of my flaps look like yours. But I learned so much from you, which is the main thing I learned from flaps was that previously, when I’ve done my incisions, I have failed to go over my incisions again and again and again and again and again, like four or five times, just like you teach. And that is the main lesson I want to pass on to the Protruserati listening today is that don’t just make the incision once and that’s it got over it, especially in that distal area of your tooth where you have a dense connective tissue as you taught it. So just expand on that, and what other tips and tricks and I know there’s one that you love about the Hydraulic. Tell us about that as well just get really cleaned up, because that is a real game changer. [Nekky]Yeah, so I think a huge part of third molar extractions is respect for the periosteum. And I’m sure you’ll agree with me there. Because if we have messy flaps, your patient comes back, you know, weeks later, they’re still in pain, there’s a ton of swelling, the gingiva just doesn’t look good. And really, we feel really bad as clinicians when our surgeries aren’t clean, when our patients aren’t healing. So number one, you have to respect the periosteum. And how we respect the periosteum is by making clean flaps. So when you’re making your flap, I want you to think of you making your flap with intention and confidence. Okay? It’s not just ‘Okay, I think I’ll make an incision here. Oh, no, I don’t like that incision. Let’s make it over here now.’ And then you just tear up the periosteum, there’s bleeding and swelling. So we don’t want that. So a trick that I use over and over again, is I make my incisions with intention and confidence. But then I go over my incision, at least four times, okay? And if I go over it twice, it’s not good enough, sometimes there’s dense connective tissue, especially in cases of a partially erupted third molar with, you know, chronic pericoronitis, that tissues kind of attached on that tooth pretty good. So you have to go over your incision, at least four times, okay? And then another tip that I use is a lot of us in school were taught to use the Molt 9 periosteal elevator, it’s huge, it doesn’t allow us to get to where we need to. And that’s how I was ripping a lot of flaps, as well earlier. So I use a smaller periosteal elevator, it’s called a P24G. And it’s a great little tool for reflecting a nice clean flap, as I’m sure you’ve seen there, Jaz, but I want to share with you another tip, and you can use this tip anywhere in the mouth, okay? and it’s called the hydraulic flap. And what we need to do and the goal of whenever we reflect a full thickness flap, is we want to get that periosteum right off the bone, and it’s just so clean when it comes off the bone, we don’t want to tear the periosteum. So a little trick that I do is I’ll use a short needle, like for anesthesia. And I’ll just inject my lidocaine all the way to bone all along my flap, and I almost bubble up the tissue a little bit, and you know exactly what I’m talking about when you just hit bone. And then that tissue bubbles off. And that’s that hydraulic flap I’m talking about. So then when you make your incision, that flap literally peels right off the bone, because we’ve already got that periosteum off the bone. And that’s a tip you could use anywhere in the mouth. And it just works great. [Jaz]That’s a massive tip. And it’s funny, you know, you wait for these gems, and then they come along at the same time. So George talked about hot pokes and fail ID blocks. And he mentioned it to me about eight weeks ago, and then I saw it again on your course. And he actually had the clinical demonstration of it. And I thought, Wow, this is so so good. So I just want to just ask you a little bit more about that when you are injecting, Are you in the attached gingiva? Or are you more in the mucogingival, beyond the mucogingival line in the free tissues when you’re doing that? [Nekky]Yeah, that’s a great point actually go right at the mucogingival junction. And so it’s easy to do, so you get a little bit of both. I find if you go in the mucosal area, the flap usually reflects quite easy off that anyway, it’s usually around the mucogingival junction and the attached tissue that you have to start reflecting your tissue. And I always start, you know, at the papilla and I go, you know distally from there. So that’s what I found works really well for me is just injecting along the mucogingival junction and you just want to bubble that tissue it takes not even two seconds. So it’s a great tip to do. [Jaz]I mean that’s a top tip. So I’m itching to go for my next wisdom tooth case. So I can try obviously we have the mentoring session which you gave me and we talked about this case that’s upcoming for me so I’ll let you know how that goes. And armamentarium like when I was in Singapore, and I keep referring back to Singapore, but that was a big part of my journey with wisdom teeth, because I was just doing a lot more of them. I knew I hated using the straight hand piece. I used it once in hospital. I just hated the access. I know you use both and you’re very proficient on both but I needed something that was super GDP friendly and so I bought the 45 degree NSK handpiece while I was in Singapore because the exchange rate was good and it was on offer so I was like yes this is great. I also bought myself a normal red ring electric handpiece for my preps and stuff, absolutely fantastic. Love these hand pieces, but the 45 degree one it’s like purpose built for wisdom teeth and for sectioning. And then when I saw on your course that you were recommending that handpiece, I was like ‘Oh my god, I’m so lucky that I actually have this exact same one that Nekky uses.’ So tell us about armamentarium maybe just give us a few tips for you know if I eventually need to use a straight handpiece and do tell us when you might think we’d use that surgical handpiece rather than the 45 degree IE what might be a potential disadvantage of that 45 degree handpiece? [Nekky]Oh totally. Okay, so first of all, I’d use a 45 degree angled handpiece 98% of the time. I love my 45 angled handpiece and I know we have the exact same one and I just think that they’re the best hand pieces out there. And I think as GDPs, we like using things that are familiar. So if the 45 degree angled handpiece not too different from our regular handpieces that we use for you know, operative dentistry, so I love the 45 degree angle handpiece. It feels great and it gives you good visibility. Now the problem with a 45 degree angle handpiece is you’re always gonna wish your bur was just a little bit longer especially if you have a more impacted tooth you’re gonna wish you just could get a little bit deeper and unfortunately you can’t always do that. So that’s when the straight hand piece comes into play. But even for me I feel a straight hand pieces is not, I don’t get the same tactile ability as I do with a straight hand piece. straight hand piece is always just feel a little foreign to me as well. Where straight hand piece shines is for horizontally impacted third molars when that furcation is just a little bit deeper because your 45 degree angle the handpiece may not be able to get all the way to the furcation to section the roots just because of the position of it. So that’s where a straight handpiece works well but for you know a vast majority of the cases 45 degree angle handpieces are the way to go. They’re easy, they’re reliable and they feel normal in our hands as GDP so I highly highly recommend them. [Jaz]Absolutely I love the 45 degree on but with a straight hand piece I found that access to there is just probably unfamiliar the way you hold it in your hand and also the patient’s lip you have to move in to get access to air you have to really move that cheek out the way a lot more but you know it’s also one of the things that the more if I was to use the surgical handpiece more straight one then I would become better at it. So it’s one of those things that you know the more effort you put in, the more time you put in, the more proficient you become using that particular armamentarium. [Nekky]For sure but for GDPs like we’re using not everyone is going to be doing third molars all day so is it you know worth the investment to spend a ton of money getting a straight surgical handpiece or can you use that 45 degree angled handpiece and you can use it you know it’s a section in upper first molar and you can section a lower third molar so i think you know in terms of you know armamentarium that we can use everywhere as GPS I would go with the 45 degree angled, myself. [Jaz]That was one of the best investments I’ve made in equipment that 45 degree handpiece because I took out loads of wisdom teeth in Singapore and it was all thanks to that handpiece because it just gave me the confidence and the access that I really needed so I’m just, again, like I said I’m so glad that that’s the one you recommended as well. Which takes me to my last question Nekky before we just do the outro is your big three tips, okay? To dentists everywhere who maybe have taken a few wisdom teeth out for and they just need a few nuggets, a few gems. Can you just share with us your three magic Nekky tips. [Nekky]No problem. Okay, so my first tip right off the bat, clean incisions, respect the periosteum clean flaps, the cleaner your flap is the the more you’ll be able to see, the less stress you’ll have because you’re not constantly pulling on your flap, and the faster that patients can heal. So right off the bat, you have to get good at flaps, no more messy flaps. And Jaz, just like I showed you, flaps do not have to be messy. You just go over your incision numerous times, you use the right instruments and you know where to make your incisions to just literally open that area up so easily and so quickly to make a messy flap takes longer than it does to make a clean flap. So right off the bat you have to get proficient at flaps and it’s not difficult. Two, is the key to third molars in my opinion is hitting the furcations in sectioning teeth. If you want to get faster at taking out third molars hit your furcations and I made stickers and my stickers all say I give them to all my people and I’m like ‘Man, hit your furcations’ and that’s what third molars is all about. If you get good at hitting your furcation, you’re taking out third molars. Okay, and lastly, after you’ve taken out the tooth, it’s all about rinsing your flap, I’m not rinsing the socket, I’m rinsing my flap, if we can get all the little shards of bone and tooth and all the gunk that comes along with extractions off of our periosteum before we close it up, you’re gonna find patients heal so much faster and they don’t come back with a lot of post operative concerns. I feel a lot of post operative concerns comes from having messy surgical sites. So if we can have clean flaps, we rinsed the area, smooth bone, we use a bone file after we take out third molars, we don’t want jagged bone around there, everything’s smooth, everything’s clean, we’ve rinsed our flat and we close it up your gold. [Jaz]Amazing. Nekky, you’ve honestly covered so much in the last I don’t know like 35, 40 minutes then that was really a gem pack because I like to call it I mean the way I found you was, my colleague John I know you listen to this, Hello John. Baby number two coming for you soon, John. So I’m very excited for you john. So John works with me. He’s actually my boss and he referred me these wisdom teeth and I looked at him and it was just just a tiny bit beyond my comfort level, right? And I shied away and it was really bugging me and it was really bugging me that okay I wish I had someone to mentor me, hold my hand through this and so that you know obviously I saw your course on course karma, you know, splint course also was on course karma so was RBB masterclass so then started speaking. I’ve been doing a course now you had that one to one mentorship with me as well to discuss exactly those cases so if anyone want to see how to take out this wisdom tooth, this mesio-angular wisdom tooth which did actually concern me and worry me and then also the same patient upper right third molar mesio-angular quite less common obviously for an upper wisdom tooth and you just completely alleviated all my concerns, you talk me through exactly how to do it, you show me some clinical videos so now I’m totally ready to target that but your entire course, the third molar experience was just phenomenal. Now, I was telling my Protruserati on the Protrusive Dental community Facebook group, so guys if you’re not on this group already, please do a search on Facebook, join us and I was telling these guys ‘Okay, I’m doing this wisdom tooth course, it’s okay so far 200 lessons Oh my god.’ Okay, that’s I mean that’s amazing 200 lessons but I was like, I was like desperate to get through it, get through it, get through it because just you did the same thing that I do on my splint course which is you don’t rush to the juicy bits that that dentists really want, right? The dentist wants the clinical videos, right? I always desperate for these YouTube videos in 2017 whereas you saved them all like I don’t know 50, 60 of them of all these surgical extractions that you do which is absolute gold, but I respect the fact that you really covered the theory, the flaps, the everything we talked about, the when to get a CBCT, how to manage preoperative complications, post operative pain before you then literally throw all this gold of clinical videos which you know, massive kudos to you how you organize that so that’s been absolutely brilliant. And I think we’ve been emailing and it’d be really kind of Nekky to offer anyone who’s listening, who wants to learn wisdom tooth surgery from the third molar experience 15% discount using the code “protrusive”. Is that right? [Nekky]Yep. “protrusive” Yeah, for your group man. I think this course, I created this course because so many people have fear in frustration of third molars and it doesn’t need to be that way. Why don’t we have people teaching this out there because we all have to take out the third molars and we don’t do it correctly so why not teach us all how to do it but it’s not taught easily in dental schools and so I wanted to fill that gap and be the mentor that you know I didn’t have when I was going through it so I’m really proud of this course, it took me years to make and [Jaz]It’s like a lot of hard work I mean even just to get the clinical views and some videos you actually on purpose made it to like it felt as though I was there, I was extracting it the way you angle it and you made a point so I’ve made the record this video so you feel as though you are, you know, lower right molar tooth, you are using the blade to make the decision and what I learned on there not only has helped me to take on these courses also with your mentorship which I’m so grateful for that specific case I know you’re there to support and I remember that you actually sent me this personalized Whatsapp Video was like ‘Hey, Jaz. Great to have you on the course. Look forward to doing that.” That was a real surprise. But I was also proud that I was a first ever delegate to send the video back to you. [Nekky]Yes, ever. Half the people don’t even text me back. But it’s, I think it’s cool. I like to meet the people in my course I don’t want you to take the course and then I never get to talk to you. So I like to, you know, carve out time and talk to everyone individually see what they’re having problems with because if we’re not here for each other, what are we doing this for? I’m literally here to help you and I’ve dedicated my evenings after you know taking out third molars in the day I want to help my fellow dentist because we all need to get better together. [Jaz]You really do live and breathe third molars and honestly it really shone through in the course. Absolutely fantastic. But like I said, I had my reservations Nekky, that okay, Can you learn third molar online and what you showed with the videos and the number, the quantity and the quality of the videos made me feel so much more confident plus the mentorship that you offer was amazing. So guys, if you’re looking for a third molar course, Nekky’s is the one to do. Do use the code, he’s generously offered 15% off, it’s “protrusive” and you know it’s just shows how much hard work you put in. So Nekky, thank you for that course. Thank you for mentoring me. I mean obviously send you some photos of these roots that when I hit that furcation, and I get those roots out I’m gonna send them, I’m gonna WhatsApp them straight to you, brother. [Nekky]That’s right. I’m gonna send you out some stickers now too, because you got to hit those furcations every day. You need to remind yourself it’s gonna be great. [Jaz]That’s such a cool tagline, man. Nekky, thanks so much for tackling all those. Kameran thanks for the question that you sent in on our telegram group. By the way if you’re not in our telegram group is protrusive.co.uk/telegram there’s so many great dentists I think over over like almost 400 dentists on that telegram group and it’s just, it’d be great to have you guys on if you’re listening. Nekky join that, Are you on telegram, Nekky? [Nekky] No I’m gonna have to though. [Jaz] Okay, you will be now. Download telegram on your phone. [Nekky] I will be now. [Jaz] Join our telegram, it’s like WhatsApp on steroids. Okay, so join our telegram and you will be our resident third molar mentor. Thank you. I really appreciate you coming on, Nekky. Thank you so much. Have a awesome weekend. What are you up to? [Nekky]Man, this is a huge honor for me. You know just hidden to the office, we’re expanding our office right now after all this COVID stuff it’s hard to find workers so everything’s behind so you know I’m just trying to play catch up and having fun doing it. So it’s good. [Jaz]Well, thanks for carving out time for this but also I just remembered when we had that mentoring session, okay? It was like, I don’t know 10:30 here. It was 4:30am and you look so fresh and so good and so pumped. I was absolutely amazed, blown away by the service. So I shall have to mention that. Nekky, thank you so much for your time, really appreciate it. Thanks for all those gems. [Nekky]Absolute honor. This is a dream come true for me. So you’re a dental legend, Jaz. So it’s great for me to be on here with you. [Jaz]Thank you so much Nekky. Jaz’s Outro: My goodness isn’t Nekky such a charismatic man. I mean, I love his style of teaching. I love his deep voice. I love his AV setup. He’s like been one of the best guests I’ve ever had in terms of good audio and video equipment. So kudos to you buddy. Like I said if you want to join the course, if you want to find out more about the course is a thirdmolarsonline.com that’s thirdmolarsonline.com I’ve done it, it was sensational. And with the one to one mentoring that he gave me. I just feel really confident to tackle that case that really sparked my desire to learn more about tackling more complex wisdom teeth. So the code to use is “protrusive” Nekky, thank you so much for giving 15% off to all the Protruserati. I hope you guys make use of it and hopefully Nekky will also join us on our telegram group to be our resident third molar expert. Nekky, you did a fantastic job on this episode. Thanks so much. I’ll catch you same time. Same place. Next week. Guys, thank you so much for listening all the way to the end.

Building on from Basics of Occlusion Part 1, I am joined Dr Mahmoud Ibrahim who takes us on his journey from hating Dentistry to eventually loving occlusion and aesthetic Dentistry. We geek out over occlusal contacts, the occlusal examination and freedom in centric! https://youtu.be/emfAS95VARU Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: When you’re checking occlusion after placing your restoration, check on the contralateral side with the articulating paper (19 microns, for example) to see if it is ‘passing through’. If it does pass through, double up the articulating paper (now 38 microns). You can keep doubling-up if you need to, until the paper holds. How does this help? You’ll know right away if you need to adjust anything, and if so, you’ll get a better idea of how much adjustment is likely. “Keep everything nice and smooth, the patient has nothing to grab hold of and push against. That’s probably going to make sure your restorations last a lot longer.” – Dr. Mahmoud Ibrahim Jaz Edit to the above quote: By ‘Smooth’ we don’t mean highly polished or glazed. We refer to the movements of the mandible being smooth, rather than jerky or abrupt. 3-minute Occlusal Examination PDF – Click here In this episode, we talked about: 7:59 Mahmoud’s journey in Falling in love back to Dentistry 13:16 Tripodized Contacts 19:55 How to maximize cusp to fossa 26:54 Bonus little trick on avoiding high restorations 28:40 What do we check in a basic occlusal examination? 38:15 Freedom from Centric/Freedom in Centric 49:11 Relevance of the Centric Relation Contact Point 56:41 Disadvantages of doing MIP vs Centric Relation Contact Point Join us in our Telegram Community, where we can always help each other out! If you loved this, be sure to watch the Part One of the Basics of Occlusion! Click below for full episode transcript: Opening Snippet: As the mandible is moving, everything should be smooth, and then also everything to be shallow. If you can do that, like you will dramatically reduce your rate of failures with the anterior restoration, just those two gems that you gave there... Jaz’s Introduction: Hello, I’m Jaz Gulati. And in this episode, we go one step further carrying on from basics of occlusion part one, right,? Thank you so much for the awesome feedback you guys gave for part one, and I’m so happy to have my brother from another mother cut from the same occlusal cloth, Mahmoud Ibrahim, who is a fantastic dentist, you see his work on Instagram. He is amazing. But just learning about a story from this episode is so, so great, because it’s the first time we had a proper chat. I’ve been following him for a few years now. And I didn’t realize that he hated dentistry when he qualified right? And I look at his work now. And I think whoa what happened so as well as so many clues or gems. So I’m going to give you a little preview of in a moment that we share with you. I love just him sharing his story with you of what happened, what was the spark that changed him from hating dentistry and actually trying to follow a career of making websites to then falling in love with Dentistry again in a big way. And they’re really killing it at the whim as he is. Now, I hope you got your coffee ready because there’s a lot of stuff that we’re gonna cover in this very intense but very jam packed episode. Hope you like the analogies and stories and in cases that we discuss, we’re trying to make it as friendly as possible for all my beloved listeners. The watchers is great to have you if you’re on YouTube, hit subscribe. But for those who listen, you are the originals, I will always make sure that the content is easy for you to consume on your commutes. Right? So the kind of things that we cover is what is the difference between the so called tripodized contacts, and is it really better than cusp to fossa and how can we maximize stability with a cusp to fossa occlusion? Okay, we go very much back to basics there. We also talk about what happens when you store someone not in centric relation? Like we talked about a couple of scenarios where you might do that in the previous episode, but what actually happens, what are the risks that you accept, okay? and we also cover what is this concept of freedom in centric or freedom from centric and where do we apply it? where do we believe in it and if so, how do we apply it, right? So if you’re still hungry from that part one occlusion, just listen all the way to the end. This is absolutely jam packed Mahmoud you were absolutely awesome. The Protrusive Dental pearl from this episode is something that we actually discuss in the episode and I’m not sure you just highlight it here I think it’s so good that it deserves its own place which is basically when you’re checking the occlusion, okay? On that topic again when you’re checking the bite, imagine you’ve done a restoration at the common thing to do is to stick your articulating paper on the side where you’ve done the restoration and just look at the marks, right? But what I like to do is after I’ve finished restoration, take my rubber dam off, let the patient have a bit of a rinse or swallow whatever I just put them back instead of checking the same side where I’ve done the restorations I actually checked the other side. Now I know my articulating paper is 19 microns, okay? So I check on the other side. Now, if the patient is holding on that side, I either the articulating paper is not passing through. I know that my occlusion on the right side where I was working is accurate to within 19 microns, okay? Now if that articulating paper passes through, okay? Then I know that I’m out by at least 19 microns so then what you do as Mahmoud says in the episode as well is you double up the articulating paper now we’re on 38 microns, right? So you, patient bites together, you’re checking the other side okay? And now the patient is biting, okay? They weren’t at 19 now they are at 38 microns ie thicker paper. So now you know that you need to do between 19 and 38 microns of adjustment. Okay, now you’re saying ‘Jaz, I don’t know how to do exactly between 19 and 38 microns of occlusal adjustment.’ It’s more just give you an idea, right? Ideally, you want to be checking the occlusion like with an indirect restoration before you cement, right? So if you can do this, before you cement you know exactly how much you need to adjust. Like I’ve been there before, adjusting crowns in the past, where I’m just doing tiny little adjustments and checking it, tiny adjustments and checking it, okay? Had I checked this and I know that way, I’m way out on the other side, I would be more efficient in my adjustments. So hopefully that makes sense to you. Join the main episode with Mahmoud and at the end, I’ll reveal one of the future episodes that are planned regarding helping you with your occlusal goals. Main Interview: Welcome, Mahmoud to the Protrusive Dental podcast. And I just wanna say like it’s been great to know you last couple of years, mostly on like, you know, WhatsApp, Telegram, social media. I love seeing your adhesive cases that you do and I love how much you love occlusion like me. We’re all geeks and your contribution to our telegram group you know, with over 300 something dentist now, your contributions, always really welcome. You know so much wisdom that you share. So thank you for coming on my friend. [Mahmoud]Thank you very much for inviting me. I mean, it’s very, very flattering, actually that you’d asked me to come on here have a chat with you. You’ve had some serious sort of occlusal heavyweights on here. [Jaz]I regard you in that same line and honestly, some of the content you post and the stuff that you put on telegram I, you know, you know what we’re talking about. And I want to be able to share that and put you on a pedestal and really champion people like you who have been, you know, like I said in the last episode basis of occlusion, but we’re on a journey, right? at different points. And I feel as though we mean, you have had a similar journey. But I like how you are constantly running, you’re running in this journey. And you’re like, yeah, let’s keep going. Let’s keep going. I’m learning. I’m loving it. So just give us a flavor actually a about where you work Mahmoud. Where are you qualified? And what has your, particularly with occlusion, What has your journey look like? And maybe I’ll say a little bit about my occlusal journey in terms of the courses that I’ve done the past as well. [Mahmoud]Sure. Yeah, I mean, you might find that there’s a the crossover is more than you think. Because obviously I listened to you on your podcast. I know a lot about your part of this, so I qualified in Manchester 2005. And, believe it or not, this is probably where our journeys do differ a little bit. I absolutely hated density when I qualified. I did not want to be a dentist. The first five years were me trying to find a way of earning a living not doing dentistry or earning a similar living not doing dentistry. [Jaz]Wow. So you diversified into different fields. Give us a flavor like what does that look like? What were you doing? Did you open some sort of a franchise or something or like you know what were you doing? [Mahmoud]No, no, I didn’t get quite that far. So I taught myself how to sort of build websites, WordPress and things like that were fairly in their infancy at the time so it was a bit it was a bit more challenging probably than it is now. But yeah, built a couple of websites. I had an idea for doing a bit of a dental bind group sort of thing. I think that exists now. But yeah, I tried my hardest to not have to be a dentist for the rest of my life. And then looking back at it I’m like, that part of me is like Oh, that was such a waste but you know, our paths were a little different and I probably wouldn’t be where I am now if I hadn’t taken that time to figure out what it is that makes me enjoy dentistry, No. [Jaz]So what sparked you? What changes give us that moment where everything changed for you? What year was it? What happened? Was it a cause? Was it a mental?Was it a patient? Was it an experience that you had that you thought you know what actually I do like dentistry after all because I the reason why this was a shock to me and for those who already follow you, know you, like you produce such beautiful dentistry and you’re so, you’re oozing passion when it comes to enthusiasm for dentistry. So to know that hey, at one stage you’re like building websites and you are trying to stay away from denture as much as possible not only is that going to be inspirational to some people who may be going through what you’re going through at the moment, right? And say you know what, you can get to the other side because I think if you are practicing dentistry there’s a danger of not loving it, there is a real danger if you let the day just if you’re clock-watching all day long, you know in any job, in any profession especially dentistry, I don’t want to be in that so I want to know, so share with everyone what changed? What was the spark? [Mahmoud]It was a disappointment. It was, so I was doing a class four composite actually on a patient and I was doing it the way they taught you at dental school, you know, no rubberdam up to date, No, you know, mylar strip, you’re not building a palata wall, you’re not doing any of that, you’re getting the strip in place somehow, you’re squeezing all composite in, you’re pulling it and you cure it and you kind of end up with what you end up and I looked at it and I was like, this is absolute garbage, it’s rubbish. So I was like well okay, every other thing I’ve tried so far to get me out dentistry hasn’t worked, so I’m going to do it, let me at least do it well, and believe it or not the first place I went was YouTube. Things would probably so this was in about five years in so it’s 2010 maybe and qualify 2005 until 2010-ish Yeah, I just started looking up YouTube videos. How’d you do decent looking class four and as I started to get into it and realize all the tools you had at your disposal and I started getting better and my crown fits went from being ‘oh my god I hope it fits. Oh my god, I hope the occlusion’s okay. What is occlusion?’ You know that sort of thing. When it became ‘I know this is gonna work. I really enjoyed it.’ The occlusion part of things actually again I probably will find this very similar to you. It was, what is called? The [Jaz]Yes, DT. The original DT [Mahmoud]Yeah. You know Lane Ochi, Michael Melkers, john off the these people. So I was starting to get into my Dentistry and I was like, Okay, I want to do slightly more intricate work, slightly more complex work. And I was seeing these guys producing this work. And the great thing about that the website at time was you know, they’d be step by step and especially the people we call mentors. Now You know, Michael Melkers and ? , they didn’t just before and after, and there you go, it’s more of a, here’s the before, this is what the patient presented with, what would you do? And it wasn’t I do 17 veneers it was, how do you find out how to? How are they gonna last you know how you’re gonna make them last? How are you gonna make him look good. And it was all about [Jaz]Making a method out of it so that you can actually get to a good endpoint. And what I respect about both those clinicians is that they’re really also great educators in the realms of communication as well at how do you communicate a big case, rather than, Hey, you need, you know, 17 crowns wherever, like, Hey, you know what, here’s a problem. Are you gonna own your problem? Or not in a way? [Mahmoud]Absolutely. And, yeah, that’s kind of where it started, really, because I learned, luckily, without making too many of my own mistakes, what to look for, in terms of red flags and things. And that’s kind of where it started, it became a, like a growing up when I was at school and stuff, like my favorite topic sounds such as so geeky, but it was physics, right? Physics I really enjoyed. Because you could be given a certain set of facts, you know about how the world works. And you can then take that and apply it to a new situation, and figure out and possibly predict what’s going to happen. Whereas biology or something, some of it is a lot more learn, you know, learn by memorizing or that sort of thing a little bit. I kind of always equate occlusion to physics in a way. Because it’s all about force distribution. It’s all about resistance. It’s all about figuring out how to make things last in a hostile environment. And it’s kind of like the CSI part of dentistry if you like. And that’s what drew me to it, it was very, each patient is different, and you just go put the pieces together and try and come up with a formula that would work for them. [Jaz]That’s a really cool way to put it in. I always, as you’ve heard me say many times a podcast like you know, as Steve Jobs said, you can only join the dots when you look back, and then we look back at your physics interest. And then it only make a sense that, okay, you’re applying it through occlusion. And you’re right, there’s so many similarities there. Like, you know, in a hostile environment, like aerospace engineers, they’re designed these aeroplanes to work in hostile environment. And they’re thinking, Okay, what about the fo-, you use that word force distribution. And I mentioned about the force management that Ed McClaren said in the last episode, and I definitely see occlusion like that. Now there is a danger and I know you know this already as more, I’m just showing this for everyone else. There is a danger in making it like overwritten it, making it too much about engineering and then dissociating that from the patient as well because there’s so much resilience that everyone’s has, you can get away with a lot as well. But it’s knowing with which patient you can get away with it, and which one you can’t. And then being able to apply the the force management because you want your work to last longest, but also realizing that there’s a whole bio psychosocial element to it as well. So let’s just, why don’t we just dive right in to the main question, you know, I got around about four or five questions I want to just to quiz you on but then also add my input, and then also have a little debate and I said to you already, man, if we disagree with something, which I don’t think will happen, but if it does happen, amazing, because I want to be able to just sound out a couple of ideas, right? So when planning for contacts, what I mean by that is, when you do your restoration, and you stick your articulating paper in and you get the patient to bite together, what should those dots look like now there is something called Tripodized Contacts, and for a little bit of history is like more an arthrology and this is essentially it’s like cusp to fossa, so the lower, let’s say the lower molar, lower first molar, the buccal cusp in the central fossa of the upper molar, except there’s now that cusp is making three little dots in that fossa, right? It’s making three little tripodized dots. Okay? And before I really go into it, just explain what your understanding? Is any more that you want to add on to that? [Mahmoud]Yeah, that’s exactly right. And I think another important point to make is that it’s important that the cusp tip in Tripodized Contacts does not make contact with the opposing tooth that’s a part of the definition I believe. So the tip itself, the very tip of the cusp doesn’t actually, it’s the three point to contact where into which the cusps sits prevent the tip from hitting the bottom of the fossa if you like [Jaz]Yeah and then that’s good because with the Tripodized Contacts is the main claim benefit and it makes sense in terms of engineering is that the net result of the force from this tripod is through the long axis of the tooth which makes sense engineering wise and but there is a problem with that. And this is why many of us include myself and I know you have as well have moved to cusp to fossa so so just talk about what are the challenges? Maybe when you first learned, did you just try in doing Tripodized Contacts or did you learn from your mentors that actually, this may be overkill, what are the challenges when you’re trying to implement this Tripodized Dentistry? [Mahmoud]Yeah. So I mean the way I learned specifically, I’m a very visual person. So the way I looked at it when I was looking at Tripodized Contacts versus cusp to fossa, was okay, so if I’m going to try and replicate this, whether it be in a direct restoration, or an indirect restoration, first of all, it’s very, very difficult to achieve. [Jaz]Can you see that Mahmoud, by the way? Can you see this? So I just put the image up, can you see this? [Mahmoud]I’ve got it. [Jaz]Alright, sweet. So this is a you know, obviously, you mean, you I want to make sure that we respect the listeners of the podcast while you’re commuting, chopping onions, or gardening, that kind of stuff. But if you’re watching on YouTube, then you can see a visual, but we’ve described it. So this is just a visual aid for those who are watching. [Mahmoud]So as you can see, I mean, the three point contact, sort of in the middle of that lower molar, for example, being able to build your cusps. in that fashion, getting each one exactly right, to get even contact on each side with the opposing tooth, is difficult. Now, let’s say you’re just gonna grind it down into that, if somehow you grind one of them slightly more than the other two, you’ve been introduced inclined contacts, which are very, you know, inherently unstable, as we know. But even so you get it right on that first time. Now, what’s stopping the patient from wearing one of those contacts more than the other two? And again, introducing an incline contact. The last one, again, is more of them brain exercises, depending on how close those contacts are, you know, the tripod, how small that tripod is, if it’s a bit bigger, how hard are you getting your patient to clench when you’re checking that contact? Because that is then going to affect how much shearing force you’re going to put on the sides of those cusps? So if you’re not doing it hard enough, what if they are a nighttime clencher, or daytime clencher or whatever? And you’ve done this in your beautiful ceramic, and you find that it starts to crack. So it’s just and then the last thing I guess is, is it necessary? I know that the concept was introduced to give the tooth positional stability, but I think we’ve seen through Pankey, Dawson, Spear, I mean all teach cusp to fossa, as you show on the picture there. [Jaz]So I’ve just put a photo of the cusp to fossa on which we’ll describe and go into and maybe their advantages over the tripods. But as you’re saying, you’re saying exactly how I agree with you, yeah. [Mahmoud]Yeah, you know, that we can’t forget, for example, that the main thing we learned at dental school, for example, about positional stability fatigue is neutral zone. Now, your neutral zone is still there. So if you can get one or two, maybe even three, cusp to fossa contacts on the tooth, it’s sitting within a socket, within a periodontal ligament, you’ve got the tongue, the cheek on either side, you’ve possibly got mesial and distal teeth on the mesial and distal. Chances are it’s going to be stable, it’s probably an unnecessary addition. Unnecessary complexity to add the Tripodization? [Jaz]Well, the only thing we haven’t mentioned is that okay, we mentioned the case of a direct case and you’re trying to get those contacts and the challenges that we have there and then also about what if the patient is a clencher, and then how well you’ve engineered that tripod. But also if you’re doing any, if you’re doing a big case, a full mouth rehab case and you’ve prescribed to your technician, a tripodized scheme, like your technician will be spending forever in a day to try and get that and then you know, what is the chance that as you fit those crowns, it’s going to be exactly how it was on the articulator, okay? We know that doesn’t happen, and therefore then you’re grinding and doing it and then essentially, you’re getting these cuspal incline contacts. So it’s much easier and better and by the way strong pay respect to Mr. EM Langenwalter, DD, it’s DMD for these images. That’s why I’ve kept this EML on there because this is his work. That’s why I base, it’s one of the clearest diagrams I could find online of tripodized versus cusp to fossa. So yes, lab work is going to be challenging with that, so it’s not best to do and then one thing to just summarize what you just said there is that Okay, if you’re going for tripodized contacts, what is the alternative? We know cusp to fossa, but then some people might say that Oh, with cusp to fossa, then you because you only have one contact. It’s not stable enough. But just as you said, we know the tooth is not going to go mesial and distal, because if you’ve got a tooth, either side, you’ve got the contacts. We know it’s not going to go buccal or lingual because it’s in the neutral zone, right? And therefore, this serves the purpose and it fulfills the purpose of maintaining that vertical position of the tooth. And together this is why many dentists are cusp to fossa. But one thing I know that you’re very good at because we spoken about this before is that actually the definition doesn’t just finish at cuso to fossa. It’s a cusp to a flat area, flat landing pad or flat area rather than finishing on incline. Now I know you are very good at implementing this you know show me photos of you implementing this, it’s something that you’ve been speaking about on our telegram group as well. So if you don’t mind just explaining a little bit about How to Maximize cusp to fossa for our benefit in terms of the flat areas. And what’s the benefit of that? [Mahmoud]So it’s all about simplifying the process in order to get the end result correct to the patient. Basically, landing pad occlusion is something I learned off of Michael Melkers and Lane Ochi initially. And the concept is that you take the, where the opposing tooth is going to contact your restoration. And instead of it being at the bottom of a fossa, you raise the bottom of that fossa up into like a little flat receiving area where the stamp cusps or the functional cusps directly contact thus directing the force down the long axis of the tooth, number one. Number two, it gives you an area that’s very easy to adjust if the occlusion is high, and we can maybe talk about the trick of you know, figuring out how high by doubling up your articulating paper, etc. But it’s very easy to grow in that flat area down keeping it flat. Whereas if you’re trying to deepen a fossa, it becomes very tricky. And the other thing it does is because that area is flat, and it’s usually sort of hard, you know, maybe a millimeter diameter, or at least that’s what I tell my technicians to do. It’s got sort of inbuilt into it, something we will discuss later, which is that freedom in centric concept. So that’s why I really, really like it. And it’s made my indirect restoration adjustment fit so much easier. [Jaz]Absolutely right. And it just makes sense physically, rather having your three dots and now going to cusp to fossa but not just cusp to fossa in the depth of the fossa, you actually have a strategic area, which is going to be perpendicular to the functional cusp or the stamp cusp. And just it’s not only it’s beneficial to us as dentists, for the technician, because it’s easier for them to make. And it gives us that freedom in centric or freedom from centric, and we’ll talk about that. So the conclusion of this question is okay, we used to do tripodized contacts, because an arthrologist believes this was the optimum way. Now the change has happened to us to cusp to fossa but it’s a cusp to flat receiving area or landing pad different terminologies. And that makes sense. Now, before we get on to like how to check how high the occlusion is a little bit, I just want to ask a really important question, which is some dentist might be thinking, listening to us and saying, Wait a minute, wait a minute, does that mean I now have to start fiddling around with everyone’s natural forces to create these flat landing pads? What do you say to that, like, you know, how can we implement this on Monday morning? When should we be implementing this and when should we be accepting the status quo? [Mahmoud]I mean, if the patients, I mean, you know, this, I think there was a, I can’t remember who said it, but it was either Pete Dawson or one of those said that I did hundreds of equilibrations on hundreds of patients and some of them may have even needed it. It’s a kind of a similar concept where, if someone’s got no functional problems, they don’t have tooth wear, they don’t have tooth mobility, they don’t have sensitivity, they don’t have TMJ issues, muscles headaches, if everything’s working for them, there’s absolutely no need to change it. The only time I apply these concepts is I’m restoring the tooth anyway. And all I’m trying to do is give the patient something that’s going to work so they can chew on it, it’s not gonna be sensitive, it’s not going to break hopefully it won’t break. So you know, you only apply these things when there’s a need because you are already doing some dentistry or sometimes it’s you know, the patient has an aesthetic concern that is there that’s the main reason they’re here but you are also responsible for making sure that your dentistry last so if you’re going to then be changing the guidance or opening the vertical because you want to you know give them more freedom whatever is, then again I would apply these principles because just because their natural dentition had something for a while. If I’m then going to be putting my own stuff in there I’m going to give it the highest chance of success without compromising things like aesthetics or function you know, I’m not going to give patients teeth they can’t chew with just because then they won’t be able to break them. But you’re also want to use as many of these tips and tricks as you can to make your life easier to make your work more predictable. [Jaz]I just want to highlight that, Mahmoud and I clearly agreed, the reason it’s important to highlight that is because I don’t want young dentists listen to this and then next Monday morning, they checked the patient’s mouth and the patient’s got like some craziest skeletal class three occlusions that Oh my God, I’ve got to get my handpiece out and start drilling to create these flat landing pads. No, no, it’s not the case at all. So the way I like to explain it as just like you know, to add on to the beautiful way that you said it is a one definition by Jeff Okeson. So Jeff Okeson is a very big name in the world of TMD occlusion. He defined the dynamic individual occlusion, okay? Which is the occlusion is considered acceptable if the patient is functioning efficiently without pathosis, okay? So that’s one thing and then when I did the Dowson Academy, Ian Buckle following on from Pete Dawson introduced the concept of ‘okay you have your general patients and you’re complete patients and your general patients are the ones who you know even though they have an AOB, okay, there’s no, they don’t have any fractures, they don’t have much wear, they’re doing fine, they don’t have any pathology at all, no TMD they’re doing fine, stop, don’t fiddle around with them for the sake of fiddling around with them and changing anything because they are, that occlusion is working for them. Then you got your other patients whose occlusion is not working for them. And then they may or may not also want an aesthetic improvement or they may not have like several caries lesions and then you need lots of crowns and restorations.’ Now if you’re going to be now doing committing yourself from dentistry anyway, then just like you said, why not take that opportunity to maximize success and put this engineering concepts in to get better longevity. So that’s why it’s important to say that hey, don’t go around thinking that Okay, everyone needs to have this if what they have is already working for them then great. But if you’re intervening, whether it’s single tooth, and you’re just going to make your crown and you’re gonna tell your technician just like you do to have this and we’ll talk about the level of training that you individually need to you know, speak to a technician have that communication because you can’t just write in your technicians lab slip, please give a cusp to flat landing pad occlusion and they’ll just do what you want. You have to spend that time sit down with [Mahmoud]No. What I did was got them to come on your course. I got both of them to come on the 2020 occlusion [Jaz]Amazing and that was so good to see and you know, massive hats off to you for for getting them on there. And massive kudos to them for wanting to learn and say okay, how can I make better work for Mahmoud, you know, so that is a amazing. So that we can maximize the time we’d, you didn’t mention, that’s not the official question. But we as we’re talking, let’s talk about a scenario where, you know, patient bites together after restoration. And now it’s high or is proud. I’ve got a little video that upon just recently about nine little techniques, little tips to make sure that you don’t have high restoration. But let’s say well, we are proud. And what is that little trick that say about doubling up you’re articulating foil? [Mahmoud]So we’re assuming we’ve already cemented it in [Jaz]Yeah, let’s go for it you cemented in and the patient bites together. And we think we’re high. [Mahmoud]Yeah, I mean, assuming you know that, you need to know the thickness of your articulating paper, but I would put it in on the contralateral side. You know, let’s say it’s 20 microns, and it pulls through, I would double it up, put it in on the contralateral side, if it pulls through, you know that you’re going to need to reduce by at least 40 microns, maybe more and double up again. And you keep going basically until it holds that will give you an indication of how high your restoration is. Now obviously, ideally probably want to do this before you’ve cemented on. Because if it turns out that you’ve got to reduce a millimeter and you know you’ve only done a millimeter and a half reduction, which again might come on to something we speak about later. You probably want to re prep. [Jaz]Absolutely and so that’s beautiful pearl, it’s a great way to test it. And in the opposite scenario, you know, you check and the patient is biting. So sometimes you don’t checking the occlusion, I will do this technique straight away. I won’t even check the occlusion on the side I’m working on, you probably do the same. I check on the contralateral side. Okay, they’re holding my 20 microns. So I know that I’m at least within 20 microns, I’ll then pull out my shim stock foil and check the contralateral side. Okay, they’re holding on the shim there, amazing. I’m within eight microns now. And then I’ll check the tooth in front and behind the one I’ve worked on, and they’re holding it on there, right? I don’t need to check anything, really. So that’s a good way of doing it. So I’m glad we’ve covered that as well. So look at how much value to build in this episode. Shall we move on to now, What do we check in a basic occlusal examination? [Mahmoud]Okay, so when I did my MSC at Manchester with Stephen Davies. And he absolutely and he uses a form on his TMD clinic in Manchester called a three minute articulatory system exam. And I found this fantastic because it gives you a very easy to follow checklist of everything you need to check. And it’s something [Jaz]We can. I asked him by email, Can I share? This was like four years ago, I asked him Hey, can I share this with dentists? He emailed me back saying yeah, that’s totally fine. So you remind me, what we’ll do is if you go to the blog post for this website, and on the telegram and on the Facebook group, I’ll stick it on. So it’s three minute occlusal examination, what you need to record and it’s really quick and easy. It’s really valuable information by Stephen Davies. You know, all his work, amazing, we’ll stick that on to benefits of all. [Mahmoud]I have added a few little bits to it. In terms of additional thing or or maybe you know, what do you do when it’s an you know the result or you’re finding is negative or you find a problem? Because if everything’s a no no, no and everything’s clear, it’s fine, you’re done. But what do you start to look at if it’s a positive and that isn’t or so it just as a memory jogger. [Jaz]Can we put their Mahmud modified version? If that’s okay with you? [Mahmoud]No. I’m not gonna claim with some yeah. All got it in for that. And but yeah, so it covers things like, you know checking the TMJ palpation, for pain, you’re checking for noises. So clicking, popping, crepitus. I don’t have a Doppler, but I do like to use a stethoscope. And then you’re looking for range of motion protrusive, lateral, maximum opening, and you’re looking for any deviation. And then we do the muscle palpation origin, insertion. And I like you also don’t believe that lateral pterygoid can be palpated. So I do a resistance test. And then the rest of that form goes into skeletal class, incisor class. And then see, again, something we’ll look at later, which is does CR occur in MIP. So that’s actually something we’ll need to clarify on the forum because it says CR does equal CO. [Jaz]Which is using the older definition. Exactly, which is why everything in you know, it just goes back to this the definitions, right? So Exactly. [Mahmoud]So we’ll clarify that but and then it goes into checking things like working side interferences, non working side interferences, I put them in air quotes. And then whether the patient has canine guidance, group function, etc. And then at the bottom, it’s got a sort of compression test. Now, I used to wonder whether that’s the same as a load test or not, I think the objective is slightly different because you’re only compressing the joint on one side. So basically put like a tongs bachelor or cotton roll. Yeah, on one side I’d get the patient squeeze hard. And if you, again, this is where I go back to sort of visualizing again, if you’ve got something in between the teeth on this one side and you squeeze, you can imagine your condyle is going to move a little bit higher up on this side and compress the joint space. If that if you get pain on this side, it could be that there’s an intracapsular problem. But it also helps tell you if there is discomfort on this side that it might be muscular. And again it’s not you know, you’re not dissecting the patient, you’re not doing an MRI, not you know, it’s a three minute exam. So it’s just to give you a base to start [Jaz]The compression test I learned it as it is load testing at one side. It is load testing at one side at a time. So it’s very similar and I think it can be and a lot of people tell me ‘Hey, Jaz what I do, I don’t have a leaf gauge. And I that’s the advice I give them Okay, get a spatula on the other side. And then the only difference to add on to that is I will actually what I do is I use a hand upon my hand and I put it on the angle of the mandible, the opposite side where the spatula is and actually push a little bit so I’m really maximizing how far the condyle is going up against the glenoid fossa. Yeah, so that is just given the extra and then you find it Okay, is there a load test negative or positive. So I got a little diagram here for those watching, again we’ll describe it like the side that you put the spatula, it almost gaps the joint there, the physiotherapist called gapping the joint, right? So you’re moving the entire mandible, like you know, in a side to side kind of way. So now there’s a gap, supposedly, where you got a spatula, because the spatula is in the way between the teeth, there’s a gap. But on the other side, there’s compression. So as you get the patient to bite together and put your hand on the angle on mandible will push upwards, that is a way of load testing. And it’s great that Stephen Davies had this on the form, because not everyone has access to a leaf gauge. So this is the quick and easy way to do that. So that’s awesome. [Mahmoud]Brilliant. I mean, if you don’t mind I wanted to go sort of a little bit into how I because it’s great to do this on every patient because then you have a baseline I do also maybe think about things a little bit differently when I know what I’m doing for the patient. So Spear teachers, I think four positions of occlusion, right? But the one of them has two lumped into it, so I tend to think of five. So you got if you think from as far back as you could go no more. Okay, let’s consider it Yeah, as far back as you can go physiologically and comfortably, all the way forward. It’s easy to think about, so you got centric relation. Then a little bit further forward, you got MIP that’s two. Further forward is your pathways, your guidance pathways you know there’s protrusive, lateral intrusive, wherever it’s the guidance pattern, and then you end up on some form of edge to edge position. And then past that you got crossover. So generally what I think about it is with what I’m doing with whatever treatment I’m doing, what am I going to be changing? You know, what is my restoration going to be in the way of? So, you know, a few of the cases I’ve posted on my Instagram recently are sort of composite veneers and things like that it’s, you know, everybody’s doing that these days. So, purely facial composite veneer, you’re not gonna be changing, you’re not gonna be affecting CR. Obviously, we said you do the baseline examination, because you want to know that there isn’t any pathology, there isn’t any reason to interfere with those positions. But assuming that the examination is clear, your composite veneer is not going to affect CR, chances are, it’s not going to affect MIP, it might affect the guidance pattern, depending on how much length you’re adding. So then I’m thinking, alright, I’m just going to make sure that whatever length I add, isn’t going to make the guidance any steeper. So by making sure that the composite that I add if the you know, if the angle of the palatal surface is sort of that way, you know, whatever the angle of the palatal surface is at the moment, I’m either going to try and maintain that, or make it shallower. And then you’ve got your edge to edge position, which is probably the most important when you’re doing something like composite venners, you want to make sure that on that terminal, you know, only when the patient sat on the edges, again, you get forced distribution. And everything is smooth. When by smooth, I mean, the when the patient gets onto the edge, or if they want to slide on the edge, there isn’t any clunkiness to it, there isn’t any point the patient can grab, hold of and add resistance, because that resistance means they can put more force on because while the mandible isn’t moving, so they’re just gonna push harder. And then the same sort of thing with crossover. You know, you don’t if the patient naturally goes past the canine position. So crossovers, basically, once the patient has guided, let’s say left, and they’re coming onto the tip of their canine and they’re sitting on that tip, that’s their canine guidance. Once they go past that tip. They’re into that crossover. That if they go past that tip, and it’s a big drop, you know, or for their central incisors. [Jaz]Or they crash together [Mahmoud]Yeah, exactly the lower incisors crushing for the [Jaz]Jerky movements. It’s about identifying and eliminating those jerky movements from the transitions. [Mahmoud]Exactly. Keep everything nice and smooth, the patient has nothing to grab hold of and push against. That’s probably hopefully going to make sure your restorations last a lot longer. [Jaz]I think in the last 60 seconds, what you’ve covered here is if you can program your restorations, to always have a degree or a high degree of smoothness, and I don’t mean like a highly polished surface. I mean, as the mandible is moving, everything should be smooth. And then also everything to be shallow. If you can do that, like you will dramatically reduce your rate of failures with the anterior restoration just those two gems that you gave there will make a massive difference to everyone’s listening or watching or doing their restoration. Just remember, if you don’t remember anything else in this Episode, remember smooth and shallow. Okay? You will be absolutely fine. So I’m glad you’ve added that in. Now in the interest of time, let’s go to because it you know, following on from smooth and shallow, let’s talk a little bit about freedom from centric or freedom in centric. I’ve got a diagram to show later as well. In fact, let me just load it up. And then we can talk about it while I’ve got the diagram up. [Mahmoud]This is probably, this might well be the one place where not necessarily we disagree, but we might have differing conclusions but yeah, just [Jaz]Okay. So tell me about whether you believe in or you incorporate freedom in centric or freedom from centric, whatever you call it. But you know, from the way, What is that you understand about this concept? [Mahmoud]Freedom in centric, freedom from centric, long centric, I see them as all the same thing. And I think it was introduced by Schuyler?, and it was basically supported by the theory that CR, centric relation is not a pinpoint position. Now, I don’t know whether you agree with that or not. But to me, that tends to make sense mainly because if you take a system such as the articulatory system, you’ve got two very big shock absorbers in the system, you’ve got the disc and you’ve got the periodontal ligament. Now, any system that has shock absorbers in it, there’s gonna be some play. Again, just that’s the way it makes sense in my head. So to assume that Centric Relation is an exact pinpoint, didn’t sit well with me. So this makes sense. And it’s all about taking something that you’re designing on an articulator putting it in the mouth, they’re not the same. The articulator is there to basically the only function of the articulator is to make sure that you’re adjusting for less time in the mouth. Basically. So you can’t, I don’t want to call it a fudge factor but freedom does give you a little bit of room for error of one function. Okay? So that’s what we talk about when we’re talking about landing pad occlusion because the other thing is when I first got introduced to freedom in centric, it was really an anterior, you know something to the anterior teeth, little bit of room behind the upper incisors for the patient to wiggle [Jaz]So I believe that is the long centric concept, right? So, yeah, it’s a very similar context. So in one, in long centric, you’re looking antero-posteriorly and freedom in centric. You’re looking left and right. Is that the, what you follow as well? [Mahmoud]The thing is, I think it’s probably one of those things that in practical terms, it doesn’t matter. Like it needs to be in all those directions because the patient, you can’t tell them, okay, you can have freedom forwards and backwards, but I’m going to lock you in left and right. So you deal with it. So I just think, again, it gives you the thing that I didn’t understand before it was like, okay, you’re giving them this freedom at front, but if you are giving them Tripodized occlusion at the back, what’s the point? They can’t move anyway. So this is why landing pad oclusion give them that room to wiggle around, couple it with the anterior long centric. Give them that freedom to move slightly where the teeth are still actually loaded. So that’s the important thing, is it? Cause if you just give them that room, but they are moving and hitting the inclines at the back. Yeah. There was a problem. So they’re still actually loaded on the teeth, but as soon as they’ve gone past that area of freedom, you’re engaging the anterior guidance. Now the other advantage is as, because they’ve moved a little bit, hopefully you’re thinking that condyle has started to move and hopefully if you can get the condylar movement in harmony with your anterior guidance, you’re going to separate the back teeth, everything’s going to be again, that magic word, just nice and smooth and shallow as needed. Well, a shallow is, can be while still discluding your back teeth. Yeah, that’s kinda my thought with freedom in centric, basically. [Jaz]I agree. And just to add on to that I think the tubs, is it freedom in centric or freedom from centric? It doesn’t really matter because the term centric here is used as the MIP, centric occlusion. Okay. So just whatever that bite is. And I usually, when we’re doing, you know, rehab dentistry, it is in, within the arc of centric relation. So ie centric relation and MIP are one and the same when there sort of designing either these splints or this many restorations or rehabilitation, so let’s just take it from that. And then as you move within that space or away from centric relation, there is a bit of freedom and I’ll just call this like a wiggle room. Okay? And sometimes to understand what something is, we must understand what it isn’t. Okay? So I learnt freedom in central freedom from centric the best way I learned it is to, to rationalize it like this. Okay? First learn what it isn’t. It isn’t this. Okay? It isn’t that as soon as you bite together. Okay? You A) you’re locked in. And B) when you grind left and right immediate, I mean, absolute immediate disclusion that you’re pretty much on an incline and you’re just discluding straight away. That’s what it isn’t. What it is, is that when you bite together, you can just a little bit, tiny bit tiny wiggle room left and right. Little bit forward. Okay? Before that inclined starts, okay? Now it is debatable and we will never know whether this has any success or importance or bearing, but just like he does to you, it makes sense to me as well in a system which has got squashy parts to attack, to give, make your life easier, to have a little range rather than a pinpoint area. But also I just do find that this also reduces resistance, right? Cause I had that initial flat bit, they’re not on an inclined straight away, and that is contributory to reducing resistance. So I, something I would incorporate in a bigger case, but here’s what I do. I’m going to stopped sharing my slide now. Here’s what, how I incorporate it into orthodontics. So there’s what Andy Toy taught me. So I started to apply this to orthodontics and the way that when I finished an Invisalign case. Okay? And for those who do orthodontics, any form of orthodontics, just when you finished, okay? Get the patient to bite together and get them to clench hard and get them to grind left and right, I had a case the other day, it was a class three case I had, and I just got rid of the anterior crossbite. But now when I got her to grind left and right. Upper lateral was in fremitus, okay? We don’t want that. Okay. Because that was a tooth that was in crossbite. Now I got it back into position. The reason it was in fremitus is because all those years of being in crossbite, it never had any pathway wear so had this like massive kind of like mamelons, but this huge concavity of the palatal of the incisal edge. Right? Whereas if you look at the other teeth, they were nice and flat. So I got my bur and I smoothed it to sort of accelerate it. Now people often think like some orthodontists say, no, no, no, I’m not gonna do any tooth adjustment. I’m going to do lots of put the patient in nine months or finishing to get everything as it is. That doesn’t make sense to me, because the best analogy I have for this is I imagine the maxilla is a lock and the mandible is a key, right? Now through orthodontics, you are tampering with that lock and you’re tampering with that key. You can’t expect the lock and the key to now fit together. Yes, they are the same lock, same key, but just slightly different. Right? So you need to now get your tools out to just reshape that key and reshape that lock so now things fit together better. So the way I can make it tangible in terms of that orthodontic case is I do a bit of adjustment on that palatal, the lateral incisor in enamel. Okay? Now I’ll check again still a bit of fremitus, okay? But not so much, again, I get a soft Lexis, just smooth it out. Get rid of that sharp corner of the leading edge of the lower incisor. Okay? Again, that contributes to making it smoother as well. Okay. And patients love that. Okay. And now that tooth is no longer in fremitus, but now here’s the magic thing. Okay? So as per Andy Toy taught me this, and I’ve been using it and getting lots of success is you get the patient to clench together grind. Okay? And then as they grind left and right, you ask a patient, ‘can you tell me if you can feel that there is a back tooth in the way, is there a tooth that’s in the way’ and straight away, she said, ‘yeah, over here.’ So she pointed to her upper left premolar, and I put my finger on it and I got to grind left and right. And that was in heavy contact. Now the beauty is when you finish an Invisalign case, all the teeth are mobile, right? They’re a little bit mobile because everything’s moving, right? So you can actually feel it more on your finger. And when you just adjust that a little bit, now you don’t need much adjustment, you’re just, you’re almost creating a flat landing pad with your lovely littel bur, but just literally a tiny bzz, that’s it, that’s all you need. And then get the patient bite together and grind left and right again, everything feels smooth and even, and that for me is how you finish an orthodontic case as inspired by Andy Toy. And I’ve been getting a lot of success with that, so that there’s no more fremitus, everything’s balanced, everything feels smooth and everything feels comfortable with the patient. And the patient is not aware of any tooth as she is clenching and grinding. And that’s all point, I want to test it during the clench. I want to test it when it’s going to be a maximum loaded. I want to test it through a potential parafunctional activity. And we test everything to parafunction, where we hope that it’ll surpass it in function. So that’s another way of how I incorporate this little bit of freedom within the patient’s post orthodontic occlusion. [Mahmoud]That’s fantastic. And the analogy is, [Jaz]Thank you. I thought of this morning before speaking to you, I thought, okay, let me think of, I was thinking of how can I explain this the best unless you don’t have this morning, but I’m gonna continue to use it. Thank you so much. I’m glad you liked it. So okay. We talk about freedom from centric and how we both like it. And again, once again, it doesn’t mean that we go to all our case and start incorporating this in, when everything’s working for that individual is when we are doing dentistry is where we’re doing a full mouth rehabilitation in an enamel aka orthodontics. It’s when we’re doing crowns and anterior restorations, you want a little bit of wiggle room, right? So I hope that helps people in terms of learned the definition. I’m glad that we, yeah, I don’t think there was any disagreement between us, buddy. I think we both agree there. We talk about a basic occlusal examination as well. The only thing I might do differently is a lot of a new patient examination. Like there’s so much to check for sometimes. So I will check for the degree of hypertrophy of the muscles, but I won’t in every case check the origin, the body and the insertion of a masseter, for example, I’m saving that for, okay, are we now going further? Are we gonna be doing some dentistry or is this a patient who’s complaining of headaches or they do actually have significant hypertrophy. So I, sometimes I reserve that for my so the, my basic is like a, BPE, Like a BPE of occlusion. I’m doing certain things, okay? This is a high functional risk I’m going to do more. And one thing that you do, which I don’t actually do it, you mention the full range of motion. I think that’s great practice by the way. So I think you should do it, but for me, the first time I see someone, can you stick your three fingers in your mouth? They can. Okay, fine. I’m going to move on now. Okay. That’s my BPE. That was a code two or code one, or code zero BP. If they can stick their three fingers in that’s a code four BPE equivalent, right? So like, okay, now I’m going to get the ruler out. So it’s about, it’s about maximizing your time and efficiency, but I think if you could, everyone could do it the way you do it, it’s the best. It’s the gold standard way. I’m just giving those people who might have only 20 minutes new patient examinations, something to work with here you see. Right, let’s cover now, buddy, the relevance of the centric relation contact point. I’m just looking at the time. I think we’ve got another 10 minutes of this episode. We have to cover in the next 10 minutes. Okay? The relevance of the centric relation contact point, and then which ties nicely with this. What if you rehab someone not in CR what could happen? So, Mahmoud, let’s go for it. What do you think is the relevance of the centric relation contact point in terms of you as a restorative dentist? [Mahmoud]Okay. So I mean, it becomes relevant in a few cases. Number one, I think, and the most probably important one is when you’re trying to restore the terminal tooth in the arch. So if you have a lower seven that’s fractured and you’ve discussed it with the patient and you’re going to crown it, there is a hot, you know, there’s a good chance that tooth is the centric relation contact point. [Jaz]This last tooth in the arch syndrome. Okay. As requested by Oh gosh, I forgot his name. I’m so sorry. He messaged me yesterday. Might have been Jordan. I’m not sure. He says, can we have an episode on this? And I was like, yes, this needs its own episode. So yes, in lawsuits in the arch syndrome is one. But I think we can, we’ll literally that half an hour talking about how to recognize it, how to prevent it, how to communicate to the patient with it. So, yes, let’s just take that as a point. That yet that is one very important point, but I’m probably gonna get you back, buddy. And we’ll just discuss all about that, this concept. Okay? Because that can take a whole, a lot of time. So yes. Can tell me some more? Because I want that to be its own episode. [Mahmoud]Okay. So next I use it, personally I use it to verify my centric relation mountings so you know, you check what it is in the mouth when you’re doing your so most of the times he ends up for, to use a leaf gauge. So I’ll find the centric relation contact point. I’ll take a picture of it. Now you verified it with shim stock. You know, it’s not a false contact. Once you’ve taken your two or three CR bites, then you’re getting the mounted. I will then check that contact on the mounting, if it’s exactly the same as in the mouth. And the two bites are the same, you’re pretty comfortable that your mounting is correct. So if I’m going to do an appliance, whether it’s full coverage or anterior only I will check where their centric relation contact point is, and that will also give you, it will show you how much space you’re going to have at the front, if they can only hit on that point. Now, if they have a huge gap, you know, that should they, deprogram enough and you get mandibular repositioning and they do end up with an anterior open bite. You can show them how much of an open bite they’re going to get. And that gives you really good informed consent because they’ve seen it. And we know all the other social risk factors around zero. [Jaz]I’m just going to remind everyone. So the A), if they have a large slide and then when you put them in centric relation with the leaf guage, for example, and then suddenly their mandible opens up. Okay? Especially if it’s vertical and now they look very different than mandibles moved a lot. And if they, just like you, Mahmoud said, if they deprogram, then they could have an AOB, not because the anterior intruded or the posterior distruded it’s because the manual shifted. But the other two risk factors here is if they’ve got a lack of a cusp to fossa relationship with the back, if they’ve got all flat teeth and then the mandible almost will find it difficult to remember, ‘oh, this is how I used to bite, because it can’t find is bite again. And the other one is if they start off with a minimal overbite in the first place, then even a tiny shift of the jaw will reveal the underlying AOB. So those are two other factors. So yeah, another great point there, so also to identify those who might be high risk of AOB, and like you said, I love the fact that you said it’s not only anterior only appliances. It’s also Michigans, Tanners, any appliance, okay? Can cause this. And some people naturally over time through nothing at all will develop an AOB because over time the teeth flaten and they almost deprogram themselves. And then now that all my teeth used to fit together, now they don’t anymore. [Mahmoud]They’ve equilibrated their own centric relation point around the point basic. Yeah the other time we use it, again, if you are, if you have a anterior tooth wear patient, occasionally you can, if you find that centric relation contact point again, you check and see that can give you enough space anteriorly to do your restorations. And the reason that is handy is because again, if you think about it, if you restore them in that position, they’re actually still at the same OVD posteriorly. So the risk of them having a problem with that thing or, you know, as studies have shown, you know, whatever OVD they had after you’ve restored them, they’re going to resort back to that OVD somehow. You don’t have that problem because you’ve actually maintained the same OVD [Jaz]I believe it’s also to do with the muscle length, the muscle length at that CCRP is the same as it was in MIP sometimes. You know, sometimes if you have a vertical component, technically there is a vertical change, but at least that the muscle length would still be happy at that first point of contact. Cause it’s already used to going there, you see as it’s developed with it. [Mahmoud]Exactly. You’ve explained it so much better than me. I tell you that you’ve been this living a lot longer. Yeah, I think [Jaz]Those are all ones that, yeah, I mean, I just wanted to bounce off to you to cover those. I mean, the main thing is we know, as we discussed from the last episode and hopefully you agree with me, Mahmoud that it is a position of a high restorative convenience reproducibility, which is very advantages to us as restorative dentist. And I like the fact that you covered the last one, the big one is that we’ve got tooth wear you feel like, oh my God, I have no space to build up these front teeth. But actually when you check the, you suddenly have some space in their centric relation contact point, and that will be useful. The only other one I’d say is if you do screen your patients routinely for where is their central relation contact point, and when you check it’s on a tooth on, let’s say a premolar or a first molar or a second molar but that tooth has got a large restoration. It’s got a nasty crack point there. Then that is something that you, you know, if you take a photo and show the patient that look, this is your position where it hits first, and it might be no coincidence that this is a tooth that’s the most battered or most destroyed, most damaged because when we grind, we like to go in that position. And so therefore for this tooth is high risk. Maybe we should be more proactive with it rather than reactive kind of thing. So sometimes just to identify, is it on a tooth that’s already quite compromised? And perhaps when it comes to restoring that tooth, you may be then opting something indirect, gold, perhaps rather than direct because, oh, now I now know one more piece of information about this tooth that this is actually the centric relation contact point so this may change. You might actually be a little bit more destructive and sometimes, very rarely, but to make sure that actually your future proof the restoration, right? And then this leads nicely to the two scenarios I spoke about last episode. Mahmoud, you’ve been absolutely brilliant spiring on me here. It’s been so good to just bounce ideas off. I want to say that last episode I struggled so much. It was like, ah, it was like just the monologue. I just loved having your head. And you know, you’re such a knowledgeable guy, you said all the right things. It’s amazing. So that, that scenario that you have that I discussed in the last episode, whereby you have someone who’s very class two div one, right. They’re very goofy. And then you find that if you take them into centric relation, they become googier or you have airway concerns. And then maybe in that position, you’re going to just restore them in arbitrary position. Okay. What are the disadvantages of doing MIP, complex dentistry versus not doing or versus doing central relation contact point complex dentistry? [Mahmoud]I mean the disadvantages yeah. You lose, you probably lose the repeatability of the position. So, I mean, I’ve had a few people so ask in terms of my workflow when I do these things and it’s like, okay, you, you know, you’ve got your CR and you’re going to get a wax up and I’ll always do my best to try that wax up on, you know before I touch anything. So you always try for an additive wax-up and then, so you do the additive wax up, you flush it on and the bites all over the place and you think what’s going on? Well, it’s probably because you spent 10, 15, 20 minutes deprogramming the patient when you took the CR by records. So what makes you think that now you can just stick, you know, they’ve not been wearing an appliance, they haven’t been wearing a anterior deprogrammer and you’ve tried this flash on in, and they’re not biting on it the way it is on the articulator, because their position is different. You haven’t deprogrammed them again. So it’s kind of, it might be the same thing, you know, you’re going to assume you’re going to restore them in this position that isn’t CR, so you, it’s not repeatable you do your wax up. And basically you’re going to have to rely on putting it in and adjusting it and using the mouth as the articulator and hoping you can adjust in enough and it might be fine. It might be absolutely fine. Or you might end up adjusting the daylights out of these frustrations. You end up with teeth that looked like chewing gum or fracturing easily because they’re thin, or I guess worst case scenario is if that patient does go into CR when they parafunction, you’re probably going to be, you’re going to have them, they’re probably only going to be occluding on sevens. Now, chances are, even if your beautiful zirconia or whatever it is you put on there, you probably still won’t be enough. It might well fracture. And that is not even taking into consideration all the other, you know, there’s three parts to the system. You got the teeth, you’ve got the TMJs, you got the muscles and, you know, the failure might happen with any one of them. You can have symptoms of the TMJ, you can have symptoms of the muscles. You’re gonna have problems with teeth. So it’s one of those where I would draw their beans CR because I know that it’s a repeatable position. So when I take my wax up, put it in the mouth, when I take my provisionals, put them in the mouth, I know that I’ve got repeatability. So again, like we said earlier, it really is a position of convenience and there’s nothing magical about it. It just happens to be somewhere you can guide the patient into, or their muscles can guide them into, which is my preferred method. And unless the bone has remodeled, then you’re going to get them there, thereabouts every single time. [Jaz]Well you, you said all the main points that I had in terms of what are the compromises that you make, but the main one I’m going to highlight is the last one you said basically, where if you just build everything into MIP and sometimes you have to, because of those two scenarios that I said, right, but just accept the fact that when their the masseters and temporalis everything contracts and the mandible distalizes and they hit their centric relation contact point then they, just like you said, maybe occluding only in the sevens and just like maybe the, before the crown that you did or before the restorations that you did, they already had a battered and destroyed tooth. Well, they’re going to do the same to a restoration. So factor that in. So maybe this patient will need some sort of appliance or, you know, whether it’s built in to CR or not to give them that extra protection on that tooth, because you know that, okay, you haven’t been able to mitigate that one scenario because the fact that you’re taking compromise. So basically imagine that they’re grinding backwards into their centric relation. And as they’re grinding backward stairs, there’s no smooth transition. They’re hitting against, these are Rocky bumpy inclines of the crowns basically. And that’s where potentially chipping and problems can happen as well. Wow. That was an intense one, Mahmoud. We covered all those and that was really intense, but I really loved it, man. I honestly really enjoyed talking to you. I enjoy sparring with you there, and I think me and you are cut from the same occlusal cloth and yeah, I’d love to have you on again, on a last tooth in the arch syndrome. Cause I think that’d be really useful. It’s really bugging me that the, my colleague who messaged me saying, ‘Hey, Jaz, can we have the episode in this?’ I’m going to find it, I’m going to record it in the outro. So thank you for the person who recommended that. Mahmoud, you are having, number three, your wife is having number three soon, right? [Mahmoud]Correct. Yes, definitely not me. [Jaz]Yes, of course, she has some role which is why you’re off today because it might have been happening. So yeah, I wish you all the best. And you know, it’s great to have you on and thanks for being part of our telegram group, It’s been really great to have your input and I hope that we may meet someday very soon. Where’d, you live again? [Mahmoud]Sutton Coldfield so. [Jaz]Amazing. Well, I hope we meet one day soon. I’m sure we will, mate. [Mahmoud]Yeah, I’m sure. Thanks so much for having me. It was good fun, actually. Jaz’s Outro: Well, there we have it guys. Mahmoud Ibrahim. How awesome was he. You need to follow him on Instagram, it’s drmoidental, moi as in Francais, right? moidental. So dr-m-o-i-dental, his work is amazing, message him. He’s such a great guy. And if you’re enjoying our telegram app, where me, Mahmoud, lots of others are on, they’re always helping out, Pav’s on there. It’s protrusive.co.uk/telegram and that’ll take you to the telegram group. Join us. We’re always a helpful community there. And I just want to say a shout out to Dr. Chiggz, Gohil Chiggz. Thank you. It was you who recommended that we cover the last tooth in the arch syndrome ie you place a crown or you do a crown prep on the last molar and you get the patient to bite it together and you’ve lost all the space. How can we manage that scenario? So we’ll cover that at some point soon as well. And also before I forget on the website, protrisive.co.uk under this episode, I will put the three minute occlusal examination initially by Stephen Davies and contribute to or modified by Mahmoud. So I’ll stick that on again, as a handout, I’ll even email it to you if you’re on the newsletter group. Okay? Thanks so much for listening all the way to the end and I’ll catch you on the next episode.

Dr Jane Lelean will teach us how to implement ‘Hypnodontics’ techniques so that we can calm our patients, create a positive environment and even reduce post-operative clinical complications! https://youtu.be/oesEIRfJvdE Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “Hypnodontics isn’t just for patients, many dentists are using it to reduce their stress levels and their anxieties too” – Dr Jane Lelean In this episode, we discuss: Is there an official qualification before practicing hypnodontics? 8:24 Two general types of hypnotherapy 9:13 Evidence-Base of hypnodontics in Dentistry 11:57 How can we incorporate hypnodontics in our practice 15:45 Reducing post operative complications and pain with hypnodontics 26:43 Changing the post operative instructions 30:02 Help from Hypnotherapist regarding Bruxism 36:28 Check out The Institute of Dental Business to learn more about Hypnodontics and Hypnotherapy with Jane Lelean. If you loved this episode, please do check out What Every Dentist Should Know About Managing Dental Anxiety with Dr. Mike Gow Click below for full episode transcript: Opening Snippet: So Hypnodontics isn't just for patients. Many dentists are using it to reduce their stress levels and their anxieties too... Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati, welcome to this interference cast a non clinical interruption today on Hypnodontics, hypnosis in dentistry and how you can apply it on Monday morning. I’m joined today by Jane Lelean. Now I hope you enjoyed that previous occlusion episode, I did the basics of occlusion. I’ve got basics of occlusion two coming up, I’m recording with Mahmoud Ibrahim tomorrow, and we’re gonna put together our philosophies to come up with something even more impactful, try and build on that first episode, really just set the scene on why occlusion is confusing, why occlusion is both perhaps overplayed at some points and when it might be super important. So if you haven’t listened to basics of occlusion, go back one episode and listen to that one. Anyway, today is about hypnosis in dentistry. And not like, not in a wishy washy kind of way. Like I want you to be able to apply some techniques on Monday morning with your patients to get results. The kind of results I’m talking about is this, right? I am very used to now when I’m explaining risks to patients, or once I’ve done let’s say a deep restoration, I say to my patient, “Hey, you know what, you could get a severe throbbing ache. And if that happens, that’s a sign that the nerve is dying. And that can be a very painful thing. It might be worse at nighttime. If you get a spontaneous pain, please give me a call, take some painkillers.” This is very much a risk from this procedure, right? So I set them up, In my mind, what I was doing is I was underselling and over delivering so that when they don’t get that pain, they think, ‘Wow, Jaz is awesome.’ So there’s a benefit in that, I guess. So I guess I’m happy with the way I’ve done things. But today, what Jane showed me, what she’s gonna share with you is to think about it in a slightly different way. How can we use the power of hypnosis? Which is basically like an altered state of the mind to benefit you and benefit your clinical outcomes. Like, if you tell your patient Look, there are certain patients who are almost like easy to hypnotize. So if you tell them, “Look, you’re gonna get swelling, you get pain, like this.” And then they come back two days later say “Yeah, it’s swollen and painful.” And you’re like, “Well, that’s normal.” But they sort of, they made this like Mind-Body connection, they make themselves worse, they make themselves more sick. So equally, if you can sort of hypnotize people in a way for want of a better word, put these people in an altered state of emotion, altered state of mind, then your clinical outcomes might be better, might get less swelling, less dry sockets. It was just an interesting concept. And I want to share that with you today. So I hope you enjoy what Jane Lelean has shared in this interference cast. And I’ll catch you in the outro. Main Interview: [Jaz] Jane Lelean, Welcome to Protrusive Dental podcast proper, it’s great to have you. We did a little bit about NLP last time, but that had some video issues. There’s a much better platform so I’m hoping you can give us a lot of value today. Welcome. How are you? [Jane]Okay, so what I’m going to talk about today is hypnodontics and hypnotherapy is like the first cousin of NLP they are so closely related, and which is why I do both. And hypnodontic is a really, really exciting field. It is a specialist area of hypnotherapy. So in the same way we may all have BDS or an equivalent and we’re general dentist and dentists go into different areas of speciality or special interest. I know yours is TMJ and splints and educating dentists. Hypnodontics is a specialist field of hypnotherapy where the therapist is dealing with and spending most of their time dealing with issues that are related somehow to dentistry. So that could be people that are anxious, people that are phobic. It could be people that have sleep issues, bruxism, anxiety, nail biting, gag reflexes. There are some therapists that or some patients really, that don’t like local, and they don’t like that feeling afterwards. And it’s possible to use hypnotherapy so that we don’t need to use local and I know that many dentists will doing work overseas where they cannot get access to local anesthetics, will use hypnotherapy so that they don’t use any form of anesthesia. You can use hypnodontics to reduce or eliminate post operative complications, post op pain. Oh that the list is endless addictions whether it’s sugar or smoking. Yeah, it’s just it’s fascinating, the more you get into it, and it’s all about where the unconscious affects our present behaviors. So if there’s something that’s happened in the past, a trigger or our unconscious other than conscious or subconscious, whatever you want to call it, is influencing how we are now then hypnotherapy ,hypnodontics has the potential to improve it for patients, and therefore dentists. So hypnodontics isn’t just for patients, many dentists are using it to reduce their stress levels and their anxieties too. [Jaz]Brilliant. Well, we had Mike Gow on the podcast and he is someone who has been in a procedure where they placed implants without local anesthetic and that really whet the appetite of the Protruserati because they wanted to learn more about hypnodontics, which is why I’ve got you on today. I also want to just do an introduction for you, Jane, you’re someone who is a real leader, you know, I use that term with purpose, you are a true leader in our profession. What you do with your coaching, with your positive influence is just sensational. You’re always helping dentists. Tell us about how you got into where you are now in life, and how your sort of careers molded over the last sort of few decades. [Jane]So I suppose my career has molded advice to decades is that I mean, you can see all the books behind me, you commented on them earlier. They’re an eclectic bunch of books, and I’m just led by my interests and my possibilities, what is possible. And I just go down these rabbit holes and explore what is possible so I know that there are some dentists that will go “Do you know, it’s absolutely impossible that you can place implants without local? And I suppose this comes out of my NLP is that, it is this way of thinking. That is, what happens if it is possible. I’m not saying is. But what happens if it was. And then that sparks a curiosity and widens horizons and pushes out boundaries to say, what is possible, and then that’s how I just end up doing what I’m doing because I like to think that nothing is impossible. [Jaz]Amazing, and I think you’ve done a really good introduction for hypnodontics you describe exactly what it is and although I might not need the hypnodontics, the whole area of hypnotherapy to help me stop nailbiting, sounds amazing. So we did a little discussion earlier about should we finish this session today with you carrying out some hypnodontics on me or hypnotherapy on me and I said, “Maybe let’s, I want to be very engaging for the audience. And maybe that may not be appropriate.” But I may actually book in a teaser with you afterwards will tell us how to do that, how we can book a trial session with you to help me stop biting my nails. So you’ve already piqued my interest with that, believe it or not more than anything. And now I just want to basically bring to surface exactly what we can learn from you in the next 20-25 minutes and so about how we can apply the theories or fundamentals of hypnodontics, so we can help our patients with all those things that you mentioned earlier. So you’ve mentioned about, what is hypnodontics, you’ve mentioned beautifully about what is the scope of it. What training do we need? Like, you know, you mentioned the analogy that general dentists and specialists, is there an official qualification you to hold before you can practice hypnodontics? [Jane]Yeah, so hypnotherapy is a skill. It’s a tool. It is a process that we need to learn how to do and once you’ve understood the basic process, so there’s some fairly elemental steps in taking a client in a hypnotherapy session that you need to learn them. And so you do not need to go to a specialist dental hypnotherapist training, you may choose to, but you don’t have to. You just need to learn how to do hypnotherapy. And there’s two general types of hypnotherapy. There’s Ericksonian and the Elman. My experience is that the Elman approach is much more suitable for dentistry because it’s a much more directive quick, fast, rapid or immediate induction process. Elman can take much longer to bring somebody down into that altered state of hypnosis, and that’s all hypnosis is, it’s a whole altered state. So there’s nothing unusual about hypnosis. It happens every single day. So if you’ve ever been in your car and driven somewhere and suddenly realize you’ve lost half an hour, that’s because you were in an altered state of hypnosis. If you spent several hours watching the TV and not remembered what you watched, or you’ve been in a film, and it’s like you’re so engaged in the film, it’s like you’re there. That’s all hypnosis. This is a normal process. But you do need to learn how to do it, so that we can lead patients to just find a hypnotherapist. So I’m happy to share people that I worked with. So my initial training was done with a guy called Michael Watson, who Phoenix services in America. Then the Cheryl Elman that I’m doing quite a bit of work with at the moment, and she is the daughter in law of Dave Elman, who is the hypnotherapist that really specialized in training with dentists and doctors. And he developed the rapid Ellman techniques, barrel kamar, who works again very closely with Cheryl Elman, and then a girl called Sharon Wackash. And she’s doing an awful lot of work with dentists as well. So whether you work with somebody like Mike because I know Mike Gow does training programs, whether you choose to do your training with a dentist who is also a hypnotherapy trainer, or you just choose to do a hypnotherapy trainer that then you take on the imagination and the creativity to apply to your patients. The choice is yours. Yeah, so it’s exciting, but you do need to get trained and you do need to be indemnified. [Jaz]Certainly is and what I want to know next Jane is leading on from Okay, someone who may be considering adding another string to their bow in terms hypnodontics and I can see the myriad of positive benefits from patients and ourselves as practitioners by incorporating this. Is there much evidence now before I use that E word lightly, because from the realms of TMD, and occlusion, I can tell you now, the quality of evidence is poor, but it doesn’t mean that we can’t help our patients. Is it similar with hypnodontics? Except the quality research isn’t quite there yet? Or am I wrong? And do we have some good studies that that show the efficacy of hypnodontics? [Jane]Have you seen this is really interesting. So I know that NLP works. I know that hypnotherapy works, hypnodontics works. And the thing about these modalities is that each approach when I work with a client, I work differently with each client because each client is an individual. And they will be using different words, they will be responding different ways or whilst they might be presenting with a similar situation. As an experienced therapist or coach, I will work with each person differently, which means that it does not lend itself to double blind evidence based trials. And therein lies the rub that some people will say, well, there is no evidence. And no, there may be no evidence in the way we used to as dentists where we see studies where everything is replicated, and there’s maybe only one variable that’s being measured at any one time. In a hypnodontic session, in an NLP session, there are too many variables to make it a study-able and research-able. But the experiences, that it works, [Jaz]I mean, I’m so glad I drew that, I touched that parallel between TMD and occlusal appliances, and how it’s difficult to study that and everything you’re saying about hypnodontics is exactly the same as that department because like you said, everyone’s different with the whole field of TMD and the etiology of TMD. Everyone A) starts off with a unique malocclusion, okay, so that whole link is difficult to explore. Everyone has different sleeping patterns, different hours they sleep and that has a huge influence. Everyone has different levels of stress and different levels of perceived stress. Everyone has different anatomy and different degrees of hypermobility and everyone has different coping strategies. That’s why we can not ever produce high quality research. We would even need a sleep studies to do that. So I think it’s very much the same in hypnodontics that just like you said, it’s it’s almost impossible to produce a high level research when there is so much variability. I totally agree with you. [Jane]Absolutely and hypnosis and NLP is all about the words. And again we do know that placebos and nocebos are significant. So even the language that we’re using with our patients when we’re fitting the appliances will determine the success or will influence the success of those things, because we cannot not influence people. And I find this field so exciting, because the words that we use, that when we get really precise about the words, we can influence and impact the outcomes of treatment in ways that we didn’t think was possible or individual words are significant. And because we talk to each individual patient differently, because they’re an individual, that’s Yes, yet another variability that is built into that equation of splint therapy. [Jaz]That’s fantastic. Let’s go into the very tangible part, the episode now where Jane, I would like you to speak, you have the overmighty dentist now, and you’ve got thousands of dentists listening to you now. And we want to learn some ways that we can help our patients on Monday morning, right? So what are the most common scenarios that we you think we can manage? And how can we incorporate hypnotherapy is even reasonable for you to suggest some ways that we can help our patients from this episode, is that crossing a line or can you help us to help our patients? [Jane]Okay, I what I’d like to do is share three things with you. This is not hypnotherapy. But because it’s not the process of induction and deepening. However, it is, they are things that influence a therapeutic scenario. And the most important thing, when you’re working with a therapist, is the level of rapport that we built. Now, most of us have seen When Harry Met Sally, and there is a scene in When Harry Met Sally, that is significant, it is not that scene, not the thing that everybody thinks about. It’s just before that. it’s when they go into the restaurant, and they say do you want the speaking or non speaking side. And we think that’s funny. But we all intuitively know which couples are getting on and which couples are not getting on. And the way we know is unconsciously we are looking for whether they are matching one another. So their body language, their language patterns, their whole way of being is similar, or whether it’s different. Because people like people like them, I’ll say that, again, people like people like them. And in this world of where people fear litigation, this is the one thing that we can really do that reduces that risk of litigation, and is our role as the dentist to be the flexible one. And we become like them, we match them, we mirror them. So we do what Desmond Morris in his book manwatching, we develop what we call a body echo. And you will know and if we, when we can get back into pubs on Monday, I invite people to actually look at other people and watch their body language. Those people that are getting warm, just notice that they’re crossing their legs in the same way that they might be drinking at the same time. Notice where their eyes look, the forward, backwards, but most importantly, their breathing rates. When we get really deep rapport, we will breathe at the same rate as people. So that’s something that I mean, I could run a easily run a four day training program on building rapport. But as a first step, that’s something that I would invite the people that are listening to pay attention. And notice how they can match that patient more so they become more like that. And then we can pay some leave that we spend enough time matching them, that we can bring them to our into our world. And this works so well for anxious patients. Because we know that anxious patients breathe from up here really fast and sometimes they erratically whereas calm, relaxed, people breathe from really deep down in their belly long and slow. So we can influence and bring patients out of anxiety by initially going towards and matching their way of breathing. Don’t want to take it on full blown because you don’t want to be having a panic attack, but pay attention, match that match it, match it, match it as closely as possible. And then you test steps, and you change your breathing. [Jaz]I think I’ve accidentally discovered this before Jane, I’m just making it really tangible for dentists listening, because we’re, those of you who follow the podcast, and who are friends of mine know that sometimes it can be overly energetic. And when I have certain patients who are also very bubbly, energetic, and we get on like a house on fire, but then when I have a patient who’s a bit more, maybe introvert, or just a little bit quieter person who doesn’t like all this extra energy and noise, and the past, I have been told by patients can you just slowed down a second, and I can tell what they mean that I am just too much for them. And so I picked up on this a few years ago. And I do make a conscious effort now. And I didn’t know what I was doing was what you’re describing. And it like, you know, mirroring them whatnot. But when I do have someone who is just someone who talks slower and takes more more time and not a thousand words a minute, like me, I make a conscious effort to slow down with them. And that single thing that I change about myself to make sure that I can better appeal to all patient types has made a difference in terms of getting along with all my patients. So I didn’t know it was that that I was doing. But that might help to drive the point home present is listening and watching. [Jane]It is the fundamental, we’ve got four pillars in NLP, and rapport is the most important thing. And it is our responsibility to match and be like the patient, we step into the patient’s world. And when we’ve established that rapport, then we can bring them into our world. So if you with those patients that have got lower energy than you, if you go to them first of all, and take on their way of being and establish that rapport, you will then be able to bring them back into your world and increase their level of energy. And so that’s report, that’s the first thing that I invite people to pay attention to, and play around with. Because it’s wonderful. [Jaz]Brilliant. So number one is matching and mirror and be like the patient because people like people who are like them. So that’s a really good tangible tip. What other thing that can we implement on Monday morning to help our patients? [Jane]Okay, so the next things are to do with language. So, Jaz, I want you to think about something. In my head, I’m very clear about an image that I want you to think about. And whatever you think about when, as you’re thinking about what I want you to think about, I absolutely don’t want you to think about a green elephant playing tennis. Okay? Don’t think about a green elephant playing tennis. But I do want you to think about what I want you to think about. [Jaz]Initially, I was thinking about being on the beach, but then suddenly on this beach appeared a green elephant playing tennis. [Jane]Yeah, okay, because our brains cannot process a don’t. So when I tell you not to do something, or don’t do it, you have to imagine it before you don’t do it. But you will. It is impossible. [Jaz] Don’t worry. [Jane] don’t worry, actually tell somebody they have to worry before they stop worrying. So, but you don’t know. But you were unable to do what I will think about what I wanted you to think about because I never actually told you what I did want you to think about. So what I did want you to think about, Jaz was a purple rabbit on a trampoline. So by telling you not to think about a green elephant playing tennis, how likely were you ever to think about a purple rabbit on a trampoline? Impossible. So pay, again, I invite the listeners to pay attention to when they use words like worry or don’t [Jaz]Or it won’t hurt is a common one that dentists would use. [Jane]Absolutely, that’s the green elephant playing tennis. This is going to be comfortable or I don’t know what your technique is. Some people waggle their lips around when they’re giving their local. So tell them what they are gonna feel direct their attention, you’re gonna feel me wiggling your lip, you’re gonna feel me squeezing your lip. So direct the patient’s attention to what you do want them to focus on. So that again is another powerful and pay attention when we’re talking to ourselves. Because that word comes in. Don’t be such an idiot. Or actually what do we want for ourselves instead? Think clearly, think slowly. [Jaz]Yeah, pay attention exactly at pay attention because when you start actually paying attention to this, we will realize as dentists that we make this mistake all the time. And I would actually encourage you all to tell your nurse about this because they might not know. And they might also be saying to the patient, “don’t worry, you’ll be okay, don’t worry, you’ll be okay” while they’re having in the middle of extraction. But once you educate your nurse, and then maybe you nominate your nurse, because they’re the ones who are with you the whole time, with every patient, you nominate your nurse to say, if I, if you observe that I made this mistake, after the appointment, can you tell me and then slowly, hopefully you can improve and improve and improve and you can completely change the language to get rid of all these negatives, because like you said, we can’t process a negative. So I think that’s a good, that’s a good way to implement it, would you suggest Jane? [Jane]Depending on what relationship you’ve got with your nurse, so it’s useful to have an immediate reminder that you’ve made the mistake. So it’s like when we’re training a dog, we train the dog immediately, praise, immediately criticism. So if you’ve got a great relationship with your nurse, she could just use her 3 or 1 syringe, just squirt the water on you trouser, like, don’t know what sort of funny you want to have underneath the chair. But there’s way that they can get you can get immediate feedback. And obviously, praise is really important. Teamwork is really important, engage the team and give that feedback when they’ve done it as well, well done. Really noticed that you’re focusing on using the purple rabbit on the trampoline language. And if you’ve got kids, it will make a massive difference. [Jaz]Amazing, then Jane, how many more pearls do we have to give us. I’m hoping for, I’m hoping to get at least one more for you that we can go on Monday morning and implement. Please. [Jane]So one more is about how you can reduce post operative complications, and post operative pain. Because we have to tell patients could be a possibility. So after an endo, there could be a possibility that they could have some discomfort that requires pain relief for maybe a week. But actually, we don’t want the patient to experience it. So the language we use is things like other people sometimes experience rather than saying you could possibly because when your patients know you like you and trust you, they want to please you and they want to do what is the right thing. So the unconscious will often say, Oh, well, okay, the dentist said, you will experience some or you could experience some pain, maybe that’s what I’m supposed to do. So I will experience it, the unconscious is a curious thing. But that’s not what we want them to do. So instead of using the word ‘you’ and make it an identity level statement, when we’re talking about post operative complications, possible post operative complications, we talk about other people, ‘A small number of other people sometimes experience’ and it’s best not to, you don’t need to. So can you again see how with the language we’re directing them away from, and yet we are still telling them. [Jaz]This is amazing, Jane, because the penny has really dropped for me here because as you were saying, and then if you saw my facial reactions I was I was really thinking back to how I communicate risk and post operative discomfort to my patients. And I thought I had a good way until you just completely busted it now and stepped on it, which I’m grateful for. So my way of doing it was like dry socket, for example. Very common complication, very nasty complication. So the way I say to my patients to make sure, like, for me, I want them that if it does happen to them, I don’t want to be a surprise for them, because I want them to remember that I warn them. So what I do at the moment, which is not the best way after you teaching me now is I say that, if you were to get a dry socket, this is what you would feel. And you feel this and this and this. And if you do feel this, you should call me because that’s a dry socket and it’s a very nasty thing. And when they have it, no one ever says ‘Oh, you didn’t warn these’ ‘Oh, it happened just as you warn me,’ which it ticks the box of they will remember that I want them but it’s a horrible way to do it. Because just all the reasons you said, they internalize it. It’s almost like that guy, classic hypnosis. You got that little gold or watch as you are going to sleep. So I’m essentially hypnotizing my patients to get a dry socket or something, right? So I think your way is amazing and I’m going to implement this straightaway. So from now on, I’m going to change my language to say to patients that what some people experience is a dry socket. [Jane]And I would, yes, what some other people so you really want to create this distance and I will often use my hands, that ‘some other people may sometimes experience something that we call a dry socket doesn’t happen very often. And I’m sure it’s not gonna happen for you, because and for those other people, this is what they could experience. And I’m sure for you, what you are going to have is a completely comfortable, quick healing.’ Because you’re in, you can even lace it with some sort of evidence that they can connect it ‘because your mouth is clean, because you brush your teeth twice a day, because you listen and take what I say, seriously, I know I’m fairly certain that for you that where we’ve taken the tooth out today is going to heal quickly and perfectly. Other people doesn’t happen like that. And they may experience and for them, what they need to do is ring me’ [Jaz]Jane, I want to ask you, what about the Do we need to be changing our post operative written instructions? Because they are often written like, you may experience this, you may experience that. Do we need to change an all the practices we work in collectively? Do we need to also think about what we present as written information? Or does that not have as big of an effect? [Jane]Absolutely, we need to stop making it an identity level statement, that’s at the identity of the patient. And also, one of my other things is health issues with NLP. And so if I said that somebody is diabetic, that’s an identity level statement, and it’s fixed, the chances of moving beyond that, once they’ve been told you they are a diabetic is difficult. Whereas if we were to say that currently, you’re showing the signs and symptoms of diabetes, how does that change? [Jaz]It makes it not personal to you, it almost dissociates you from it. [Jane]It is but it also creates that possibility that it can be changed because it’s only currently today, you’ve got the signs and symptoms could be different tomorrow could be different next week. Whereas when it’s an identity diagnosis that you have, it’s fixed and that becomes somebody’s way of being and so I snuck in a three and a half there, pay attention to how we’re describing these. [Jaz]That’s amazing Jane I think you’ve given us real good gems to practice on Monday morning. My personal favorite was number three honestly it was a wow I mean some of the things that you said number one and then number two. Number one as a reminder was matching and mirroring. Number two was I’m trying to think number two was now. What was number two? [Jane]Green elephant playing tennis and a purple rabbit on a trampoline [Jaz]Number two was yes using the language so make sure you don’t use those negatives stop saying Don’t worry. And number three was wow is actually going to have a huge impact on my practice. Because I felt like there was number one and two I do a little bit of well already but number three has been a complete game changer for me because I need to communicate complications completely different way and thank you Jane for introducing that to us. I’m really hoping that those listening right now will be able to go away. And immediately on Monday morning be implement these changes and even go to your post operative word document instructions, change the language on there and print it so you can make these actionable steps now, don’t wait till next week. Do it now or allocate this task to a manager or someone, get it done now. It would be fantastic. Jane, it’s been great to have you on thanks for sharing all this. But tell us if Dentists wants to. Because I know you’re coach, you’re hypnotherapist. I know you’re doing some taster sessions that you’ve opened up to the dental community. Tell us about how we can get involved and what kind of people might benefit from that. [Jane]Okay, so firstly, dentists who are stressed, overworked, have got habits that they don’t like they might be drinking too much, biting their nails or all sorts of stuff. They will benefit from hypnodontics, hypnotherapy. And I do a taster session which does if hypnodontic’s right for you. You can go onto my website, use the book now button website is www.theinstituteofdentalbusiness.co.uk book a taster session. I won’t be doing any therapy in that session. What I will do is a hypnotic induction and bring you back out so somebody can experience what it’s like to be in that lovely beautiful altered state of deep relaxation. And everybody can be hypnotized. Some people need to learn the skill. There are people like me, I am so hypnotizable that I just go out immediately really quickly. Other people need to learn how to do that and develop that skill. And that might take several sessions to teach them how to do it. But if somebody uses a book now session, it’s one taster session, experienced some hypnotherapy. And also for those dentists that may have patients that are anxious that they don’t want to keep doing IV sedation. Why do we want to keep ramming bumps into patients? Let’s just deal with the underlying phobia, anxiety so the patients never have to come back. So if they’re interested in how hypnodontics can be used for their patients, either for them to learn themselves this skill or to work with people like me, that will then work with their patients on a referral basis. Yeah, just give me a ring and find out. [Jaz]So two things there, Jane. One is for everyone listening is that wow, I mean that if you are in a rough patch, or you think based on this episode, that hypnotherapy could help you. I think Jane is so trustworthy. You can hear her knowledge, her passion for this in great depth. So do reach out to Jane, if you want to experience it I think that’s a great offering you have there, so thank you. And number two, it was inevitable I’m gonna bring occlusion and bruxism into this somehow is that my patients who need additional help so they have the occlusal appliance, they’re having the physiotherapy because that’s what we need as part of conservative care, but they’re still a little bit in an anxious state. I have been looking online, finding these people who are hypnotherapist not necessarily dental online to help them manage their anxieties. Now what you’re suggesting is I can be referring these patients, I would prefer to refer them to a dentist like you. So I can there’s a pathway there on your website for me to refer my patients to you, Is that right? [Jane]Yeah, absolutely. And there are a number of dentists like me, there’s another lady called Mandy Kent, who is really developing into this field. She is also a dentist, a general dentist, there’s got a passion for supporting her dental patients in the same way that I do. So there’s a number of us out there that we understand what’s going on for the patient’s in a way that a general hypnotherapist doesn’t. But they can learn if they want to embrace hypnodontic. So in the hypnodontic community, I would say it’s probably about 75% hypnotherapist that have developed an interest in dentistry and the remaining 25% is may even be 80-20 but there’s far fewer dentists that have developed an interest in hypnotherapy than hypnotherapist that have developed an interest in dentistry and it’s that blend, it’s that Venn diagram in the middle that that’s where hypnodontic sits. [Jaz]Amazing. I look forward to implementing the three of those tips that he shared in hypnodontic especially point number three I love that and also I knew you’re a coach, I knew the hypnotherapy for dentist stuff is great that I now have a pathway in you. I will not gonna be saying to any general hypnotherapist, even though they might do a good job. I’m gonna send them all to you now, Jane. So that’s gonna be awesome. And for those of you who caught that, please do check out if you need some hypnotherapy for yourself. You know, you got to look after yourself. Check out Jane on www.theinstituteofdentalbusiness, was it .com? or .co.uk, I’ll add it to my website. [Jane].uk.co and you’ll recognize that the blue, she’s got the little toothbrush on it. That’s me. [Jaz]Excellent, Jane. Thank you so much for coming on and giving up your time to share these really tangible tips and pearls for our community. And we appreciate it. [Jane]And thank you for inviting me and sharing with dentists so that they have got a much wider perspective of what is possible because when we went to dental school, we would just given a tiny little insights. But then our career has the opportunity to open up and blossom and that’s what I love about dentistry is I think it is a really exciting career because we can be in charge like no other profession and take our careers into the realms of the things that interest out. Lovely so thank you for giving me the opportunity to share my passions with other dentists [Jaz]Thank you for coming on and giving so much value. Jaz’s Outro: Well, there we have it. I hope you enjoy that interference cast. Hopefully you can employ those techniques that Jane shared with us to your patients on Monday morning. So hoping you found this quite applicable as an episode. I try and make these atronics extrapolate from the guests as much as I can to make it very, very tangible for you as a listener. So hit subscribe if you haven’t already. Oh, and I emailed you guys recently. If you’re not on my email list, go to protrusive.co.uk/newsletter or click below in the description I’ll link it there if you’re not already and those who got my email I said, Listen, if you got any topic suggestions for future episodes, please do email it back to me, and I will consider it and I’ve had such great suggestions. So thank you so much to the Protruserati, who’ve sent in some suggestions as I’m hoping to cover the topics that you’d like. Anyway, thanks so much for listening, have a fantastic day, whatever you’re doing, and I’ll catch you in the next episode.

What is Occlusion? Canine Guidance…..Group Function…that’s all right?! If only it was that simple! I hope to simplify Occlusion no matter where you are in your journey starting with this back to basics episode. Occlusion is the backbone of complete dentistry and full mouth rehabilitations. https://youtu.be/nCRepLglJBk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: If you think your patients are in Canine Guidance, check again. This time check while the patient grinds really hard. You will notice that most people are really group function and even have non-working side guidances! “It’s very difficult to say that one occlusion is perfectly correct for all individuals. And I don’t think we’ve identified an ideal occlusion for a specific person.” – Dr. Ed McLaren In this first episode on Occlusion I shared: Canine Guidance vs Group Function 5:54 Evidence base about Occlusion and TMD 10:34 Challenges in researching Occlusion and TMD 13:13 Different Schools of Thoughts about Occlusion 19:42 Centric Relation 23:27 Centric Occlusion 30:34 What is Occlusion? 35:29 Occlusion vs Occluding 37:12 Test driving the changes 46:11 Check out my 9 point checklist to never have high restorations again on YouTube: https://youtu.be/zX4fcYn7POM No More High Restorations Be sure to check out the best Dental Event of the year, the Dentinal Tubules Congress And as a reference for the terms, here’s THE GLOSSARY OF PROSTHODONTIC TERMS 9th Edition If you liked this episode, you will also enjoy Posterior Guided Occlusion  Click below for full episode transcript: Opening Snippet: And we also have excellent clinicians like Ed McLaren, who said it's very difficult say that one occlusion is perfectly correct for all individuals. And I don't think we've identified an ideal occlusion for a specific person... Jaz’s Introduction: Hello, Protruserati, I’m Jaz Gulati and welcome back to the big episode I was telling you about this is the basics of occlusion carrying on from the the back to basics series in August, a lot of you messaged me with your occlusion questions, so I’m going to answer some of them today, but not in like a Q&A format. Because we’ve done that already in question 15 I’m just gonna take you through a journey, right? I’m gonna take you through a journey that’s going to be mirroring some of the things that I’ve picked up in my journey. And the point of this introduction is to just tell you that we are all in a different place, in our own respective journeys. So some of you may be listening and you might be a dental student, right? And you may be placing your first ever restoration tomorrow, let’s say and you are just thinking, Okay, when I stick that colored paper inside, articulating paper, and you get I get the patient to bite together, what are those dots going to look like? And you’re just like, that’s occlusion to you, right? When the patient bites together, how will it look, right? Whereas some of you may be beyond that. Some of you may be quite well versed in raising the occlusal vertical dimension, opening up bites, placing multiple units and multiple restorations at the same time and having some degree of control of the occlusion. So each individual is in a different place in their journey and the learning never stops. Now, if you are brand new to the world of occlusion. Welcome to deep dark world occlusion, I’m going to try and not confuse you too much. But try and give you a few things to think about. I’ll hopefully make sure that as you learn, right? It’s going to head you in the right direction. Because the thing with dentistry and the thing with occlusion is that sometimes the first time you learn something, right, it doesn’t really, really sink in until maybe a few years later, it’s happened to me so many times where a few years later, the same concept has been repeated and explained to me in a slightly different way. But the only thing that’s changed, I’ve gained more experience. And now that thing starts to make some sense. Now, if you are someone who’s very experienced some of the things that I might talk about saying this episode might offend you, okay? They might be against your occlusal religion, okay? But you know, my philosophy, right? Listen to everyone and do what feels right to you. So don’t take anything personally. Okay? These are just my views and opinions, some things that I’ve gained from my mentors. Now, just before we start the episode proper, a couple of shoutouts, haven’t been shoutouts in a while. Okay? Shout out to Afif who reached out to me on Instagram to say thank you, because he is Algerian, he’s a French speaking dentist, and he wants to be able to communicate dentistry in English, right? So he’s using my episode, right? Or my content to learn English and dentistry. And he said, Thank you for that. And I was like, well, that’s awesome, man. More power to you, Afif and also, thank you for the lovely message from Allah. Allah reached out to me on LinkedIn, to let me know that she was kind of in a stuck position. And then from the podcast, she found it very positive and uplifting, and therefore it helped her to reconnect, I don’t know how, but she said it helped her to reconnect with her principal and reconnect with dentistry again. So again, guys, messages like these really, really helped me to keep going. So thank you so much. I just want to do a little plug for the Dentinal Tubules Congress like wherever you are in the world right now, I hope you are safe. I hope you’re well. And the UK the COVID situation is, I guess, kind of improving to the extent that we’re now having in person dental education again. And usually my favorite event of the whole year is the Dentinal Tubules Congress. This year, it’s gonna be in Brighton, and that’s just three weeks away. So if you’re in the UK, and you haven’t booked yet, and you want to come to the dental event of the year, please check out the website dentinaltubules.com. Look at the Congress, look at the speakers. It’s just full of great memories for me every year, it’d be great to catch up if you’re coming. So this episode’s Protrusive Dental pearl, some of you may be listening for the first time, well, every episode I give a Protrusive Dental pearl. For the fellow Protruserati who always listen, here’s my pearl for today, right? So it’s all about canine guidance. And I know I’ve spoken about this concept before, but I’m just gonna make it into an official pearl. So now it’s official. Okay, when you observe canine guidance now because this is a back to basics episode, I’m going to actually describe canine guidance like some of you I thinking, Okay, I know what canine guidance is. It’s about the only thing you learn about occlusion in dental school, right? So canine guidance is when the patient bites together. And as they bite together, and then they bite on the back teeth and they’re about to now move that lower jaw side to side, they’re now grinding or they’re taking an excursion either left to either right. Now, certain teeth contact at certain points as they grind their teeth left and right. And when they’re grinding from in to out, so in their normal bite to out left or right, the teeth that are contacting are the canines. Okay? Now this can transition quickly on to the anteriors. And that’s still canine guidance with a rapid transition to anterior guidance, that’s fine. But if they start in canines, but now they’re involving premolars and molars, or that is now called group functions, that’s the difference between canine guidance and group function. In canine guidance, you’re pretty much only on the canine, and then you maybe come on some anterior teeth, whereas in group function, you may still be on the canine but you’re also on some pre molars or sometimes like an anterior open bite situation, you may be on just the molars and not the canines and not the premolar, that still group function. Now, what is the relevance of this in terms of Protrusive Dental pearl? Well, sometimes when you are observing for canine guidance, or when you’re observing a patient’s occluding scheme, you’re checking their lateral excursions, ie when they’re going side to side. And you may notice that as you tell Mrs. Smith to grind left and right, it looks as though that she’s in canine guidance. But okay, when you actually get Mrs. Smith to clench really hard together, and then grind left and right, you might then notice that actually, this patient is not in canine guidance after all, this patient is in group function, okay? And the first person to teach me this was Pav Khaira, who is the host of the dental implant podcast, and he also came on episode 76, to about finding your niche in density. So if you haven’t listened to that, please do listen to that. Now he taught me this concept He showed photos of himself, like in canine guidance, and then pressing really hard and actually, he was in group function at that really blew my mind that, like how come they never, This is important. How come they never taught me this in dental school? Because when you complete someone’s restorations, and you think that you finished these restorations in canine guidance, but really if you check a bit more thoroughly, you know, is that actually they’re in group function. Is that a really a bad thing? Well, depends if you designed for all your restorations in that specific scenario to be in canine guidance but really, they’re not, then that is kind of a problem, right? It’s not what you plan to achieve. It wasn’t as part of your goal. Now when I had Andy Toy on the episode, now, if you wanna go back some episodes, it called the posterior guided occlusion episodes, part one and part two. Andy Toy took this a step further, he explains that actually, it might be more than just we’re not in canine guidance, we actually had these non working side guidances. Now I don’t like that term, non working side interference, because interference is like a nasty word. It’s like it’s in the way, right. So just to roll this rewind, back to basics. What I mean by a non working side interference is if I’m grinding my lower jaw to the right, okay? I should be feeling contacts on the right, that’s fine. That’s working side. But if I’m grinding to the right, and I’m feeling okay, I’m feeling that my left teeth are dragging or touching or grinding. Some people will classify that as a non working side interference. I like to call that a non working side guidance because interference, very harsh term, but actually, even those patients who you think are in beautiful canine guidance, and you see the opposite side completely disclude that you see a big gap between them. When you get the patient to grind together really hard to the other side, they might actually have some areas where they have a non working side guidance. Okay, so let’s just play you a snippet from this episode. [Andy]Right? So you’ve got group function with posterior disclusion on the proposed opposite side. Yeah? Okay. Now just slide out to preferred side again, about a third of the way out. And this time, you’re going to crunch back with force. Okay? And just in feel what’s happening on that opposite side, as you come back in to MIP. Main Podcast: [Jaz]So ultimately, what we can learn from Pav Khaira and what we can learn from Andy Toy, is that when you’re checking the guidance, don’t just check it like in a passive glinding state, check it with force, okay? Because you have to ask yourself, when is this patient going to generate force? Okay, well, they’ll generate a joint function when they’re chewing something hard when they’re really going for it, technically has some force being generated. But think about a function is that there aren’t that many tooth to tooth contacts happening during function actually, there’s food in the way, right? There’s a bit of chicken in the way of something, right? There’s a you’ve got a bolus that you’re squeezing together with your teeth, and therefore your teeth don’t touch very much. So really, the main issue or the main consideration here is parafunction. When our teeth are grinding during the day or at nighttime, and they’re rubbing together in an inside to out motion, whereas an outside to in motion is functional. Inside to Out is a parafunctional, it’s grinding, okay? It’s something that really shouldn’t be happening, but it does is very common, okay? Therefore, I want you to check it because when you place someone’s restorations, I want you to check it at the time where it’s going to be tested, ie in parafunction, your restorations, your materials that you place are going to be tested by the patient, they’re gonna be under cyclic fatigue. And they can be under the most fatigue during parafunction. So it’s important, you recreate that environment in the chair. So you can dictate where you want the contacts to be. If you’re happy with everything, do you need to make something steeper? Do you need to make something thicker? wherever it might be? So I’ve been speaking a few minutes, and I’ve introduced a few concepts for you, right? And these concepts, they’re very, very difficult to find evidence for, in fact, the quality of evidence in the whole rounds of occlusion and TMD is really, really poor. Okay? And basically, most of what you read and even most of like the textbooks on occlusion that you read, when you go to the references section, it’s mostly theories, concepts, observations, suggestions, even the titles of these papers are suggestions or observations, okay? A lot of the evidence in occlusion is about articulator accuracy. Now we know an articulator is not the human, okay? We know it’s trying to mimic the jaw, but it just can’t, it will never be able to mimic the jaw because the jaw is biological, there’s squishy parts, there’s PDL, and therefore, that’s where the shortcomings are of articulator. So all this evidence base, you read on how to make your articulators programmed a certain way, essentially, they’re going to help you with your patient while your patients in the chair and a lot of the other papers are looking at like proprioception from teeth, muscle behavior, for example, an anterior guidance, we know that our muscles don’t contract as much compared to when they’re grinding on their back teeth. So we know that already, but we’re not able to draw any conclusions from that. And even a lot of the papers are all about reproducibility of centric relation, and don’t worry if you’re thinking, whoa, whoa, whoa, whoa, I’ve skipped the hair down. I’m talking about centric relation now. I’m gonna come on to that nicely, but just know the fact that there’s really a lack of evidence and lack of quality evidence, even when it comes to, you know, do certain malocclusions cause temporomandibular disorders, right? Because the classic people like Luther 2010 Cochrane Review says there’s a real lack of evidence to support that malocclusions can contribute to TMD. Now, that doesn’t mean that it doesn’t cause TMD. It just means that there’s a lack of evidence. So is there really factor in and sometimes I value people who’ve been practicing for 20, 30 years, and they’ve made some valid observations, because remember 1/3 of evidence based dentistry is the clinician’s experience as the same with bruxism and TMD. We know that lots of patients grind their teeth and some of them grind really hard. Yet, these patients may not get TMD, whereas a lot of patients who have TMD, they don’t have major signs of bruxism. So it’s one that we can’t prove, although papers go for and against. So generally, the general theme is that occlusion has poor evidence base, and so does TMD. Why is this? Well, try to understand why, let’s compare it to a completely different field of study. Let’s talk about the science of bonding or biomimetic dentistry trying to recreate highest bond strength, try trying to make sure our composites and our ceramics stick to tooth as best as possible. Now, if you’re designing some studies, to find out how well your restoration stick, or how well your restorations perform, we know that we can follow clinical protocols that from one patient to the next patient, you can keep pretty much consistent. We know that we can get large samples because the restorations that we place and we can follow these patients up. And also some of these studies which are done in the lab IE benchtop studies, they still help us because even if you have an extracted tooth, and you’re etching the enamel and you’re bonding and you’re checking the bond strength, a lot of that information can be transferred to in the mouth bond strengths, right? Although Yes, we know when a tooth is out is not as moist, or whatever is dried, is brittle, all those factors. But a lot of these studies when they quote Hey, this bond to normal, it’s gonna give you this when you megapascals that’s probably been done on a lab based study. So when it comes to the science of bonding, because it involves material science, and tooth structure, a lot of this we can do outside the mouth, right? Now compare this to difficulty in occlusion and TMD evidence, right? There are just too many variables. Okay? Let me make it really tangible for you. Imagine you have to design a study, and you’re looking at canine guided rehabilitations versus functional occlusion. Now, what I mean by functional occlusion is when Riaz Yar came in podcast some episodes ago, he talks about how over the years he used to be a disciple or a preacher of canine guidance and he really moved away from that, he’s really moved more towards group function. He thinks that the really key determinants of good occlusion are the first molars and the upper incisors, right? So if we can put like, those are completely two different schemes, right? One is like pretty much more group function based and one is canine guided occlusion. So if you’re going to rehabilitate someone, right? You’re going to give them like, you know, 32 crowns or lots of restorations and change the occlusal vertical dimension right? Change their bite, basically. And then you’re gonna give them either canine guidance or functional occlusion and you’re gonna check Okay, which is the best occlusion, right? Well bear this in mind, right? Lab studies are gonna be pointless, right? Doing it all in an articulator in group function and articulator in canine guidance and trying to come up with some sort of conclusions. It’s gonna be pointless. Okay? So we know that that we can’t correlate lab based studies when it comes to testing occlusal schemes to our patients, and we have our patients, the biggest problem we have is that populations are just too different. For example, people come in different sizes, people come in different skeletal classes, right? How are you gonna make someone who’s severely skeletal class three into canine guidance? Okay? It’s not going to happen. Okay? Same with someone who’s very close two, Okay? They’ve got a huge overjet. Okay, how are you going to make them class one. How you going to make them have canine guidance? Yeah, it’s possible. But then you have to bear in mind that’s different to someone else who’s less class two. And that’s very easy to give them canine guidance. So those are some of the stumbling blocks. Now age of a patient, okay? A young patient we know is different to an older patient. Now, an older patient might have more restorations and may not have as good of a healing capacity as a younger patient. The sex between a male and a female, obviously, now, male, female, different populations. Right? Now, when it comes to bonding restorations for males and females, you know, you’re probably not going to have any difference, right? The enamel, dentine is probably gonna be the same, if not very, very, very similar. Whereas when it comes to male versus female, we know that TMD will affect women compared to men by a ratio of 9:1, so nine times more women will get TMD compared to men. So isn’t that going to have some sort of bearing on our findings? Now, what about people with a long face versus a short face? Right? Their biomechanics is gonna be different. And what about their muscular hypertrophy? What about that lady with very thin muscles, compared to that patient, when they clench together, you feel this massive bulge. Okay? That second patient is generating a lot more force. So how will that affect your findings when you’re comparing these populations? And what about the periodontal status, we know that the periodontal states can vary in different patients at different times in their life, and you might have someone with a reduced periodontium, ie that they’ve already lost some bone in the past. So they might have a little bit of mobility compared to someone else who’s got zero bone loss. And, in fact, they’ve got really thick bone, they’ve got exostoses, those patients are gonna be very different. Now compound that with the different angles and cuspal slopes that patients have, so people naturally have steeper cusps, and people have shallow cusps. How will that feed in to your findings? And what about the big one? Do they bruxs? Do they not? How many minutes a night do they brux for, for example, some landmark studies show that the average normal bruxist so someone who doesn’t grind very much, just grinds for about two or three minutes a night. Okay? So that might be me and you, for example, well actually, it’s definitely not me I’m actually a massive grinder, right? So I’m probably someone who’s called a pathobruxist. So I’m probably grinding for more than 11 minutes per night. With significantly sustained muscle contractions, I’m grinding with much more force. So patients who will grind to varying degrees, they’re different, right? So how are you going to test these when it comes to the different occlusal schemes? And then of course, you got heavily restored versus minimally restored, tooth contact time. And you know, what the list is just completely endless, for example, this is just imagine you’ve somehow found the perfect two population samples that you’ve counted for all the confounding factors, you’ve got two huge populations that represent the general public really well. Okay. And then you have to ask the question, does occlusion change? Of course it does. We know that teeth wear we knew that, we know that patients diets are different. And we know that all of those factors I mentioned above, right, can change. I mean, heck, patients could even change their sex, right? So you know that their muscle size can change, you know, that they’re gonna get older. You know that they’re gonna grind more, grind less, enter periods of stress throughout their life. So how can you actually study these two populations or study these two occlusal schemes? On functioning humans? It’s just impossible. That’s why we might never ever get the evidence we need. And this is why we have so many different occlusal camps or occlusal religions. You know, we’ve got the Dawson, Kois, Pankey, Neuromuscular, PGOs, Spear, just to name a few, right? So each one of these camps think that maybe they have got it understood the best and the occlusal schemes or the slight nuances. I think, personally from studying a lot of these guys, is that they’re all doing the same thing really, they’re trying to improve the health of a patient. They’re trying to get longevity of their restorations, but they just have a few different theories. And this actually is a source of a lot of views, or fistfights, sometimes at US congresses I hear so they have slightly different views. But the way I see it is what can I learn from each camp, okay? Because that’s why I’ve done some Dawson, that I’ve done some Spear. And I’ve listened to Lukas Lassmann, who is a disciple of Kois and Michael Melkers, who and my principal, Hap Gill who’s talking about Pankey. So I have got lots of mentors from different schools of thought. And I just like to learn from all of them. Because I think there’s so much to learn. If I can just get a little bit from each school of thought then I can come up with my own school of thought, and I pretty much have and you will, too, you will have your own philosophy. Now, some episodes ago, I recorded about protocols and philosophies. I think it was one of the first ever interference cast that I did. And I talked about Dr. Jerry Lim in Singapore who inspired me. And I asked him like, hey, Jerry, which occlusal camp should I train with? Right? I don’t know which one to go with. They all seem so good. And he said, you know, why it doesn’t matter, just pick one, and go all in, like really learn it to a tee. And you will find success. And I think that’s true. Because all of these camps, right? They might treat someone differently, the end result might be slightly different. But they all seem to work and they all enjoy success. Now I like taking Kois, for example, I’d like one of his quotes, which is “The idea that we do have controversy makes us realize that we really do not have solid evidence based science to help us make decisions.” So I appreciate the fact that Kois being such a huge educator in Seattle understands that actually, we really, as a profession, lack evidence, and therefore that’s why we have so much controversy, I still respect everything Kois has to teach. In fact, what an amazing Dentist he is and so many of his publications that I read, I’m just in awe of him. So we should learn from people like Kois. And we also have excellent clinicians, like Ed McLaren, who said, “It’s very difficult to say that one occlusion is perfectly correct for all individuals. And I don’t think we’ve identified an ideal occlusion for a specific person.” If only it was that easy. So for example, you might be a dental student right now. And you’re learning all these things at dental school about the perfect occlusion, canine guidance, the mutually protected occlusion, everything in balance, that kind of stuff nice and smooth. But you see your first patient on clinic, and maybe they have an anterior open bite, or maybe when they bite together, there are complete skeletal class three, right? And you’re like, Wait, hang on, this doesn’t look like the textbook at all. And when you see that in practice, and you see a year on year on year, and you start seeing that, okay, a lot of patients have, let’s call it sub optimal occlusions, or non textbook occlusions. And they’re doing just fine. And it makes you think there’s got to be something else at play, you know, there’s not just the occlusion here, there’s a whole person behind it. There’s a whole masticatory system at play here. So we see these things in practice, which aren’t quite like what’s in the textbook, and then you start to go to occlusion courses. But then you realize that since this term center relation was created, it’s changed definitions 26 times as a profession, we can’t even agree on the term centric relation yet is supposed to be this really big deal and occlusion, which I’m going to explain now. Right? So let’s talk centric relation. Okay. It’s a very controversial topic. A lot of scientists think that there’s some sort of magical place that you put some in centric relation, and they will stop bruxing. This is not true at all. Okay? You put someone in centric relation, and suddenly, this might get rid of their headaches, or this will make them a more complete person or whatever, you read a lot about the value and importance of centric relation. Some dentists really overplay this, right? Let’s look at the definition. Let’s talk about why I think centric relation has a role. But it’s not this amazing thing that everyone needs to be in centric relation, because remember that 97% of us are not in centric relation. So we are normal. So essentially, the people who are IN centric relation who are abnormal, so let’s stop chasing this perfect ideal thing. Now we know that there is a benefit of centric relation. I’m gonna come to that in a moment. Let’s just take a look at a glossary of prosthodontic terms definition from the latest one in 2017. Okay, so don’t write this down. Don’t make a note of it, please. Okay? Because I’m going to explain why shortly. But you definitely don’t need to make a note of this, okay? It’s a maxillomandibular relationship, okay, independent of tooth contacts. So we know that you can actually grab someone’s mandible, put them in centric relation and stop hinging, but we know that as long as a tooth doesn’t touch that centric relation, as long as soon as the tooth touches, technically, you’re not in central relation anymore. And now you’re in a tooth born position, which might have a different name like centric relation contact point, for example, but to be in purely centric relation, like your complete denture patients, right? You take the dentures out, you can put them in centric relation. So it’s not a position that’s dependent on your teeth right? In this position independent topth contact, in which the condyles articulate in the anterior superior position against a posterior slopes of the articular eminence, this is a bit which confuses a lot of people or loses a lot of people that everyone can follow the fact that it’s between the mandible and maxilla, everyone can follow the fact that there’s no tooth contact, but it’s this anatomical reference that confuses people. Okay. Why does it confuse people? Okay, I think there’s a very good reason why it confuse people. Because when you’re in the clinic, you’re trying to apply centric relation, right? You can’t see the condyle, you can’t see the articular eminence, you can’t see the posterior slope of the articular eminence, right? So this is a bit where people get confuse because they can’t see it. It’s just this abstract concept of what might be happening in the jaw unless you get a scalpel and actually dissect and have a look at what’s happening. We don’t know this, right? So this is where the term I know is needed. But unless you can see what’s happening, which you can’t, it’s not going to help us right? Now, it’s in this position, the mandible is restricted to a purely rotary movement. Now I’m going to play devil’s advocate and say that this is probably not true. Okay. Some of the CBCT data, MRI data showing that actually, there’s no such thing as pure rotation. There’s always a little bit of translation, but let’s just go with it. Okay, let’s just go with the fact that it’s pure rotation, I think that’s usually to benefit the articulator more than to benefit us, right? So, that is confusing, right? If you’re listening to this, you’re driving like, Whoa, okay, now, this is really confusing. This is why I don’t want to learn occlusion anymore kind of thing. I think, you know, let’s look at centric relation, not in terms of this very long paragraph, which by the way, a lot of dentists are upset about because they feel as though there was no mention of the disc, right? So we know that between the condyle and the articular eminence, there should be a disk, right? So to really be in centric relation, right? There should be a disk on top of the condyle, right? And a lot of people are upset that in this latest 2017 Glossary of Prosthodontic terms, there was no mention of a healthy condyle-disc relationship, okay. But anyway, going away or moving away from that description. My take on centric relation, that is that the anatomical description is not really clinically relevant, like I said, right? For me, as long as it is repeatable and reproducible. Now, there’s also different ways to check and we talked about that another time. But as long as you’re in the same place, every time be on your splint be on your restoration, be in sometimes just the way it feels like you can, you know, you can deprogram them straight away. whereas others, they are really stiff, you can’t move their jaw, right. And they’re the ones who need what we call deprogramming, allowing their lateral pterygoid muscles to forget where their bite is, allowing it to relax, allowing the lateral pterygoid muscle which is pulling on the condyle, to just let go, let that muscle stretch, and to let it go in that anterior superior position where it wants to be, right? But for us, it’s the most important. The most important takeaway thing about centric relation is that is a convenience position, right? Like, if you’re restoring someone, and you decided that okay, you know, open up their bite. And now you’re going to fill in with lots of crowns and lots of fillings. You shouldn’t just pick but you can do, but you shouldn’t just pick a random position, okay, let’s just build your bite forward by two millimeters and just build it there. The patient might adapt, but they might not okay, but then what if halfway through, you’re trying to move between temporaries and then definitives. And then you just hacking away and you’re just observing where the jaw is ending up and just finishing in a random place, there’s a real danger that you lose what you made in the diagnostic wax up. And when you’re transferring that to the mouth, everything just gets lost. But if you go to this clinically repeatable position, which is basically not quite the furthest back, you can go so this whole term of retruted contact position, very old term were going to move away from that, that’s like pretty much shoving the condyles back as far as they want to go, right? We don’t want to do anything to do with that. But this position when you are there, and it is repeatable, that’s a very useful position for us, okay, so that when we do take off our temporaries, and we do place our definitives, then we’re trying to then balance our restorations. And our end goal is always that same position that we had from the beginning and not this random position, you can always be sure that what you’re trying to achieve on the articulator we’re trying to achieve from the blueprint is going to end up like in the mouth with the correct guidance as you planned it. If you’re going to random arbitrary position, you might end up where you want to go, where you might just get random contacts that you weren’t expecting. So that’s the major benefit for me of centric relation, okay? And it has to be this sort of this snug position. I like this snug term, like centric relation is snug, right? And when you’re manipulating the mandible, the lower jaw and you’re moving around and you’re in this hinge in motion. It’s called Romancing the mandible. And there is something quite special about when your patient centric relation just hindering them away. And with experience, you gain that so if you’ve never done this to a patient before you will gain that experience with time and we have to remember that actually centric relation, most of our dentistry is not going to be in centric relation, okay? Most of our dentistry is going to be in whichever bite they already have in their existing maximum intecuspation position, ie how their teeth habitually bite together. This only I trying to get them more fancy, we’re trying to open up the bite, we’re trying to change things in significantly, then that’s when we’re entering centric relation dentistry. And for you as a restorative dentist, it is a point of convenience. Now to confuse you even further or even less, I hope after this little segment is centric occlusion, right? Okay. This is a massive source of confusion. And this really pissed me off okay, Excuse my French but let me tell you why centric occlusion pisses me off. Okay? Right now, whatever you’re doing before you advance, just in your mind, think what is the definition of centric occlusion for you? Okay, in your mind, what did dental school teach you is centric occlusion? Okay, so you’ve got your definition in your head. Okay. Let me tell you what the glossary of Prosthodontic term said in May 2017. Now May 2017, okay? The 9th edition of the glossary Prosrhodontic terms came out and the top song in May 2017 was despacito. I will not sing it for you Don’t worry, okay. And it define centric occlusion as the occlusion of opposing teeth, ie the upper teeth, when the mandible is in centric relation, okay? Let me say that again. The occlusion when the mandible is in centric relation, okay, this may or may not coincide with the maximum intercuspal position. So, for all of you who said that is the same as MIP? or is your habitual bite? Or is where all the teeth meet together when you bite? You are wrong, right? So, dental school taught me that they taught me that centric occlusion is MIP. But actually, the glossary says that no, in 2017, it said that it’s your basically is your centric relation contact point. That’s a term I like. The reason I like that term more than centric occlusion is because lots of dentists will say centric occlusion. And they mean completely different things. This is absolutely catastrophic for us as dentists who want to learn, who want to advance in the field of occlusion, because you might communicate with a dentist, or you might read a book, or you might watch a webinar. And you get so confused by which definition of centric occlusion they’re using, because a lot of dentists I know, are still using the old definition of centric occlusion, which is MIP. Now let’s go back in time, okay, let’s go to December 1987, the fifth edition of the glossary of Prosthodontic terms, okay, the number one song that year, that month was faith by George Michael, another cracker. And actually, the definition was the same as it is in 2017. So here I was thinking at one point that oh my goodness, I can’t believe I didn’t realize in 2017, they changed it, well actually no. Even in 1987, it was the exact same definition. Okay, can you believe that? Right? So I am a little bit annoyed that when I started school, in 2008, okay, in Sheffield in dental school, they taught me that it’s MIP. Why didn’t they teach me? Why my tutors teach me that was a 1987 definition at least. Okay? So I’m thinking that Whoa, a lot of people are just stuck in some sort of like 1956 description or something, right? Because when you go back in time, even more to July 1977. The top song was undercover Angel. Okay? A song I hadn’t heard before it actually YouTube it when I was searching this up, okay? And that’s where they described centric occlusion as the centered contact position of the occlusal surfaces of the mandibular teeth against the occlusal surfaces of the maxillary teeth. Man, I don’t even know what that means. That’s so confusing. Okay, but I guess at least from 1987, we can safely say that the definition is not MIP. Okay? It’s the first point of contact as your teeth are in centric relation, the first thing that hits so I always use centric relation contact point, the first place where you hit so no wonder we are confused in occlusion. Not only did centric relation change 26 times, we are still confused this day as a profession about the definition of centric occlusion. Okay, why does this matter? Like what you’re saying, Jaz? Come on, man. It’s just definitions. Calm down. It’s not going to affect the beautiful dentistry that I’m gonna give my patient. Well, it does matter, okay? And even as far back as 1956 in the Journal of Prosthodontic dentistry, where in that year, the very first Glossary of Prosthodontic terms was released. Okay, Carl Boucher said “The correct choice of words to express an idea is important to an author, because the communication of his idea is his objective.” The dentist and the student are the readers of the chosen words. The words must have the same meaning to them, as they do to the author, the need for a precise system of the nomenclature with precise definitions for terms use in prosthodontics is obvious. And I totally agree. Only can we start merging these religions and start playing mice, we actually have a level playing field of terms. So hopefully now, after this little ramble, you know that centric occlusion, according to the latest terms, is the first point of contact, it’s not MIP. Why don’t we just use maximum intercuspation position as the term for MIP and move away from CO. Now let’s look at the most important definition I haven’t covered yet. Right? Like what is the definition of occlusion? Like why even study occlusion? I’m not talking about the very long and boring definition in the glossary of Prosthodontic terms. I’m going to give you a couple of definitions of occlusion I really like. These two definitions of occlusion I’m going to share with you helped me massively to understand what we’re trying to achieve with occlusion, what is occlusion in daily practice? Okay? So first one is from my mentor, good buddy, Michael Melkers. He said, “why don’t we just rename occlusion to stopping your dentistry from breaking?” Okay? It’s basically a solution to help meet a goal. And that goal is to get longevity and good looking teeth where you want them, right? So if you start thinking about occlusion like that, and not when the teeth come together, and as you go into excursions and this kind of stuff, right? It’s just about getting predictability and stopping your things from breaking. And in a similar fashion, Ed McLaren, who also is we have at the Tubules Congress in Brighton. So I look forward to seeing him again, great clinician, UCLA, he says that “Clinician’s are trying to design the way the teeth come together, so that we prevent some sort of breakdown, whether it’s of the teeth, the periodontium, or the joints.” okay? I love the term he uses, which is called force management, right? Occlusion is basically force management. So when you think about occlusion as force management, you start to think of it perhaps a little bit too biomechanically, rather than deserved as a human with emotions at the end of the body. But I do like this concept of force management. Okay? A lot. I think when you’re rebuilding, complex dentistry, force management should be was all about. But I’m going to completely play devil’s advocate here because you need to hear this. Okay. So far, we talked a little about, you know, canine guidance, some different definitions of centric relation and centric occlusion, and what actually occlusion is to me and why it’s important to prevent failure. But is occlusion really to blame? Right? Like, you know, how people say, ‘Oh, this patient had a really bad occlusion Or it’s because of the occlusion, this patient got TMD or check the occlusion there might be something wrong. What you have to think, right? How many minutes a day do our teeth touch together? How many minutes a day? Should they touch together? Right? And if you’re thinking 20 minutes, you’re right, right? So if our teeth should only touch 18-20 minutes a day, then why are we so obsessed about 1.4% of the day? Okay. We don’t focus on the whole 98.6% a day. No, we have a whole religions and courses and everything based around occlusion, which apparently, most of us should only be doing for a tiny fraction of the day. Okay. So why do we place so much emphasis on this small portion of the day, right. Now, granted, some people will be clenching, grinding during the day and at nighttime, and they will probably exceed that 18 minutes. And this patient might be the same patient who develops muscular hypertrophy. Like if you think about it, this patient is going to the dental gym, this patient is working out their masseters, temporalis, middle pterygoid, right? And therefore, they might have larger muscles. Now the problem with larger muscles is they start generating more force. So maybe we start seeing a little pattern here. Now to make it, to drive it really home and make it tangible. I discussed this with my one of my mentors, Barry Glassman who really got me to think about not occlusion, but occluding right? let that sink in. Not occlusion. But occluding Let me explain this concept to you, right? One way that Barry explained it is when you open up an anatomy textbook, and you’re looking at the anatomy of the entire body and you see a skeleton laying down, okay? what kind of posture or what kind of position is that skeleton in? Well, it’s completely like you know, like completely flatted right the skeleton is laying down there’s no bones in any different funny positions that just the arms are by the side everything is like normal. What you don’t see in anatomy textbook is a skeleton I can opposing trying to sort of bold pretend biceps, right? You don’t see the skeleton in a contracted way. Why? Because you need muscles for a skeleton to be able to move its bones right? Now, when you’re looking at bones. You’re just seeing bones, there’s no muscle. So why is it that in dental textbooks and in all the photos that we see, we see patients in their maximum intercuspal position, all the textbooks anatomy, dental anatomy, occlusion courses. Oh, let’s finish. Let’s look at the post op image right? The patient’s teeth together. Why are we doing this, right? It’s the same as seen that skeleton in that textbook with the biceps bulging right? The point I was trying to make is that a we need to think that actually is not the bite that’s to blame when things go wrong. It’s the biting IE is the muscles, right? It’s the muscles that contract that bring our teeth together. So sometimes we put too much emphasis on the bite, and not enough emphasis on the biting. And if you think about it, those patients who are biting for longer with higher forces with stronger muscles, they might be the ones that could cause more issues, more damage, more breakdown to the PDL, more breakdown of the periodontium, more breakdown of the joints, and more breakdown of the teeth. So remember that, yes, occlusion is importan but occluding might be the missing link between why some people get problems and why some people don’t. So how do I bring this all together from going to so many different occlusion courses and learning how to wax up these teeth and spending so much time to make sure that our fine tuned a patient’s occlusion versus, actually it might not be so important because it’s the OCCLUDING that’s important, the muscles, ie the role of splint therapy, or the role of counseling your patient for awake bruxism might be more important, like we know, for example, some patients when we finished our restorations, and we get them to bite together, right? Some of them if they bite together, and you’ll notice that Whoa, you’ve jack them up open so much, right? And there’s like, no, there’s so much space on the other side that things aren’t touching together, the MIP is a way off, okay? You’ve left them really high or really proud. But when you ask the patient how things feeling, they say it feels great. Whereas you go the other patient, everything looks like you’ve got, you nailed it, right, you’ve nailed the MIP, you have got everything looking perfectly. There doesn’t seem to be any high spots, but the patient will tell you, yeah, I can feel that this is a tiny bit high. I bet that second patient is probably someone who’s used to feeling how their teeth meet together, they’re so used to it, that they’re spending a lot of time in that position, hence why they’re able to give you that really high level feedback. So the answer might be treating your patients in terms of risk. That patient who does feel every little micron, that Princess and the Pea patient, that Goldilocks patient, okay? When you engineer that patient, you know that you need to over engineer that you need to really fine tune the occlusion. And if you’re giving that patient a rehab, and they’ve destroyed their teeth before, you’re going to follow the principles of a minimally stressed occlusion, you’re going to try and get everything contacting the same time, you’re going to try and get anterior guidance, canine guidance with the transition to anterior guidance, which I’m going to probably cover in the next episode, because there’s only so long I can cover in this one. But what I’m trying to say is you’re going to really work hard to make sure that you design that occlusion, you design that blueprint, you take full control of what you’re trying to do. Whereas that patient who has very soft and gentle muscles, who is probably an 18 minute chewer, or maybe even less, and who really, if you leave them proud and jacked up, they won’t even realize that patient when you’re restoring them, you can get away with a lot. You don’t have to give them that textbook occlusion, right? You probably still will, because you want to reduce your risk, okay, you have a pain patient. You want to follow the textbook rules to get maximum success. But sometimes you can get away with a lot more with this patient. That’s how I like to think about it. I’m going to echo again Ed McLaren’s sentiments about force management when you start getting patients to bite together instead of looking at them as dots and lines you think of force management you start taking a step back, you start feeling their muscles, you start feeling their joints, you start knowing that okay this patient’s grinding and when they’re grinding they’re generating a lot of force because there’s a lot of resistance to movement right? They’re struggling to move their jaw and they’re struggling to move their jaw, guess what’s absorbing all that force? It’s the teeth, it’s the PDL whereas someone else as they’re grinding they’re gliding beautifully left and right that patient may not be generating as much force. So it’s all about force management, it’s about being a good conformer. Why mess up someone’s occlusion? Why change their occlusion if everything is working for them? So most of our daily bread and butter Dentistry, right? Become a good conformer, check the occlusion thoroughly with your fingers. When you put your fingers, your fingertips on the teeth and you get the patient to bite together you can sort of figure out what kind of occlusal contacts they’re gaining. Some will feel heavy, some will not feel not so much and then at the end you’re hoping that once you’re done with the restorations, when you’re done with your crown or when you’re done with your composites that things will feel the same with your fingers again or you and even when you put your articulating paper in the marks will look the same as they did before. Now I found it very useful to take an intra-oral camera photo pre-operative contacts and compare that to post-operative contacts so I know that I have conformed to the patient’s occlusion i.e I haven’t changed anything, okay? It’s a bit like why would you want to change anything, right? It’s a bit like when you’re five years old and you go into the kitchen and you know where the secret chocolate stash is and you you’re kind of you know sneaking around like a ninja and you find that chocolate, right? Once you’ve eaten that chocolate, what do you do? You hide all the evidence, you try and put everything together back how it was so no one realizes you are there. You want to be that dentist, okay? You want to go inside okay and you want to come inside you want to stop your restorative procedure coming away and you’ve hardly changed the thing, the tmj, the periodontium the dentition hasn’t had to do any or very little adaptation, right? Be that dentist, who is that five-year-old who puts everything back together how he found it and lastly one big lesson i want to just give you now to give you some sort of a food for thought for future lectures is test driving your changes, right? Sometimes when we’re doing bigger cases and we’re going for lots of crowns and we’re doing extensive restorations it is so so so important to test drive everything because that’s when you can test whether your force management is correct, that’s you can test where the patient is comfortable, that’s when you can check that the patient is as you planned them in centric relation if you plan them in centric relation it’s not always that we want to go into central relation and i can cover that in the next episode a bit more but in a nutshell, there are times where you don’t want to put someone in centric relation because imagine when you put someone in centric relation their lower jaw goes all the way back okay? What is that doing to their facial profile right? That’s probably not making them look very well also what is that doing to their airway, okay? That could be collapsing their airway, right? So there are times where you would actually make a conscious decision not to rehabilitate someone or restore someone to centric relation because that position may be less favorable for other reasons, aesthetic or airway to give you two examples. So I hope I haven’t confused you and I hope that gives you some sort of food for thought about hey why are we so bogged down in occlusion where actually a lot of our patients are only chewing for 18 minutes a day, well actually some patients might be doing more than that be more destructive, generate more destructive forces and in that patient you might be over engineering them. You’re probably safer off really looking into force management whereas someone else you can just do the best job you can to conform and that’s all you need to do. Now maybe next time, next episode we can look at being a good conformer. What i mean by that is what kind of context are you looking to finish with right like there’s a whole theory of tripodized contacts to make sure that everything is nice and stable is that really necessary? We can look at what we check for in an occlusal examination. The relevance of the centric relation contact point. Now we talked about centric relation when the teeth meet together finally in centric relation, what is significant about that, okay? Both in terms of your planning and also in terms of your daily patients that you see, are their teeth at any risk by being in that position and i also want to just introduce you to these terms which are freedom from centric or some people call it freedom in centric and i’ll tell you the nuances between them but i think that’s really good because when i’m finishing an orthotic case, I want them to have this wiggle room and i’ll tell you what i mean by freedom from centric and why it might be advantageous to have your patients in this, have this feature in their occlusal scheme and I’ll touch more into what if you do restore someone not in centric relation, what are the bad things that can happen so for example if someone is going to have a messed up aesthetic result or you’re going to mess up their airway and you’re going to choose not to put them in centric relation or you’re just going to do a rehabilitation and you’re just going to be lazy, you’re just going to open everything up and stick some restorations on and hope for the best what potential considerations should you keep in mind if you’re doing that because i know some dentists do that and that’s fine but there are some things that we should know, some compromises that you might be making, some risks that you might be taking. Jaz’s Outro: So thank you so much for listening or watching all the way to the end. I really appreciate it. Now if you are wanting to learn a bit more then the next video i have for you to watch if you’re watching on youtube is or if you’re going to protrusive website I’ll link this video on. I’ve got a video on the nine point checklist to make sure you never have a high restoration again so that when you’re doing your composites on the rubber dam when we take the rubber dam off you get the patient to bite together you’re not having to hack away so much or hardly anything. So my best nine tips so you can click here now if you’re watching on youtube or if you go to protrusive.co.uk i’ll link that short little video i think it’s about eight minutes on just my top tips on making sure that when you do conform it’s less stressful for you. Thanks so much for listening all the way to the end. Don’t hold your breath for part two because these episodes take me a long time to come together. Do check out the newsletter for these kind of updates if you haven’t already is on protrusive.co.uk/newsletter and i’ll catch you in the next episode.

Vertiprep? Dirtyprep? There are some Dentists who will literally opt for an adhesive onlay for every indirect restoration. That’s not cool – they are not a panacea. On the flipside, there is a breed of Dentists who identify as ‘Verticalists’. They will vertiprep their grandmother if they could. The answer lies somewhere in the middle – everything is case dependent. In this episode, with the return of my friend Jorge Cardoso, we revise Vertical Preparation, decision making protocols for indirect and then explore the nuances of digital scanning for vertical preps (even if they are super subgingival). https://youtu.be/AAWRJjEKN_U Check out this full episode on YouTube! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Impressions vs Digital. Remember, if you’re going digital, you need to be more aggressive in your tissue retraction compared to impressions. If the light from the scanner tip does not reach beyond your margin, it will not be recorded. Whereas with impressions, the wash material can flow beyond the margin and capture the sulcus, even if you cannot see it. Treatment Plan Letters with MakeMeClear discount – all of the Protruserati clan get 25% OFF the monthly or Annual plan with the code ‘protrusive‘! Trial it for 21 days and generate letters and listen to Episode 49 – Crystal Clear Treatment Plan Letters Fancy joining us for a POTENTIAL trip to Portugal for hands-on Vertical Prep? Click here and I’ll email you if/when this gets the go-ahead. We are thinking Spring 2022! In this episode Dr Jorge and I talked about: What is vertical preparation 8:17 Two types of vertical preparations (BOPT / Edgeless vs Shoulderless) 13:57 Guidelines on temporising vertical preps 17:40 Traditional vs Digital in Vertical Preparation 23:29 Criticism of Vertical Preparation with Biological width 30:19 Concept of “kissing the bone” 35:33 Spacer Protocols for Technician 40:54 Common mistakes with verti prep 45:02 Digital Scanning tips for Vertical Preparation 49:37 Sorry that Dr Jorge’s screen share did not show in the main video, we had some AV issues. Please find below an 8 min snippet where he shares his screen at various points https://youtu.be/e8psNUVMQ5g As promised here’s BOPT by Ignazio Loi Do Check out Dr. Jorge Cardoso’s episode with Crystal Clear Treatment Plans that Wow Patients and are Easy to Understand If you want to learn more about vertical preparations check out eMax Onlays and Vertipreps with Dr Jason Smithson Click below for full episode transcript: Opening Snippet: At the beginning I was going to be skeptical but then study start to come out to say that A) Zirconia feather edge margins behave as well as shoulder ones. So in terms of literature, in terms of safety, we are safe to go. Now the main advantages, you are saving more teeth, you are making your life easier, your impressions are easier, the fitting is easier and something which really attracts me periodontal stability is much, much higher... Jaz’s Introduction: Hello, Protruserati. I’m Jaz, Gulati. Welcome back to another episode of the Protrusive Dental podcast. Now this was supposed to be if you listen carefully to the outro of the last episode. This is supposed to be the basics of occlusion as part of the bigger picture, splintember series continuing on from the back to basics episodes from August which I hope you really enjoyed. But the problem is this man, it takes a long time to script my solo episodes. Like if you if you think back to September last year, so September 2020, we did the splintember series. And, man, I forgot how much effort it takes to put something together, but I’m still determined and keen to put something together, that’s gonna be you know, while you’re commuting, while you’re chopping, onions, gardening, whatever you’re doing to make it a really valuable episode, all about my perceptions of occlusion, and just the very basics from like centric relation to freedom in centric, to when to conform, and when to reorganize, and what all these things actually mean. So I am working on that. And I’m going to get it out to you very soon. So that’s why it’s been a bit of delay, in case you’re wondering. But today, take nothing away from this absolute gem of episode think of this way like I’ve delayed basis of occlusion, but I’m giving you something that’s really, really prized. I was actually going to save this one for another time in the future, because we’ve got Jorge Cardoso, from Portugal, who if you remember from Episode 49, I think it was crystal clear treatment plan letter. So if you’re looking about presenting your treatment plans in a letter, which is going to be very compelling, concise, easy to understand for your patients, then I will definitely listen to that episode. And check out makemeclear.com and use the protrusive 25% discount code because he’s been very kind to give that but today is all about vertical preparations. What are they revisiting something that we also tackled in Episode 19. Go look at me referencing all these episodes. I have enough now to reference in the past. Check that out anyway. So Jason Smithson came on episode 19. We talked about verti perhaps and Emaxs, onlays absolute cracker of an episode, even though his audio wasn’t that great. It was so so jam packed informative. Now we’re taking that verti preps. And we’re going a little bit further with Jorge Cardoso today. So we do revise like what is a vertical preparation of crown? How does it differ to a traditional crown preparation using a shamfer or shoulder? What are the considerations for anterior and posterior vertical preparations, but also then delving deeper into how we can we move away from traditional impressions and analog? And can we actually employ digital dentistry when it comes to vertical preparation? Something that’s not spoken about very much, actually. So I’m hoping you’ll find this extremely valuable. So the reason I was gonna delay this episode is because when me and Jorge are talking, we actually figured that actually a lot of people want to learn more about vertical preparations. A lot of people, a lot of dentists want to learn how to use this technique and they want to go in a hands on course now, I’ve been on Jason Smithson’s course, if you’re in the UK, and you’re looking for a really good course, on vertical preparation, Jason’s is the one to go. I enjoyed it very much last year, and it’s very much had a big influence on me as well as people like Pasquale Venuti. Who also taught me a lot about vertical preparations and the Tomorrow Tooth facebook group. But now me and Jorge are talking about an excursion to Portugal, because some of my best memories as a dentist have come from taking educational courses abroad, be it you know, Sweden, Europe or on a ski holiday, which also doubles up as a CPD sort of dentals over educational events. So these holidays are often the most memorable. So we enjoy your thinking maybe next year if you guys are interested to learn about vertical preparation hands on, but also have a little holiday at the same time tax deductible. Then why don’t you sign up on protrusive.co.uk/vertical-portugal. That’s /vertical-portugal. Now if you put your email address in there, when and if this happens, I’ll email saying you know what we’re kind of thinking we’re gonna get 15 to 20 dentists, Protruserati to go to Portugal together. No matter where you’re from in Europe or the world even to go to Jorge’s clinic and he’ll teach us hands on vertical preparations. So we can delve further into this technique. So bear that website in mind. I’ll put it on the YouTube or on Dentinal Tubules or on the main page @protrusive.co.uk. That’s it. Like I said, another reason why I was delaying this episode. But now that I can’t give you the basics to occlusion, I’m giving you this one about going digital when it comes to vertical preparations, and revising all about from a different angle, a different perspective, from how much cement space you need to making sure that you don’t get undercuts, in any form because they can be very detrimental. Me and Jorge share some failures that we’ve had using verti preparations and how we now realize actually, we did something wrong. So learn from our mistakes. The Protrusive Dental Pearl I have for you is regarding impressions versus digital. And really, the main message I want to give you is, if you are digital, or if you’re going digital, remember that you need to be more aggressive in your tissue retraction compared to impressions. Let me explain why. Imagine you have a sort of equigingival or slightly subgingival crown preparation, and you’re going to be taking impressions, that light bodied silicon material, for example, is thin enough, they can creep into the sulcus space and capture that area. Whereas with digital, if the light cannot get there, it will not record it. Therefore, in those cases where I think I’m going to get away without using code here, with impressions, I’ll be fine. But if I’m thinking, if I’m unsure with digital, you better bet I’m gonna place a cord. Okay. Now with impressions, when I can get away with just one cord, then I know that I’m going to be doing two cord techniques to get that vertical and horizontal retraction of the tissue. So everything that I do with impression, I take it one step further when it comes to digital scans, because you need to be more aggressive with your tissue retraction, need to show the scanner more. It can’t creep and flow like our impression materials. So just remember that little tip. So let’s get down to the main episode and I’ll catch you in the outro. Main Interview: [Jaz]But you’re now been on the podcast before, Jorge, it’s great to have you on again. If anyone hasn’t checked out the episode, we talked about Crystal Clear Treatment plans with Dr. Jorge Cardoso with makemeclear. You need to check it out that has actually impacted so many dentists because they came away having a clear idea of how to communicate better with their patients, both in terms of verbal and of course written. So please do check out that episode. I will link it in the show notes. Jorge, welcome back again. How are you? [Jorge]I’m fine. Thank you so much for having me. It’s always a pleasure to be talking to you. And thanks so much. [Jaz]I’m glad to be discussing today something like obviously, we talked about communication before. And we talked about written Treatment plans, which is so important and something we don’t talk about enough. But you’re such a talented dentist, Jorge that it’d be a real shame if we didn’t do a clinical episode. And like, but you’re the only dentists who are so just brilliant at everything. And I think what kind of topic can I give, so we can niche down in something. And I love how much of the vertical protocols that you have adopted. And I love how much you’re pushing the boundaries with digital. So this episode is more about vertical preparations specifically in terms of digital verti preps. So let’s just dive right in. For those people listening who still have no idea even though I covered a little bit with Jason Smithson in one episode is a little bit rushed, because we did half on Emaxs onlays, which could easily be a five hour episode and half of verti prep, which could be many episodes as well. So in your view of the world, Jorge, what is a vertical preparation? Because some dentists be like, I have no idea what this is. [Jorge]Okay, so the vertical preparation was something that actually changed completely, changed the way I approach initially only posterior teeth. And now, as for me, every time that I go for a crown, that I’m doing something which is non adhesive, every time that I go for resistance and retention, the vertical preparation is by far the best approach that I can go. So I completely changed my practice completely changed my practice. Initially, I have to say I was a little bit skeptical because I thought maybe it’s too thin, it will break or maybe the technician will not see the finishing line. There are so many things that we have inside our mind specially when it goes for fixed prostho which actually when you really think about it, and we look into literature, about 30 to 40 years ago, we already knew that vertical preparations were actually very good. So just a little bit of historical perspective. So when the PFM started, it was about vertical preparations for the finishing line was metal. So then we evolved a little bit and we wanted to do what it’s called the ceramic shoulder. So we wanted to have more space for the dental technician to layer down the ceramic. So instead of being like a feather edge margin, we started to get horizontally, a shoulder or chamfer. So that would give space for the dental technician to hide the metal on the cervical area and to provide better aesthetics and we kept like that for 20 years. But then something interesting came up which was CAD CAM right? And because of CAD CAM what happened is that we wanted to also to have a very thick amount of material in the shoulder area. Right? So instead of being minimally invasive what CAD CAM brought I don’t know if you remember the Procera crowns from Nobel Biocare which were the first all ceramic alternative to PFM And what happened is that we became even more invasive. Why? Because CAD CAM leaders wanted to have space right? So when we started to have CAD CAM, vertical preparations seemed even far away because we never thought that CAD CAM machines would be able to mill such thing, margins. So more recently and Jason Smithson and get some tomorrow tooth group and ripe group, we really start to look a lot into vertical preparation and I was curious as I started to follow them. And I in the beginning, I was a little bit skeptical, but then study start to come out to say that A) Zirconia feather edge margins behave as well as shoulder ones. So in terms of literature, in terms of safety, we are safe to go. Now the main advantages, you are saving more teeth, you are making your life easier, your impressions are easier, the fitting is easier, and something which really attracts me periodontal stability is much, much higher. So you can’t lose with vertical preparations. [Jaz]I 100% agree with you and the most common I wouldn’t say objection. But the common question I get is, everytime I posts on social media about vertical preparation, which I completely have the same reservations and revelations as you Jorge because initially, the first thing you think is weight, biological width concerns, how thin the material is, all these concerns that we have. And it’s just such a paradigm shift from being trained at dental school to create this clear, you know, shoulder one millimeter plus that the technician can see. So to having no shoulder and being featheredge is such a massive shift that initially it felt like I think [Mascheroni] called the vertie prep, the dirty prep. So there was a lot of resistance amongst the sulcus for the right reasons, I think. But I think once you truly understand the biology of healing, what we’re trying to achieve, and for me, the main reason now I have also switched to when I’m doing something non adhesive, ie when I have a preparation that does not have enough enamel, that I do think the most minimally invasive technique is a vertical preparation because the preservation of the Pericervical dentin and like to make it even more tangible, like you gave a lovely historical perspective is, let’s think about like nowadays, imagine you have someone with lots of recession, because of periodontal disease, and you have such a long crown height of a lower premolar. Right? If you cut a shoulder into that tooth, like you’re going to be at the root, you’re going to be into the pulp into the root filling whatever it just doesn’t make sense. So you want to something knife edge, but the way that this is a BOPT with especially with the works of Ignacio loi, which again his paper I will put on the show notes as well, great landmark paper that showing that okay, what can be achieved in the aesthetic zone, it was brilliant. And not only is it can be minimally invasive, but you can really get an aesthetic results. Like I have some cases I know you have as well, where we prepare for vertical. And then the gingival zenith will migrate and you actually are growing gingiva. And when you can do that. You that’s a cool moment. So why don’t we, Why don’t I pitch it to you, Jorge about what about those dentists that say, “Hey, by going so subgingival with the prep, are you not encroaching the biological width? Can you bust that myth for us? [Jorge]Well, the thing is that initially, I think that was the biggest barrier for me to devote to preparation, but then I realized exactly what is a vertical preparation. Well, I don’t want to make it very complicated. But there are basically two types of vertical preparations. That’s the BOPT type, which is basically edgeless preparation, something that you go, you prepare right into the bone. So the BOPT from Ignazio Loi is like evolution of the first words from Di Febo and M Amsterdam. So basically, it’s a periodontal preparation, very aggressive, okay? So that serves the purpose of going very deep, cleaning all the bacteria and also let’s say resetting the periodontal tissues, okay? So that is a very invasive preparation, and that should be reserved, that should be reserved for cases that need to do so like periodontal case or stuff like that. Okay. But then there’s another type of preparation, which is almost more known as the verti prep, which is basically a preparation that does not go as deep. And one of the main differences of this preparation is that you can actually do the impression on the same way, okay? So if you go very deep, you should not do the impression the same day, you should let everything heal. But if you go not as deep you can actually make the impressions on the same day. And usually when I look don’t go as deep I leave that to cases of posterior restorations, okay? So the BOPT what I usually do is I do adaptation and I do something like so let’s imagine the BOPT, one thing or one of the good things about the BOPT is that you can actually play around with the levels of the gingiva Okay? So you it’s a more invasive preparation, which on the anterior cases, you may say well, why are you being so invasive on anterior cases you have to remember one thing. So, the vertical preparations which are divided into like BOPT and verti prep, two different scenarios. The vertical preparations are preparations that are a type of crown, they are not an alternative to the veneer, they are not an alternative to the onlay. So, you have decided to go with dentures, you have decided not to go adhesive, then you choose a vertical preparation, okay? So in the anterior region, when we are thinking about vertical preparations is because I already have almost no enamel and darken substrate. So if I want to use a vertical preparations, I would need to be very aggressive on here, you want special on the buccal part because I want to have space to do like a ceramic shoulder like artificial new cementoenamel junction. So I go very well. For posterior cases, what I do is I do same day impression and I usually stay all in the sulcus, okay? So for the posterior, there’s no problem of impinging the biological width. Now for anterior, you see, you are going very deep with the first preparation, yes, but I never do the impression on the same day. And I always need to let the tissues heal only after they heal, then I do the regular impression. So I always stay inside the sulcus, even if I go very deep on the first impression, because I like to and I think that’s beside the sulcus. And then on the posterior one, even if I do the same day impressions, I always stay on the sulcus. So those are two different approaches. [Jaz]With the anterior one, perhaps when you’re going much deeper almost to the bone, and you’re getting that “Gingitage”, the removal of that inflamed gingiva, and then as it heals, it will form this new sort of junction epithelium. How are you temporizing that to get the sort of advantage of the biology, ie you are dictating where the gingiva zenith will go by using your temporary in a clever way. So any guidelines as to how far to extend your temporary away from the base of the sulcus? [Jorge]So basically, when you do a preparation, you are actually very deep and there’s bleeding. So even if you want to go really deep, you’ll never be able to reach very deep with your temporary. So I would advise you to say like, Okay, this would be because we are talking about aesthetics, I want to leave the margin where the adjacent tooth is or where I wanted to be, okay? Then I let it heal. And then I readjust, I can go move up, and I could move down. But basically, it’s a aesthetically driven, the placement of the margins is aesthetically driven. Now you may say okay, but you are probably if you want to go very deep, if you want, let’s say you want to increase the margin do like a crown lengthening, in my opinion, I will do the crown lengthening before that. So I will not, I will stay away for biological width invasion, always, I will always stay away from that. [Jaz]And just for the young dentists, you know, learning about this, for the first time, how many millimeters, classically are you trying to form from the alveolar crest, the bone to your prosthetic margin of the restoration. So you’re saying that if you have to go so deep that you actually want to do crown lengthening, then you will actually do the crown land thing first before you do the BOPT approach. But how many millimeters are you aiming for? [Jorge]Okay, so but what you want to have your margin should be maximum two millimeters close to the bone, that’s the maximum. Okay? So you should not go with your margin like one millimeter close to the bone because that way you can have unpredictable results. You can have either inflammation, you can have either recession. So you want to stay deep in the sulcus. So let’s imagine from the bone up to the gingival margin. You have connective tissue, bone connective tissue, one millimeter average, generally one millimeter. So those two millimeters are the biological width, you don’t want to mess with it, okay? You want to stay away from that. So when you are doing the crown length, and you have to imagine that your final gingival margin will be three millimeters from the bone and you will be inside the sulcus one millimeter. So the final gingival margin three millimeters, your prosthetic margin, two millimeters inside the sulcus. Those are the limits you should not go, you should not mess more around with that. Now, one thing is important, I talked about two options, BOPT for anteriors when you have more control, and you are more aggressive for an aesthetic concern, especially on the buccal. And the thing is, this is very important, what makes, we don’t know exactly why the result so well in terms of periodontics, but the fit is better because the cementation gap will be better. And also very important you are always thinking about the biological width the vertical way, right? It’s three millimeters. But there’s the horizontal component of the biological width this is very important. I cannot tell you the definition but I can give you a couple of examples to make light in your head, which is, you know, when you have for example, a cross lateral incisor, so it’s crossbite, everything is okay in the occlusion lateral incisor’s crossed, always that gingival margin compared to the other tooth. [Jaz]It’s gonna be thicker on buccal, usually, right? [Jorge]Why is that? Because there’s a thick bone, because there’s a thick bone and this is really important, the bone is thicker horizontally. So the wall the needs more space vertical. Does this makes sense? So this is one option. The other option is this, so look at orthodontic movement, you place a tooth more towards the palate, gingiva grows, you place the tooth more towards the buccal gingiva recedes. So the thicker the bone, the more space the body needs to get. Because usually we’re talking about three millimeters to biological width in one sulcus. But if the bone is too thick, horizontally or vertically, you may be three or four millimeters. And going back to the lateral incisor for example, if you go there with electric scalpel, you just get the gingiva, but what will happen? It will grow again, because the bone is very thick there. Okay? Now let’s imagine we can do this prosthetically, I go to the buccal area to the root, I reduce it. So when I reduce the root, I’m increasing the thickness of the bone. So the bone, the body will naturally try to create more gingiva because they need more space. Basically, you are fooling the biological system and telling it Look, you have a very thick bone. And because of that you need more vertical space. So the tendency will be number one sometimes to grow, or at least and this is very important. Number one to grow in vertical preparations, or at least not to receive as much which is a big issue that we have with horizontal preparations. And let’s be honest, I usually say these all the on social media, there is no recessions on crowns. No worries. [Jaz]Absolutely. I mean so many times. In the past, I’ve done crowns or the horizontal margin, and everything that perhaps looking good when I come to fit it, there’s already been some recession. You know, one millimeter is not much but it’s a shame because you remember prepping equigingival or slightly subgingival about this and recession that’s happened. But with the vertical, like even if I’m doing PFM, and I’m having a metal color, going subgingivally, when they come back in the future, the gingiva has migrated and grown and I can actually get the flat plastic moving away. And I can see that metal color tucked in beautifully subgingivally, which is another reason why again, I have also, like you, move to vertical. So because I think in the interest of time you want to cover the digital aspects of all this. So let me just get open this up now for the questions I want to ask you. What is the difference in and you might have to describe this is in your traditional protocol when you were starting off with impressions, and it told me about the cord you might place at the beginning like some dentists, they put in ptfe first, then they prep and they keep that and they prep to the ptfe and they scan with the ptfe in, And is that also what you would do in when you were doing impressions? Or is that only now with digital? And how is your protocol different now that you’re doing more and more like myself digital vertical preparations or vertical impressions? [Jorge]Okay, so the first thing that you have to understand is that impressions are much more predictable in vertical preparations and horizontal. Why is this? Because if let’s look at traditional impressions with silicon, let’s do an, let’s think about the horizontal impression. Where will the air bubble end? In the worst place, in the margin. It always ends there. Always. If you think about vertical impression, because there’s pressure from the putty, where will the bubble go? Into the sulcus, where it’s not relevant. So it will not even if you have a bubble in the sulcus in the deep part it will not have a problem for another technician while if you have a bubble on the horizontal preparation it always stays on the margin and on the worst place possible. Okay, so traditional impressions are much more predictable in vertical preparations and I will do them exactly the same way as I will do horizontal preparations, it depends on the technique, sometimes you prefer to do double impression, sometimes you prefer to triple impression, but they are, they will always be more predictable, always I can guarantee that to you. Now, the silicon goes deep there. Now, with the vertical impressions, I think that they are more challenging than horizontal impressions with digital scanning. Why? Because there’s this they are deeper, and then the gingiva has the tendency even sometimes when you use double cord, the gingiva has a tendency to do this, to go and hide and create a shadow deep there. So number one, something that if you want to go, I always say this, if you want to do fixed prostho, you need to have an electric scalpel, or you need to have some top notch periodontal patients without any sort of inflammation, which is almost impossible. So I would advise anyone to do prosthetic, fixed prosthodontics to go, you have an electro surgery scalpel. Because this is really critical. This will allow you to do sometimes when the patient is not the better sometimes there’s a little bit of inflammation, you can just go there and cut the thickness of the gingiva. I will not cut it horizontally, I will not cut it vertically. Let’s say I will only cut inside the sulcus so you have correct space for the scanner to mill. Now, if you have a heal site, so the site is healed, the site is healed. So you do the preparation and you go for the second appointment for the scan, which is something that I rarely do. If you do that you can do double cord technique because the tissues are healed, double cord and if there is any area there that still making a shadow just go with electric scalpel and cut it there. Okay? This is number one, electric scalpel. Number two, the best way to control bleeding is, in my opinion, the retraction paste from 3M. 3M retraction paste, it’s a miracle, an absolute miracle. First situation is healed you do double cord and you’ll be fine if you want you can use like electric scalpel just remove the gingiva eventually recovering. That’s number, so double cord and you remove the outer cord before the impression, one of the good things about digital impressions is that if there is some area that you see is not good, you can go there, erase it and redo it, which is something absolutely amazing. I think that you will agree with me about that, right? Yeah, that’s perfect. Now second situation, which is what I do, I usually try to do preps for being more productive, I took the of the prep in the same day of the impression. And here we have some gingival challenges in terms of healing of gingiva and stuff like that, then we are always dealing with bleeding venture. So in those cases, my protocol is usually so I do the prep. Okay? I do the prep. I do the electric scalpel just to do some, to stop the bleeding. And additionally, I use the paste from 3M, retraction paste, which is absolutely amazing. So many people are familiar with Expasyl Paste, I think this one works better. This one is much more ergonomic in terms of the application. So it’s something that you really should have. So two things important to have electric scalpel and 3M retraction paste, so I cannot live without that. [Jaz]So at this time of prep, there’s no cord in already, there’s no ptfe in the sulcus already for you, in your in your way? [Jorge]Yeah, preparation, electric scalpel, retraction paste. And for this situation, what I usually prefer now is to do Teflon. Okay? So the thing about the Teflon, there’s like a small learning curve, what the way that you apply the Teflon is not the same way that you apply the cord. So on the Teflon, you have to do some pressure and keep it there for about two seconds and remove it. Pressure, keep it there for about two seconds and then remove it. And what happens that the Teflon will actually spread the way the gingiva and you will actually see people spread away the junction epithelium, okay? It will slightly spread away the junction epithelium. But then the good thing about the Teflon is that if you use a colored scanner, what I usually asked my dental technicians that go all the way until see the white, that’s when you stop your finishing line and you will not have any issues and it will not be impinging the biological width. Okay? So this is usually my strategy. The third case is extreme cases. One thing that I really love about vertical dimensions and we talked about BOPT technique, vertical preparation on extreme cases. What do I do? I do a mix of both of the techniques. What are extreme cases? Cases that are being considered for implant. So, remember one thing between the gingival margin and the bone we have three millimeters, sometimes you will always gain, find ferrule that you are not finding above the gingiva, but you will be able to find ferrule below the gingiva, right? [Jaz]Another massive advantage of vertical. Absolutely. [Jorge]Now, here comes the criticism. Okay now, if you go below the gingiva, now, you are at risk of going into the biological width and it is true. So, what I do is this, extreme case preparation, BOPT preparation up until the bone because I want to maximize the amount of [transparency] then what I do I do electric scalpel okay? just to remove the hemorrhage and then retraction paste that then remember we have no sulcus here, you cannot place anything because what you are seeing is the bone. So, what do I do? Direct scanner. I know this is a little bit outrageous, but then comes the trick I tell my dental technician exactly where to place the margin. Where do I place it? At least one millimeter away from the bone, but then you’ll ask, well but then you will be in the junction epithelium, so, you are impinging the biological width for one millimeter? It is true yes I am impinging but I’m waiting the pros and cons, I am saving a tooth with a risk of causing some gingival inflammation. But on the other hand, I am saving a tooth, which is for me the most important thing. Now you can ask me why won’t you do crown lengthening? I stopped doing crown lengthening on posterior teeth for two reasons. If you do it in proximally, you will lose the papilla and even with good contact points there will be full infection. Buccally or lingually, remove the bone you are compromising your future implant and you may eventually forcing vertical augmentation or sinus lift. So what now what does the literature or the research says in terms of the biological width?It says two things First, we don’t know exactly. It’s not predictable what happens in some cases you invade biological width and what happens there is a chronic inflammation that is never go away. Sometimes there’s a small inflammation for one or two months until the bone is sourced to make, to create the new biological width, okay? and some other situations, nothing happens as long as you stay like one millimeter away from the bone. So we don’t know exactly what happens. And for example, the last classification of periodontal disease, they say, you should not go in the connective tissue, which is very close to the bone. But we don’t know exactly if it’s safe or not to go to the junction epithelium. And what I do, I go into the junctional epithelium and I assume that risk per To be honest, I never had any issue, but I assume that risk of invading one millimeter of the biological width, the junction epithelium, but I will never go to invade the connective tissue very close to the bone. But remember, I am only doing these in extreme cases in good periodontal patients and also in cases where the implant is being considered. So I am taking risks in extreme cases. And in that case, I only use the preparation, expose the bone, electrosurgery, reduction paste, and then I will not use anything but I always tell the technician stay away from the deep of the sulcus because what you are seeing is the bone, stay away one millimeter. And because you have no sulcus because you cannot place anything there. Okay? I don’t know if this makes sense. [Jaz]It make sense. And I think it’s a good description of the indications of that extreme approach. So that all makes sense. You were trying to save a hopeless tooth, but also preserve some bone for the future implant and preserve the papilla. So that makes perfect sense. And I like that. I think I’ve learned something from that for sure as well. In terms of I mean, you’re obviously scanning in those preparations. And you’re telling the technician to just stay at one millimeter away from the bone, which is awesome. And as long as you use the electrosurgery, you can actually create that vision, create that path of scanning, or the ability for the light to reach there, that’s the most important thing the lights will be able to reach there unimpeded. So it can record that area. So that’s very good. I’m just going rolling back a bit to those BOPT anterior cases that you might be doing well, you’re being quite aggressive because you want to change the gingival level. Are you scanning for that as well? Or are you taking impressions for anteriorly? Because me, if I’m having any anterior cases, which mostly I do more posterior cases, I’m happy to scan. But for anterior, I have my biases still. Because I don’t have as much faith in scanning. I will really want to try and do the BOPT go quite subgingival, I’m still taking impressions. So what would you advise me in that regard? [Jorge]For the anterior cases, I do either way, if it’s like a small cases like one or two teeth, we go for scan without any issues. If it’s like a bigger case six or four I usually go for the traditional scanning but that is just a question of you know that the higher amounts of teeth, the more areas are eventually placing on the scan that’s just because of the technology but I if the technology evolves in the future, I would actually do the scanning without any issues. I don’t know if I can show you an image here because I think it will make [Jaz]and while you’re finding this if you don’t mind I’ll ask you a question while you’re finding this. So for those people who reminder these podcasts are not just audio only I know many of you drive or listen to the podcasts but these are accessible on YouTube, on Instagram on downtown tubules and a few more platforms coming soon as well. So if anything any my guests like Jorge is going to share something now you can check it out in the video part as well. I love this fantastic. So it’s definitely worth I can see the graphics already, which is good. But this whole concept Jorge of kissing the bone, I’ve seen some on social media, we like that term, okay, this preparation now, or the crown is kissing the bone. And because your crown, your metal ceramic or the Zirconia is so thin. And that it’s like it’s been it’s almost like 0.3, but then it gets tapered down to you know, infinity and such a thin smooth color that some people say that actually, the biological width is less of an issue because everything is so smooth. What’s your thought on that? [Jorge]Well, to be perfectly honest, we don’t know exactly all the reasons why they work so well. We have an idea and I think that because it’s very thin there, the adaptation is better, we know since the 80s and this is really interesting. We know since the 80s, that the other patient have vertical preparations with an adequate design of the cement with an adequate design of the cement, we know that the fit is better than horizontal preparation. So if the fit is better, if there is less of a gap, of course that the periodontal tissues will like it more, that’s number one. But number two and I cannot stop emphasizing this, you notice Do you know here the aggressiveness of this preparation? So this is the horizontal one. You can see my arrow right? This is the horizontal one [Jaz]Okay, the error I see is that between the bone and the connective tissue, there is no attachment right. [Jorge]So on the left side, what you have is an horizontal preparation, right? It stays in the sulcus. On the right side you also have horizontal preparation. And because I have, this is a BOPT technique because I like to it’s also on the sulcus, because if you let the gingiva heal, if you do like level of cord, you will never go deeper than the sulcus because unless you are very aggressive of course, but the big thing here notice the amount of aggressiveness in terms of buccal preparation on the right side, you see that? So what happens is that the periodontal tissues they get thick and because they get thick, they want to grow or at least they do not receive as simple as in case of a thinner bio type. So, basically, what you are doing is you are actually boosting the biotype because you are increasing the thickness of the gingiva not by increasing the gingiva itself, but by reducing the buccal root and when you reduce the buccal root, the gingiva wants to grow Always remember that the orthodontic movement, if it goes buccal the gingva goes away, if it goes palatal the gingiva wants to grow. So, what you are doing is like prosthetically creating that same environment. So the gingiva wants to stay there, she does not want to receive and that is because of the aggressiveness of the preparation. And what you are seeing on the right side is that you are creating a prosthetic new cementoenamel junction, you are creating a new cementoenamel junction. And you may say well, Won’t there be any food impaction? No, this works. My experience this works much, much better than any other sort of horizontal preparation. So I think that the periodontal thing is the issue really [Jaz]Amazing. And I think for those who are listening and maybe not watching this, the best analogy I can give when I was studying orthodontics is my old mentor, Mohammed Almuzian he says that the gum is like a skirt. Okay? So if you bring the tooth or in this case, the vertical crown forward, the skirt lift. So it’s like bringing your leg forward, right the skirt is going up. Okay? If you bring the vertical crown down or further into the tooth, the skirt, the leg is coming down, the skirt is coming down. So if you’re struggling with that analogy, think of it like a skirt and how you lifting up the leg, lifting down the leg and how the gingiva will migrate like the skirt, which is something else that you reminded me of, as you were showing that. [Jorge]It said it’s the same thing as with implants. So Critical Control and Critical Control is exactly the same thing. It’s the same thing. The analogy that you use is the perfect analogy for the vertical preparation and so answering your questions, two reasons why they work so well periodontally, the fit is better and if you use the BOPT technique, especially the BOPT technique, when you are a little bit more aggressive on the aesthetic area, you will increase the thickness of the gingiva and the gingiva wants to grow. Those are the two main reasons why you will get so much many good results. And there is no recession almost at least in my cases, I’ve been doing vertical preparations for about three to four years. And honestly, I’ve never seen such good, healthy periodontal tissue and stay on the long term, [Jaz]I can definitely echo the same. I’ve also been doing it for three years and I can echo the same. And it’s something that’s very definitely revolutionized, my practice, I know it has for you as well. And it’s great to be able to have that option for our patients. Now one thing that you I picked up on when you were speaking is about the correct spacer protocols. Can you just elaborate on how much of the spacer you are advising your technician to use obviously, with all my CAD CAM here, what is the digital amount of spacer in microns that you are suggesting to your technician? [Jorge]I will show you a slide which is very important for you to see. [Jaz]Amazing. Now, whilst you’re doing that, I’ll just share some of my challenges. When I initially started with vertical preparation, I didn’t know what I was doing. I had these crowns back, and they were so tight, I couldn’t seat them fully. So I don’t know if that happened to you earlier on as well. And then I learn online from my mentors that actually is because of the fact that the walls are so straight and so deep that if you need more spacer, you need more space for your cement, so I’d love to hear your current protocols. [Jorge]When you do not give the right amount of space, you see this clinical case with a fracture here on the cervical area? So you see the cervical fracture here. That is because of incorrect. So why was that? Because in the beginning, I had no notion about these. Now, if you talk to most dental technicians, they will tell you that the cement space, the traditional cement space is something like this. Okay? So this is very important. So the first millimeter from the margin is 0 micron. Okay? So they want full adaptation. Okay? And then from the inside, as you see here, they place 40 microns. So what is the issue here? And we know it’s interesting, because I’m writing an article about this. And we know this since the 80s. There are studies in the 80s that show that when you cement this, there’s the flow ability of cement to the occlusal area, and you will never get the perfect fit here. That’s number one. And worse, no fit, no complete fit and without cement because the cement will go upward. So you have an open margin. And they classically say you can have an open margin of about 120 microns. So that’s what classically it’s accepted. Now, for vertical preparations, you have to do the opposite and this is very important. So the occlusal area should be 0 micron. So when you are placing the crown it should, the stop should be on the occlusal area. And then you should open the margin 40 microns. Why 40 microns? Because this is the average thickness of the cement. So with the vertical preparation, you will not only have a better fit because the crown will go all the way. But also you will have cement in the margins, there will be almost no. And this is something that I when I was writing the article I said well, this is just something that someone said on social media. So I went to search in this literature. We know this, Jaz, since the 80s. We know this works this way since the 80s. And it’s amazing why we keep doing the opposite. We keep doing zero at the margin of the cement design And then we opening inside. Why we should be actually doing the opposite, which is zero on the occlusal and then opening all the way up until the margins? Because if you do the classical approach on vertical preparations, you will have fractured like I showed you. And I hope this clarifies it. Does this makes sense to you? Yeah? [Jaz]It makes perfect now. It makes perfect sense to me because I’ve been in this journey. I’ve had the failures myself. And I realized that actually things are just too tight at the base as a seating. And then I started playing around my spacer protocols I learned from people like Pasquale Venuti I know you’re lecturing with him soon in Portugal, it’s such a great conference you can tell us about that very soon. So I wish I was there to go on to do because I’m a bit of a vertical geek now because of you guys. But yeah, so I learned this the hard way but recently more than I had an issue where I will as I was seating the crown, the cervical of Zirconia fractured, quite heartbreakingly and I can’t figure out exactly why, and may be a to speak my lab again, did they follow the spacer protocol correctly, but I actually think I had an undercut area there and I think that was my own fault. [Jorge]Exactly. That’s also something very important. Let me share the screen again, because I was showing the images of common mistakes. Another common mistake is, so we talked about the cement space, which is critical. There’s another issue, which is, if you go with the same mindset for the vertical preparation, as you will do for your horizontal, you will always create undercuts, and this is really important. Why? Because when you do undercut, you see here, this is the scheme of when you do an undercut with a horizontal preparation, that technician has the space to cause an alleviation. They will call like, relief in this area. I don’t know if this is the correct term to say, [Jaz]Yes, they blocking out, they block out the undercuts, if you if you make an undercut in a horizontal crown, they will block out the undercuts, yeah. [Jorge]But if you make and then they’ll go to the vertical, will they be able to get it? To block it? They won’t, they won’t. So in the first, during the first two years, I had a lot of undercuts, the dental technician will call me Look, there’s an undercut, look, there’s an undercut look. There’s like why because you go with the same mindset, with the same visual hand approach. So you have to make sure that when you do the final image, you see, because if I was really paying attention, you can see here, there was an undercut in the buccal area. It’s clear. [Jaz]This is such a good image, Jorge, just wanna highlight that this image that you showing I mean, for anyone who’s listening, you need to go back to this episode and watch this because what Jorge is highlighting here is looking at the tooth, like, you know how you check for a path of insertion for crown like for horizontal, he’s highlight an area where he cannot see the sulcus, and that’s where the undercut is. Am I right in describing that? [Jorge]Absolutely, Jaz. And what are the consequences? I say, Well, I just didn’t see that. I’ll say, well, just do it anyway. Right? Because the patient she’s okay with, just do it anyway, so they did it, look what happens. It did not go all the way because it was not possible to go all the away. [Jaz]So I mean, I tend to make my vertical preparations a little bit more tapered for that reason, and sometimes I’ve been a bit guilty of over tapering. But I think this is a kind of a necessity, I just need a bit more handpiece control to make sure it’s really easy. It’s really easy to lean in and over taper it right? [Jorge]Absolutely. Look, I think that I came into this journey, I did a lot of retentions then I started to excessive taper. And now I am almost getting the right one. But my opinion, if you want to do vertical preparations stay on the safe side and do a little bit of more excessive taper. Also, because the retention of the crown will be so good. I usually use a self adhesive cement and self adhesive cement does not mean true adhesion just like RelyX™ Unicem or Maxcem but you can also use some FujiCEM reinforced glass ionomer, you can use whatever you want. But even if you do a bit of excessive taper that will not be a problem because the retention of the vertical crown is very, very, very, very good. So I usually I do a lot of retentions not then I went through a phase of excessive taper which I still do I have heavy hands, my brain is much more better than my hand. But I don’t have an issue. So in doubt, do more taper that will make you better for you, for dental technician and in my opinion also for the patient. And remember one thing when you are doing vertical impressions is not because you are doing an alternative to blocked because I think there’s a bit of confusion here. So people said Well, I stopped doing onlays I only do vertical preps don’t do that because you will be doing excessive tissue preparation. So what you have to do, you have to look at the cases and look, this is the case for a crown okay. So instead of doing horizontal, I will be only vertically. So if you if you do select the cases that you need to do, you will be on the safe side. In my opinion, excessive taper is always better than limitation. [Jaz]Amazing that is sensational. I think that’s going to help a lot of people. So all those mistakes mean you have made a Jorge if you listen to this episode and learn from our mistakes, you will be doing the correct taper. The correct spacer protocols, the correct way of scanning or taking impressions, make sure you can see the sulcus, there’s so gems that we’ve shared. So that is amazing. you’ve answered all my question. Just one more thing do you think or do you think there’s an inadequate scanner out there? Or are they all reasonably okay to scan for vertical preparations? [Jorge]So my advice if you are considering a scanner, of course you have to you have to see if it fits for you financially, but I use the Medit i500 now there’s a new one the Medit i700 and in my opinion, it’s the best value for money. It’s the best value for money the i500. Now the issue is if you are working in a place where they are doing Invisalign, you cannot use the Medit because they are not allowed to use Invisalign. So I will probably go with the itero or with a 3shape, something that accepts Invisalign, if you want to ask me what’s top notch, money is not a problem, then you go for Prime scan from Sirona, but money value for money for myself, the i500, from Medit, and the new, the i700. They are amazing, the updates are amazing. And there’s a very good support group on Facebook and the the team, the development team is very, very good. And we are you are getting a price scanner for like 50% or 60% off the price of the most well known scan, which are the 3shape and the itero. That so what is the consequence of that my orthodontist that does Invisalign in my practice cannot use the scanner, she must do manual impression. So that’s the issue. [Jaz]Yeah, I’ve seen a big, you know, hoo-ha on social media about the merits of the i500. And now the i700. I think a lot of associates are buying their own scanner because it is much more affordable. And that’s great to see. But you’re right, I think the caveat is Invisalign, but more a lot of clinics now they have multiple scanners, they have one itero for the Invisalign, and then they have the Medit for estorative and that’s okay, you know, depends on what works in your practice and the budget. you’ve answered all my questions, Jorge, you’ve been absolutely amazing with value. Honestly, I can listen to you over and over again, but just due to time, we’ll have to call it there. Please tell us about the projects the teaching, anything that you have on vertical preps. I know you got The Brain and Hands. Tell us about The Brain and Hands. This is your moment to just, How can we learn more from you because honestly, I know the listeners, the Protruserati, love your style. [Jorge]Well basically I am a nerd. I’m a dental nerd. I love to do publications. I love to teach. I create The Brain and Hands, the website which is very good if you want to, if you have any doubt in terms of cementation protocols or vision protocols there’s a step by step it’s all free. I also share some videos with with some tips. I do lots of courses here in Portugal and this vertical preparation courses because we join forces with Venuti, with Hugo Costa Lapa, with Raul, with Miguel and they did the verti prep. The verdi prep course in Lisbon two years ago, it was an English highly successful event I was there I learned a lot from them. And then I started writing an article which I really hope it comes out this year. Next one, which is basically so let me give you this in first and it’s called CARES concept. It’s called clinical decisions for posterior restorations Part One: Partial Adhesive. Part two: Full resistive or retentive crowns and the CARES concept is this you have to think about Coverage-C, A-Adhesion, R-Retention or resistance, E-Esthetics and S-Subgingival management. If you think about all these concepts, you will be able to do a treatment plan, good diagnosing and a good plan for doing single unit posterior teeth. So I hope that the article comes out this year. So to basically answer all the all the questions I hope, of how you should diagnose, plan and execute single unit posterior teeth, either if you are talking about adhesive, tabletops, onlays, overlays. Or if you’re talking about retentive resistance, which is the vertical preparation in this case and on the 10 I think it’s the 11th and the 12th of June this year, because we cannot be doing we could not be able to do it because of the pandemic but this year because of travel limitations, this evasion will be in Portuguese in June. So it’s only for Portuguese because all the other foreigners they have travel limitations. But I am pretty sure that eventually this year next year we will be doing the same edition in English and I hope that you come over to Lisbon to visit us. [Jaz]I would love that choice. And what I’ll do is if I speak to the Protruserati, who I know they want to learn a vertical and we also have been meaning to do a little getaway. Right? So if I can organize a group of the Protruserati, right? To come and fly as a group. It’ll be so much fun as a group we all fly to you. We come and look at your practice. You teach us vertical preparations. I think that’ll be amazing. [Jorge]I would make sure you have the best time of your life professionally and personally and I have fun. I will take good care of you. [Jaz]Listen as long as there’s red wine and meat. You have me. [Jorge]I don’t know if you know but my father has a seafood restaurant. And the restaurant is like 20 meters from the ocean. So I think that answers your questions. [Jaz]You had me at seafood. This is amazing. Jorge I think I’m gonna make that happen right? So guys, if you have in your mind and interest to come as a Protruserati maybe 15-20 of us something like that. Is that 15-20 too much? Is it okay? 15-20 of us to fly to Porto together to have some time with Dr. Jorge Cardoza and learn vertical preparation and have some seafood, then do this go to protrusive.co.uk/vertical. And let’s see how many people are interested. Now I imagine hundreds will sign up but then only about 20 about once they ask their wife or husband will, you know will eventually be able to come and the dates and stuff. So let’s put our feelers out, it’d be so great to have like, always wanted like a protrusive ski trip, but my wife doesn’t ski but this is, you know, somewhere in the sand, seafood. My wife is okay with that. So, you know, bring your family along, let’s make a little excursion. I’m actually really excited. So amazing. We will do that. Jorge, thank you so much for giving your time today. And I hope to see you with about 15-20 good friends who listen to the podcast in Portugal to learn about vertical. [Jorge]So Jaz, thank you so much. If that is a promise, I will not let you go by the sort of next year without coming here to Portugal. [Jaz]I love it. Thank you so much. I’m totally up for that. Jaz’s Outro: Well, there we have it another cracker with Jorge Cardoso. Don’t you just love his willingness to share his failures, and those extra tips and advice that he gives that I don’t think any other educator has thought of. So thanks, Jorge, for delivering great value there. And if you want to come to Portugal with us, it’s not a done thing. Like I don’t know, it’s always been a thing on our mind that to get a group of like minded dentists and go traveling the world and learn from amazing clinicians. Right? So now that the world is opening up with COVID again, if that’s something you’re interested in, go to protrusive.co.uk/vertical-portugal and maybe I’ll keep you up to date you know, maybe we’ll see if something works out. I’ve got a feeling it will for maybe spring 2022. Let’s see. So sign up if you’re interested. I won’t spam you or anything but if you do want to join my newsletter for like up to date episodes, infographics PDF, then join that as well that’s protrusive.co.uk/newsletter, and I’ll keep you updated. Anyway, catch you in the next episode. Fingers crossed Wish me luck that I can put together their very very mammoth task of basics to occlusion. Okay, wish me luck, guys. Okay, I’ll see in the next one.

Ask 10 Dentists for a treatment plan, and you will get 12 different recommendations. Treatment planning is an art, but our diagnosis should be highly scientific. Making decisions of what specific treatment we should recommend to our patients is the very foundation of daily practice. With the experienced Dr Paresh Shah we discuss the How, What and Why of the Treatment Planning process in this Back to Basics in Dentistry series. https://youtu.be/raZiERy8U4o Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: If you are unsure what is the best treatment plan for your patient, it likely means you haven’t asked enough questions. Ask more questions and seek your patients’ drivers and goals. “Find an experienced mentor that will walk you through gathering the information…. [discover] why it’s important to mount the cast rather than just holding it in with your hand.” – Dr Paresh Shah In this Episode, we discussed: Step by Step thorough Examination 12:50 Importance of having a Checklist 27:34 Records needed for a Comprehensive Exam 30:46 Communication between patients and Dentists about Treatment Plan – in a way that doesn’t confuse our patient 36:59 Talking Money and Fees 47:18 Check out Dr. Paresh Shah’s Instagram to learn and be inspired! If you enjoyed this, you will of course love Zak’s Presenting Treatment Plans the Comprehensive Way  Click below for full episode transcript: Opening Snippet: And I don't know what it's like in the UK, but I'll tell you in North America, I've seen a lot of it. It's just hard. There's just not enough time because you're so focused on requirements and surfaces and canals and amount of teeth you're taken out rather than going 'Okay, let's just take a step back and let's focus on comprehensive dentistry.' And occasionally, you'll get a part time instructor that pulls you aside and teaches you all the stuff... Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati, and welcome to another episode of the Protrusive Dental podcast, back to basics series. Today we’re covering this mammoth topic of treatment planning, right? Where do you even begin with treatment planning? Well, you begin here, because I’m going to break it down with Dr. Paresh Shah from Canada, all about the fundamentals of the kind of conversations you have with your patients. What is the sort of mindset you have when you’re on treatment planning? What are the stages? How can you actually use your experience and use what the patient’s goals are to help inform the best treatment plan possible for your patient? So it’s something that I used to really puzzle me when I was a newly qualified dentist, I’d see a plan that was more complicated than just single tooth dentistry. And it will be like, how do I apply what I’ve learned from dental school to this patient in front of me. So it’s something that you sort of refine as you gain more experience. Now, I’m hoping that after this episode, it shouldn’t just give you that little bit more of an edge to allow you to think more rationally about your treatment planning. So like I said, hope you’re enjoying this back to basic series. And it’s been great fun to make it and the guests have been absolutely brilliant during this month. Thanks so much for watching. Now, if you have any more recommendations for topics, I’m always happy to hear them, you can DM me on Insta, you can comment below or you can email me jaz@protrusive.co.uk, I would love to hear your suggestions and I can get the right guests on as well as you want. The Protrusive Dental Pearl I have for this episode is very relevant to treatment planning. And it’s this. If you have a patient and you’re treating planning them, and it’s a it’s a bigger, more complicated problem. And I’m thinking like not just that it’s multiple teeth, but even something like missing teeth, like something that’s so common, right? The biggest problem I used to have is like if someone has missing teeth, then sometimes what dentists unfortunately trained to do or and do do is for every patient has a missing tooth, they say to the patient, okay, there are four or five things you can do, you can do nothing and accept the gap, you can have a bridge, you can have a resin bonded bridge, a conventional bridge, or you can have an implant, or we can do orthodontics or whatever, right? And you give the same bloody options all the time. This is really confusing to patients. Okay? So if you’re unsure which treatment plan to recommend, and that just means the following that you haven’t asked enough questions. So one way to help you to be able to give them the best plan for them. The best one for your patient, is to ask more question, how long do you expect this last? Do you want something removal or something fix something glued in? Do you want to be able to chew steak on it? Or is it merely just for looks? What’s your budget? These are kind of questions that should be asking to the patient to figure out exactly what treatment plan you should recommend. And then you can just let them know that Yeah, all these other things exist. But based on what you said, what you told me, this is the most appropriate treatment plan. And that is a much better way to go than to give everyone the same bloody five options a whole time It’s better just to give them a customized, tailored recommendation that’s going to meet their goal. So remember, if you’re not quite sure, you need to just step back and ask more questions so you can understand your patient better. So I hope you enjoy the series. We’re going to hit episode now with Dr. Paresh Shah. For a next episode we’ll go back to basics for occlusion. So I know it’s September which is going to be splintember, but we’re going to tie in with like a bridge episode, which can be back to basics for occlusion. So I’ll catch you in that one. Hope you enjoy this main episode with Dr. Paresh Shah and I’ll catch you in the outro. Main Interview: [Jaz]Dr. Paresh Shah, Welcome to the Protrusive Dental podcast, it’s great to have you on, your work on social media that I’ve seen. We’ve never met in person but virtually You’re such a just a kind personnel I know very good, been very nice on social media to speak with you, DMing and comments, that kind of stuff and just inspirational to see the kind of work you do. And we started chatting and stuff and we thought it’d be really great to hear from you to pass on because all this has been like a back to basics month for the podcast. Has been to pass on knowledge to young dentists about treatment planning 101 and I’ve been really great to chat with you today. But for those people who don’t know where you are, you know who you are and what you do? Just give us a you know a minute or so on on this about you as a dentist. [Paresh]Thank you know, first of all, Jaz. It’s been really nice to connect with you. I appreciate it very much and you’re really nice sentiments about me. I appreciate that as well. I love what you’re doing as well because I like how you’ve kind of broken up themes And you’re giving people either practical tips to implement right away or food for thought. And I know for me that food for thought is a big thing. So I’ve been practicing 30 years. And it’s interesting, this, you didn’t know this, and not trying to do anything weird. But I’m right in the middle of almost finishing a textbook. And that textbook is partly about my story. But also, it’s not about teaching, treatment planning, because there are lots of different ways as you know, and different mentors in different systems. But the book is geared towards people who are, whether they’re early in their career or middle or late in the career to rethink how you’re approaching a patient. And that’s not always easy, because I think part of it has to come through taking courses with like, really good course. And we could go on for hours about that. And having great mentors and really good study clubs that actually collaborate well together. So quick thing with mine, I, after about eight years, I was just kind of doing drill and fill dentistry, didn’t really know anything different. And my circle of friends were similar, you know, we’ve just paid did this filling and did this kind of, Oh, I ended up doing six crowns one day, you know, it was kind of cool. And then all of a sudden, I got introduced to a program and a couple of mentors of mine now that from the University of Minnesota, and I went down there and started taking some courses. And it was a post grad aesthetic program. But it wasn’t all about aesthetics. All of a sudden, I’m getting introduced to occlusion and treatment planning and diagnostics. And, you know, having to put up casts and photos on a screen in front of a bunch of strangers. And it was like, Whoa, what is this and all of a sudden, it became a CSI type of thing, where all of a sudden, you’re looking at casts, and you see something there that shows up on an X ray, that shows up on a perio chart, and it’s like, oh, ding, ding, ding. And so I started looking at things differently. And all of a sudden, I’m coming back into my practice. And I’m like, okay, that cricket area, like, I know what I can do. And it started evolving that way. And then I started looking at things differently when I was doing my exams, because now I wasn’t looking to find a risk, always just a restorative solution. But I was seeing other possibilities. I was seeing implants, I was seeing oral surgery, I was seeing perio, I was seeing ortho, and but someone other people had to open my eyes to that. And I think part of the challenge is when you get out of school, there’s just not enough time to teach comprehensive dentistry. I think I feel and I don’t know what it’s like in the UK. But I’ll tell you in North America, I’ve seen a lot of it. It’s just hard. There’s just not enough time because you’re so focused on requirements in surfaces, and canals, and amount of teeth, you’re taken out rather than going ‘okay, let’s just take a step back. And let’s focus on comprehensive dentistry.’ And occasionally, you’ll get a part time instructor that pulls you aside and teaches you all the stuff. But you can’t talk about it in school. And so, anyway, I’m rambling. But that’s kind of that’s how my practice has evolved. And then, slowly as we went, I have a very close buddy of mine, Ken, and we kind of went on CE journey. And we did Kois and we’ve done Misch and, and we’ve just come back and because we’re buddies, we can help each other to reinforce what we’ve learned and go, okay, well, let’s slow down a little, let’s focus on learning the occlusion and implementing it in practice and then going on. So now I’m at the stage where I you know, I love what I do, and so much that I after 30 years, I bought a building and built a new practice rather than retiring like some of my friends. [Jaz]Amazing. What is it lovely to hear your journey? I didn’t know about the textbook that is amazing. I mean, the amount of work and effort I can only imagine how many I mean, it’s something you measured in years rather than how many months were I’m sure it’s been a project that’s spanning years. Right? [Paresh]Well, it came to fruition early in COVID. And but it’s been a lot of my journey so and what I’m trying to do is get people to just retrospectively I’m going back to cases that I did 10, 15, 20 years ago and go Okay, well what could I have done differently like it worked out but what did I learn? What do we know now like we’ve got CB CT, we’ve got so many different things that allow us to diagnose you know, at a higher level and knowing that hey, you know orthodontics plays a key role in getting teeth lined up better so maybe we could do minimally invasive dentistry. And so, just you know, when we’re in our day to day routine, we see simple thing lower anterior crowding and You know, people will, but you got crooked teeth on the top, persons only focused on just fixing those teeth. But you and I know that after 10, 15, 20 years, those teeth will keep shifting. And there’s a possibility that you’ll get either mobility on those teeth, were on those lower teeth, or mobility on the top teeth, or the veneers will chip like, our body compensates in some way, ignoring it, we could get lucky. But there’s also possibility we don’t and then what happens? So I, why not just get that fixed and lined up in the right spot, then yeah, if a person wants to just shave them down, we’ll find but at least discuss the ramifications. But and you see that every if not every day, every week in practice, why not at least approach it in a different manner than go? Oh, yeah, I can fix those 6th teeth or 8th teeth on the top. But why don’t we put this fixed? Like, let’s look at this first, get everything stable. And then you may not even have to cut down on these top teeth. Maybe we can do it with some bonding, as you call it in Europe, called edge bonding, right in North America, they call it bonding. But it is the same, like why not do that and, and approaching it in different ways. You know, if the tissue heights are off, well, why not discuss it ahead of time and maybe orthodontics or maybe crown lengthening might help not just making one crown look really long. And when it’s just little things that were sometimes we’re not taught to look for, or we don’t know how to address it or even a talk to the patient about and there’s a lot of dentistry in the general practice, you know that there’s tons of dentistry, but it’s just how we, how we clean it, and take it out and discuss it with the patients? [Jaz]Well, those little lightbulb moments, right? Our mind can only see what our brain knows, right is that kind of thing. So exactly like you said that, you know, going back to full circle to what you said at the beginning. Until you went on that residency program, you open your eyes. So unless you’ve treated someone with the upper anterior using that same example, they gave a lower incisor crowding, unless you’ve treated someone on the upper incisor only, and fold them up and seen a relative failure many years later, and then thought, Ah, that’s why this happened. Then the way to fast track that is to learn about it either from a mentor or from a course. And it’s about almost standing on the shoulder of giants and learning from others mistakes and you can then start implementing that. So sometimes it’s seeing and then learning that okay, this is a potential thing I need to have a conversation about. And it all goes back to that exam. I know this episode is a treatment planning 101 very much designed for young dentists and I’m keens as this episode progresses, to really pick your brain here, which will be amazing. And it’s such a vast topic, like we can go in any direction. But the first place I want to start with, if you don’t mind, Paresh is just to get some order and structure is the examination because I think your examination, the quality of your examination will dictate the what kind of treatment plan you can present. So just talk us through step by step. Even if it’s like something that starts before the patient actually lands in the chair, step by step, what is it that you’re doing to the patient? What are you saying to them? And then how do you come up with your diagnosis? [Paresh]Okay, that’s great. So I feel the medical and dental history is key. I know it sounds so like medical history just sounds so mood, but the thing is there. We know now compared to when I first got out of school that there are so many little clues that can lead towards just, you know, at least making sure we were not ruling out any gastric issues, sleep issues, things like that. So, and certain medications in terms of bleeding, and so forth. So it’s nice to have that. But the dental history is key. I’m not a mentor at the Kois Center or Johnson, it’s one of the courses that I’ve done. So I actually use his dental history. And the reason I use it is because it’s just broken up into subsets. And I don’t have to reinvent the wheel. That’s essentially what it is. But as long as you have a good dental history that asks specific, not general questions you can just buying off the internet, like really specific questions about the four main categories that no matter where you go, you know, I’m sure some of your mentors have taught, hey, you’ve got to look at biology, like at the look at the periodontal Foundation, you’ve got to look at the structure of the teeth, like how heavily restored are the teeth, you’ve got to look at your TMJ muscles. So ask a few questions about that. And asking a few questions about aesthetics, like what’s important to the patient. So if we have questions like that, it allows me before they come in, and if it’s an, if you’re an existing patient, and I’ve been seeing a bunch of things, and now you’re finally saying to me, “man, I wish I did this or I wish I did that years ago.” You know what? There’s still time we can do a few things. Let’s bring you back And we’ll we’re going to take between an hour and a half in two hours and do a comprehensive oral exam. And this is the same thing we would tell a new patient, but I would tell you that as an existing patient, and because it’s been a long time, there’s a lot of new procedures, technologies, materials that are available. And we might be able to address some of the concerns that you had. And some of it, it might be a little extensive. Some of it might be simple, but let’s just let’s reset [Jaz]Paresh, because I wanted to highlight something for those listening, cuz I think there’s a real gem in what you said there. Like, in our busy practices, sometimes, you know, I’ve taken over a list whereby the same dentist was there for 34 years. And now I’ve just taken over his list and his patients are in the 60s and stuff, right? And now sometimes the needs or the wants of the patient deserves more than a 15 minute check. And is having that courage to say to the patient, look, I can I’ve done my basic screening, Okay, a few issues, discuss fine, we can do that. But based on what you said, or based on what I found, you actually need something a full thorough assessment like you would have had, you know, many years ago, and it’s about having the courage and the conviction and the confidence out of the patient to bring them back and then carry out that full examination to then come up with the better suggestion, better plan. So it’s about remembering that just because you only have 15 minutes doesn’t mean you have to cram everything in. You totally need to as a young dentist, sometimes you feel shy or concerned or worried about inviting someone back. [Paresh]Absolutely. And listen, if you’re worried about I don’t like this phrase, I don’t want to step on toes because I think that’s a pile of crap. I mean, at some point in time, you’ve got to be bold, but not reckless. You know what I mean? And the bottom line is, you’ve got, you have a dentist that you respected or dentists that you respected whose practice you took over or you’re working with, or that did the previous exam. You know, for me, and I just had listened when I took over my practice, it was really heavily restorative driven, because that was back he graduated in the 60s, and I took over in the 90s. Perio wasn’t a big thing, so a lot of times he was just cleaning the lower six anteriors with a Cavitron. And that was it. And all of a sudden, I come out of dental school, Perio was a foundation and they’re going like what are you doing? Why are you spending so much time cleaning teeth? And Well listen, you know, back when John retired, when he came out of school, there were a lot of cavities, we have less cavities. So what they weren’t focusing on foundation we’re focusing on, so I wasn’t throwing him under the bus that was just reframing things. So it’s the same thing you go, listen, there are a lot of things that have changed right now, we have new materials, we have new composites, we have new ceramics, we have aligners which we weren’t using 20 years ago. So there are things that we might be able to do to help improve your smile in a conservative manner. And but I need more time. And one of the things that’s important, I don’t think we take enough. I’m not saying all the time, but every few years I think needs especially with people who have a lot of posterior restorative taking full mouth series, we have to. We got to be able to diagnose everything. We got to diagnose the margins, caries that we think. Now I’m rambling, so what i will suggest is that having a good dental history that will have some questions that can potentially lead to or like they’re more open ended questions, because they can put, if they put a yes there, you’ve got a lot of, you can have a lot of other things you can ask if they said “well, I have a fear of dentists” “Well tell me about that. What happened, how”, or “Hey, my bonding always chips I had that this week.” Someone came in at her consult, while the person did bonding eight months ago, and it’s all broken. But she has edge to edge occlusion and shear fractures. And she goes, “So I don’t want bonding. I just want veneers” and I go “Well, it’s not about veneers, it’s your bites not in the right spot. It’s not engineered properly.” So I would rather you consider seeing my orthodontist, and then I’ll do some bonding, but bonding doesn’t work. No, it’s not the and so but you can’t do that in a five minute exam. So a new patient, we asked them to come in and have a comprehensive oral exam. And part of that involves a periodontal assessment And that’s a full perio of assessment. [Paresh]That’s like I’m doing pocket depth chops on every single tooth right? [Paresh]The full, exactly what we’re doing with the periodontists that I choose to work with, which means not just pocketing, bleeding scores, clinical attachment loss, mobilities, recession, everything. That way, we and how do you do that? Bring in a periodontist, bring in one of the periodontist that you work with and say look, let’s work with the hygienist. Here’s what we need. Here’s the why. When we finish, okay, so that’s a perio and I’ll get back to that in a sec. But that the Perio assessment. Photographs, taken a full face photograph and a few digital SLR photographs at least a smile, occlusal shots. How do we get the assistance train? Well, now I had Sonny come in and do that. But before that, my orthodontist and most orthodontists do fantastic photos, and my best friend’s in orthodontist. So send the team, to your orthodontist, they spend an hour and a half of their cameras and retractors. Done. Now they know how to take pictures. Okay, so they come in and they take the pictures, we’ll take basic series of X rays. And if there’s a lot of restorative, then I’ll say, you know, we’ll talk about it and go, you know, what, we need a full mouth series. And then, in terms of the aesthetics, what I’m getting the hygenic, now they’re coming in, if it’s a new patient exam, there’s two ways to do it. But they’re coming in right now in the hygiene appointment. And I know there’s philosophically some dentists go, “No, I got to see first the other way,” you know, if you feel if you can train your hygienists well enough to at least gather the information appropriately, they can get started on some things and do the fact finding. That’s my feeling. And so they’re coming into, I have two entry points in the practice one is straight with me, which would be about an hour. And one would we with hygiene, it would be closer to about an hour and 45 minutes. Okay? And so when they come in there, they’ll gather the information. But the first thing I asked them to do is just to sit down and because that’s the same ways I would go through the dental medical history, sit, eye level with one another, and just go over the questions. And not get hung up on “Oh, I got to get the bib on, I got to start cleaning teeth.” No, this is about connecting, getting to know the patient’s why, their fears, what their expectations are, and build a relationship in that first little bit. And I tell the hygienists, if you don’t pick up the scaler, that first appointment, that’s okay. Because if that person had needs the time to talk, gather information, because it’s a complicated case, it’s okay. You can bring them back. But if you.. [Jaz]It is good as a hygienist to hear that from your boss, right? So you don’t have the pressure, you can just do as be as thorough and as complete as you as you want to be [Paresh]Right. And it’s important for the patient to understand that. That’s why sometimes, a lot of times, we’ll start in the hygiene, because if it’s a simple condition, they can get some of the act of therapy started or even done and the patient’s happy. But if they don’t, as long as you have good verbal skills, and you feel confident enough, you can communicate that “Listen, you know, Jaz, you’ve had a complicated case, your teeth are, you know, not straight, you’ve got a lot of inflammation, we need to spend a little more time trying to figure out how to get you healthier. And so I don’t think we’re going to be able to get started today, I need these measurements. So when Dr. Shah comes in, we can have a really good conversation about how we can get started with you.” And if you build that value, it does work. I’ve seen it, it does work. So gathering the information on those forth. [Jaz]And the other thing that might do Don’t be shy is the other thing that might do is if you have that patient who’s just not playing ball with that, then that’s probably not the patient that you want in the practice anyway, right? So it gets rid of the weeds. [Paresh]Right. So I’m glad you said that. Because when I built the new practice, I really defined core values as strategic anchors. And one of the strategic anchors is we want our patients to partner in their care. And so I the entire team, including the admin, they know that so I sometimes when they started just newly started with me to go, “Oh, this person doesn’t want x rays. I go well, how does that get with our strategic anchors?” Well, it doesn’t. They go “Okay, so you know the answer, right?” So explain the value of him and just say, “Listen, in our practice, our patients are used to having that in partnering in their care. Here’s what we do,” and they have to sign off a form that they don’t want it but if they’re refusing everything, then we just say “Look, this is you know, this probably isn’t the practice for you.” And it’s hard when you’re young dentist and in during COVID, It hasn’t been busy but that’s what we’re doing. That’s what we’ve been doing. But I’ve got, those are the records that I’m trying to gather in a comprehensive exam is if they come to see me first, I will gather those records. I don’t usually do the periodontal measure. My hygienists are better at it. And I will tell them, I’ll get a rough idea of what it looks like. And I’ll say “Jaz, I’m going to schedule you with Aaron or Shane or Liz and I’m going to be there that day. And they’re going to take over the second part of it and we just, I just need a diagnosis.” Because one of the things that I want to do I want to give every patient [ ? ] patient, a periodontal diagnosis, AAP classification. The reason I want them to own their condition, I don’t want to own it. I don’t want to own it, I want them to own it. And the bleeding score for the last eight or nine years since we’ve been doing this is so powerful. Because my hygienists go “Look, your bleeding score is like 13%, I wanted at five, like you got to inflammation. And maybe you’re not going to get bone loss from it, but you’re going to.” Objective measurements, and they see that chart and they see the red spots. I will tell you, most of the patients own it. And they’re like, “oh, and so what do we do now?” When the inflammation is high, what did you learn in school? A Re-Eval. “You come in at six weeks, just like at the perio and you do a reevaluation, Jaz, you got to do your homework during those six weeks, because we’re going to take the measurement again. And if not, you’re going to see our periodontist.” And we do that, it takes extra time. But you know what our handoff also to our specialists or our Periodontist is smoother, because they know what we do. And they don’t sit and go through eight months of treatment again, they just go “Okay, we know what’s happening here, let’s just get started with our surgical intervention or whatever we need to do.” But the perio is a huge part of our practice. And that bleeding score and clinical attachment loss, that is powerful. [Jaz]Absolutely and you use reminded me of a couple of things where as some of the themes were hitting there. And one thing that you know the importance of asking the right questions as you do as part of the setlist you have. And one thing that I was always taught by a mentor was, if you’re not quite sure what the treatment plan should be for your patient, you haven’t asked enough questions. So that’s one thing I always keep in mind. That means ‘Okay, I need more, I’d ask more questions.’ And then I’ll feel more certain myself what to recommend. It just is a sign that haven’t obtained enough information. And the second thing is that you said about these set questions, and the importance of having a checklist of some sorts. And it reminds me a bit of a dentist came to shadow me one day, and she saw me do two new patient examinations. And then at the end of the examinations, he said, “Jaz, I noticed that you you did the exact same thing for those two patients.” Yes, they were individually, I treated them individually. And I came up with a different diagnosis and a plan. But the way I did things was exactly the same. And then she said, Yeah, I never thought I always just go with the flow with the patient, you seem to have a more structured way of doing it. So just tell us about the importance of having a structure, are you a checklist kind of guy? [Paresh]So in my lecture, there’s even if it’s a clinical lecture, I throw it in the Checklist Manifesto made a huge impact on me years and years ago. And so read the book, checklists are part of the fabric of the practice. And what we do is we create a checklist. In fact, my assistants I’ve noticed in the last few weeks, I had a quick sidebar and a conversation with the team, I was noticing that the communication wasn’t great with the assistants, hygienists and admin and I said, “Listen, no one’s using the checklist regularly. We need to get back to it. There’s just too much information during the workflow to worry about stocking toilet paper and stuff. I mean, that’s a checklist thing. Don’t clutter your mind. Like we got to focus on patient care in our team and not go oh my god, I’m worrying about putting paper towels back. Are you kidding me? So get back to the checklist.” And the assistant said to me, “You know what, you’re starting to do things different with some of your restorative procedures.” And I go, “So what do we need to do? Because I need to update the checklist. I go, well, let’s do it. I’ll sit with you.” So what we do is we laminate the checklists, and we have a dry erase pen. And so yeah, there is a comprehensive exam, there is one for, you know, the near cementation or bonding, there is one for an annual periodontal maintenance. There’s one for a comprehensive oral exam in the hygiene room. And all I want [Jaz]it is clinical protocols and its clinical protocols as part of success. [Paresh]Right. And I want them to check it off. And the reason I want to even if it’s something that they don’t feel they need to do, I want them to check, physically check it off. I know it sounds mundane. But it’s the same thing. I said this yesterday, I said, “Team, here’s the thing, picture yourself on the operating room table. Because that happened to me last year, and I had my knee replacement and everyone in the operating room, introduce themselves to me and said what their role was, and there was someone in there with a checklist. I said, Do you want that? When you’re in the operating room or when you’re going on a plane? Do you want the pilot to glance over the list? Or do you want them to actually go No, I did look and see that switches there. That’s all I have to say. I don’t have to say anything else. And all I’m saying is it only takes you a second to check it that hey, okay. I didn’t need x rays today. But yeah, I considered it. But, and so yeah, the consistency, as you said is important. And so that’s what I do as well. And so we have a checklist in there and we’ll go, Okay, are we doing this? Are we doing that? Yeah, we grab it. And so sometimes your assistant, let’s say you’re doing an exam, they can actually get started before you come in, because maybe you’re finishing an exam, they’ve taken the patient and they go, look, I know, Paresh gonna want an intraoral scan. So let me just start it. I’ll just take it. So when Paresh comes in, it’s like, oh, you’re taking the scan. Okay. I’ll be back in a minute. Hi, Jaz. Nice to meet you. I’ll be back in two minutes. And we just were going, and you asked about records. Can I continue for a sec? [Jaz]Yes, please, please, I’m just absorbing this. Absolutely. [Paresh]One of the other records we take is an intraoral scan. So in our comprehensive exam, every patient gets an intraoral scan. So we don’t pull out the alginate and everything. And the hygienists do it if it’s in the hygiene room, the assistants do it if it’s in our room, and it honestly only takes them about five to seven minutes. That’s it. My assistants are faster, it takes two or three minutes, but I’m slower, it takes me more like five minutes. And but they do it. And you know the fear for them when I initially introduces ‘Oh, what are you going to do with it? What do you I go listen, it’s strictly diagnostics, we want to print a model if I want to send an STL file to one of the specialists, but I’m not making crowns on it, don’t worry.’ And so that’s part of the process that we do as well. So we’re gathering, periodontal charting, photographs, I also asked them to do all of the hard tissue charting on the chart as well, existing restorations and everything. So it does take time. But that allows me if it’s more complicated, I can sit now with the patient, introduce myself, talk about a few things and say, ‘Listen, I think you do realize now that it’s your conditions a lot more complicated, you’ve got a couple of areas of decay here, your your tooth is drifting over here, an implant might help. But I’m going to need a cone beam like a CT scan. So let’s gather this, I’ll bring you back and we can have a nice conversation over an hour rather than five minutes.’ [Jaz]Let’s talk about that. So let’s talk about a situation whereby you’ve gathered all the information, the patient’s wants and desires. And now you’ve also found out the patient’s needs, you’ve got the perio staff, you know, your ortho classification, you’ve got your imaging that you want. Do you always invite them back for a second visit? To explain their findings? Do you do that virtually? Or do you do it in person? Do you sometimes not need to do it if it’s a quite a straightforward maintenance case, just give us a flavor to the young dentists about that. [Paresh]Okay, so if it’s a straightforward maintenance case, and they then I would probably I typically would just bring them in start the next you kno book them in for their next restorative appointment. And if there are a few things that you know how you you’re phasing treatment? In phase one, you want to treat caries and stabilize the perio. So, you know, in during that one, but there may be elective treatment, that in terms of crowns, and maybe a bridge or implant or things like that or ortho, so I will say look, and here’s our first phase, let’s get you scheduled because the decay on a couple of these teeth are pretty bad. And I want to get that started right away and maybe minimize the risk of a root canal. So let’s get you in there. And if I’ve got if I know there’s other treatment that is elective, but necessary, I will schedule extra time at the end of one of those appointments to go over it. If it’s strictly elective. I’ll say look, let’s get through and it’s just me, I’ll just let’s get through all of the initial cavities. And then I’m going to bring you back and we’re going to discuss elective treatment. And I’m going to give you because I know what that time it’s going to be things that I feel they can benefit from, but it might involve implants and might about ortho and I don’t want to do it in five minutes. I want to spend time showing them with their intraoral scan and their their x rays and everything ‘Look Why should you maybe consider upgrading these teeth and doing this and doing that? [Jaz]Well. That’s all at the end of phase one, isn’t it? That’s all at the end of disease management. Right? You’re having that chat again, which makes so much sense [Paresh]Right. Now, having said that, if their focus has been, hey, my aesthetics, my aesthetics and I got to get the smile. No, I’m going to bring them back. Yes, we can schedule their restorative appointment, but I’m going to do I’m going to show them a smile design. I’m going to do a mock up on them. I’m going to do all of that and I’m going to schedule a separate appointment so when it comes to mock ups and smile design, I’m not doing, I’m going through a DS, digital smile design process with my lab. Or sometimes I’m doing it myself. And I’m designing the smile on exocad. And then I’m printing a model and creating a mock up. And if I don’t have time I get my lab to do that. And send me the model and a stamp, and then I’ll do a putty matrix in the mouth. And I’ll go through that whole digital smile design process. [Jaz]Do you build for that? Just because different doctors do it differently. Some will do it as a motivational thing to just cement the idea that ‘Hey, this is a good idea. And some doctors are afraid to charge because they don’t think they want the patient to see the mock up, right? whereas others like No, I don’t want any tire kickers, I want to be able to build for it to see if they’re committed to that. So where do you lie on that? [Paresh]I’m going through this process again, after this many years of my team’s like he got a bill for it. And I’m like, maybe not. And so it’s kind of a mixture. So part of it, if it’s a simple smile design that I’m comfortable doing quickly myself on my own software, because I have exocad, so I can use it, I it doesn’t take me long. So if I can do it in 10 to 15 minutes, and then send the model to our printer and print it out the next day and so forth. I’m not charging. But if I get involved with the lab, the labs charging a fee for that, and I’ll tell the patient Look, there’s going to be a lab fee for and I’ll just charge them the lab fee, which is a couple $100. And so it’s kind of a mixture. And I’m trying to get through that part right now. And I don’t think there’s a right or wrong answer. But it’s a fair question to ask. So I’m still wishy washy on it, I’m doing a little bit of both, [Jaz]No, it was just good to know how different doctors do it. So your way is valid as well. And then that’s great. Now, once you have, like you said all these different bits of information together, the funny thing is, you know, you’ll appreciate this is you and how you treatment plan now. And that same person who would have walked into you 15 years ago, they will get different treatment plans. and dare I even say it even last week, morning, afternoon, slightly different treatment plans. It’s just human nature, we know this, right? So how you treat and plan, how you diagnose it’s variable on time, experience, your mentorship that you have available to you. So I used to get very worked up about it. Like, there’s like so many different ways to treat this one individual and, you know, newly qualified as they are, should we go down this route, we should go down that route. And then sometimes what young dentists end up doing is that we end up confusing the patient, we say, Well, you could have this or you could have this. And then here’s the pros and cons and here’s the pros and cons, how do you A) come up with a plan that you think is the best for the patient? How do you convey that to the patient? And then how do you also then part of the you know, in the UK, certainly one of the sort of things that a regulator wants to do is we have to offer alternatives, and also the risk of no treatment. So you have to go through a lot of things. But how do you do it in a way that doesn’t confuse the patient? [Paresh]You know what? That’s a great question. Because, you know, sometimes I’ve been, I’ve found myself in the past, giving so much information that the patient goes through what we call analysis paralysis, they’re like, oh, man, so much information, I just don’t even want to talk about it. And then they just don’t do anything. So I think number one, like Simon Sinek says is finding out their why like, what is really, really the most important to them. And then from there, taking the information like I find for us there there was an interdisciplinary meeting that my two orthodontist buddies, and my restorative buddy, we went to that was headed by Vincent Kokich when he was alive years ago is about 20 years ago. And there was there are teams of oral surgery, perio, restorative, and up on stage and ortho up on stage, just showing a case. And there was an restorative doc that said some things because you don’t want we tend to look at things through restorative eyes, and the specialists looking at things through specialty eyes. And what we’re trying to do as a group is look through interdisciplinary eyes, we’re trying to look at things a little different. And I think as restorative Doc’s are, our lowest common denominator is just Hey, I can do restorative. And so what I try and do is I’ll try and look decipher, and it’s a little more complicated, I understand this, but I’ll try and decipher what your put together the problem list of the key things that are important to you. I’ll add the things that I note. Okay. And as I and Okay, sidebar there was a Jeff Morley and then to me ubank been teaching restorative and smile design like even 20 years ago, and I was taking a lot of their courses. And one of the things they taught me was to look at each of the records separately. So you take your x rays and you just quickly analyze all of them. Jot a few notes Put it away, pull up the clinical photos, jot a few notes, put it away, take the casts out, jot a few notes, pull the perio chart up, jot a few notes. And they say when you do that, all of a sudden, you’ll start seeing, hey, you’ve got to wear for set on a tooth. You look at the perio chart, and there a pocket and or mobility. And then you look at the X ray, and there’s a widened PDL, I’m making it simple. It’s all tied in. So I try and look at that quickly jot a few notes, come up with the list, and then I’ll say to you, okay, here, here are the things that you want to address. Now I can do this restoratively By doing this, this this, okay? However, if I do it, restoratively, can you see this picture? Can you see this too, I’m going to have to be pretty aggressive with my treatment on these to correct, what you want to have corrected. It’s maybe it’s a tooth that tipped, and let’s just keep it simple. We’ve got drifting here, someone wants an implant, or a bridge, and I’ve got a really aggressively treat all of these teeth. Whoa, what’s the risk of that? Well, I might need a root canal on these teeth. Well, I don’t want root canals. Okay. But that’s one. Well, what’s another way? Well, if you would consider seeing my orthodontist, or never, we could tip them up? Well, but I don’t want braces either. Okay, well, I get it. But are you willing to accept cutting those teeth down? If you are, that’s fine. And is there another risk? Yeah, I can cut these teeth down. But it’s tip so much that when I finished putting this crown, there’s going to be a gap over here, you will get food in there. And it may not be important to you now, but 20 years from now, you’re a little bit older, you’re on my age, and all of a sudden, now you’re getting all your food there. I mean, I don’t know about you, but I love eating food. I don’t like picking it out. But this is a possibility. And so I start bringing it that way. And when you say risks and complications, I want them to understand it in practical terms, in relatable terms of what it’s going to be, you know, they don’t need to, they’re not going to care about periodontal disease, they’re going to care about, I’m getting all my lunch stuck in that area. And when I’m sitting with my friends at the dinner table, I don’t want to be running to the washroom to clean it out. So give them something like that. So I try and break it up that way and give them a why as to what we can do. And now all of a sudden, it slowly opens up the conversation to other disciplines. Same thing with gummy smile, or uneven gingival heights, and they’ve got a gummy smile. Is it important to you? So I just did this with a patient yesterday. And I asked her, she came into nice young girl, she’s in her late 20s beautiful smile, but they’re just a little bit crooked and the gingival heights are great. And her lip dynamics are a little high. So what I and I, and I saw I mentioned I said, Look, there’s a couple there’s several different ways that we can do this, but we got to figure out why you have a gummy smile. Is it skeletally your jaw, the way it grew? Is it how much the teeth have erupted or not erupted with, even with the gum eruption? Or is it your lip is moving more than it should be? And how important is it? And so because that involves possibly orthognathic surgery, surgical crown lengthening, Botox, any of those, we know that right? So all these other disciplines because I can just throw veneers on there. But if she’s going to be unhappy with her smile, I’m dead in the water. She’s not gonna be happy with them after. So what do I do, I did a mock up, I just took some composite, dried off her lips, I put some composite over the gum tissue of one tooth that was shorter, I lengthen two other teeth. I now open up the conversation to three other disciplines. And you know what she says? This is exactly what I want. I don’t want to do anything else or you’re happy with the level in the way the reveal of the gum. Yeah, I’m happy. Perfect. Let’s do some bonding. We’ll turn this tissue on sound the bone. That was it. But I brought up in relatable ways. I hope I’m not confusing everything. It’s just something that they can relate to tangibly. [Jaz]Exactly. And you showed her a visual aid to help come up which will then inform the best of the many ways to treat because all those ways could have had a role. But in terms of what would get her happy and what doesn’t involve perhapsorthognathic surgery if that wouldn’t be relevant or to correct. So a treatment for that individual. So so that’s very relevant. [Paresh]Right. And so part of the whole thing is I’ve got my list. I’ve got my problem list. I’ve got the why. And now [Jaz]That’s brilliant by the way, the problem, I just wanted to just before you just say, I just want to highlight, I’ve got to highlight the problem list is crucial. Something I was taught when I’m doing the orthodontics and orthodontists are really good at creating problem lists. But sometimes you forget that we can do in all disciplines. And I like that how when you were saying the problem is before you are relating it to them in patient terms. So it’s something that you I feel as though is a problem list that you feed back to the patient. So this is what I’ve understood. These are the problems. And these are the solutions to your problems. I feel as though that’s the very basis of the treatment planning. [Paresh]It is and I think, I tend to as I’m doing that, lead them first with lead them or start first with restorative solutions, because that’s what they can relate to. They’re coming to get a filling they’re going to get a crown, they’re coming to get a veneer and but the risks of some of that can be mitigated possibly by crown lengthening, periodontal intervention, ortho intervention, so it allows me to then go, Okay, well, if you don’t want to cut this down, then I think you should at least have a consultation with my orthodontist. Or you should at least have a conversation with my periodontist or my oral surgeon, and it opens up the interdisciplinary conversation rather than me just going in there. Well, you need to see ortho you need to see to perio, you need to see this. They’re like, whoa, wait a minute, I didn’t want that. I’m trying to relate it and let them make some of those choices to go. I really don’t want to cut these teeth down. Okay, that’s fine. But if we can put them in the right spot, well, how long would it take? Well, you don’t want some of that is just unraveling some of the teeth, I use simple terms, like let’s just, they’re all you know, they’re all closed, let’s just unravel them a little bit. And I don’t have to touch them. Because they’re beautiful teeth, we do some whitening, put the teeth in the right spot. And we’ll fix these three chips on the bottom that we’re down. Is that can be expensive? And I go Well, you’re going to spend the money on the orthodontics, but now you don’t have to spend them on the teeth and maybe 20 years from now you’re going to have if something breaks, you’re going to have the money and you’re going to have the teeth to be able to keep them. So it’s always taking it back to mitigating risk. And allowing them to relate to like make the decision on do they want to preserve tooth structure or not. [Jaz]You mentioned fees that and money which is so important because again, I it’s something that a lot of dentists are guilty of as young dentists in a few years out of dental school. The most, the worst thing to do is trying to diagnose someone’s wallet, right? Trying to say, Okay, well, I think this patient can afford this. Let me scale down my treatment plan to make it fit this imaginary budget that you come up with which was totally the wrong way to do it. But equally, there are patients who just can’t afford certain levels of care. So how do you present your treatment plan, and then also trying to make sure to, try and do it in a way that the patient can, is within the patient’s budget? Any any tips on that as my final question. [Paresh]I use the phrase, ortho is my best friend. And even though I don’t do a lot, maybe like 5%, it’s ortho, if you can put the teeth in the system. And now I’m using the word system not for patient. I can say with system like you’re the engineering of your bite is not ideal. It’s wonky. Okay, it’s just no different than when you’ve got shifting of piles under your house and the house is settling. And you’re wondering what the heck is going on? Or the cars imbalanced. And I could in very relatable terms. Like do you want me to rebuild the house on those wonky piles? Or would you rather us Let’s take the piles out, get it nice and level. So your system is an ideal if we can put the system in the right spot. And yes, you’re gonna have to spend some money doing orthodontics, I can do single tooth dentistry for the rest of your life. If the teeth are all lined up properly and you can only afford one crown or one filling a year, Fine. I’ll do that. If you can afford three of them. I’ll do three of them. But if they’re crooked and everything and the bites not good, I’m going to put it in a failing system it’s going to steal, your risk wearing them down the road or chipping or breaking them. Go through orthodontics, line them up, keep your aligners I and what some dentists will go well but then you know I missed out on this. You don’t want you still gonna make the money. You’ve got a periodontal patient that’s compliant. They come in regularly. So you don’t make the $10,000 in one night you make it, you make $15,000 over five years, it’s an annuity, like you’re still making it financially. But now you’ve got that [Jaz]We need to hear that because that’s very good. [Paresh]Right? And so [Jaz]and then now you have the satisfaction of knowing that you’ve done the best for the patient. [Paresh]Right? And so, if they choose not the ortho then how do you do that? You transition them with transitional bonding whether it’s direct or Whether it’s with milled pmma, or something like that, you can do that. But when you do it that way, they are committing to some sort of treatment on some of the teeth because you might be reshaping on while with the ortho, you can just kind of stick them there. So you can still give them both options to stage treatment. And then they’re going to have to deal with the maintenance of chipping some of the fillings or transitional bonding. And so you just say, Listen, if they do chip or break, here’s the fee for fixing it. But at least I can transition you over four or five years, if you can only afford a few $1,000 a year, your insurance maybe covers 1000. And you say that you can probably put in a couple 1000, but you got a $10,000 treatment, I’ll get you there in three years. But we’re gonna the first year we’re going to do is stabilize your decay, and we’re going to just get your bite stable. And it’s gonna be one or two ways orthodontics or transitional bonding. [Jaz]Well, the main thing that I think to take away is that the foundation, the disease management is there. And that’s part of the thing that you know, you can’t really compromise on. So you present that. And then what you what you also pretty much said there was that you haven’t given them a plan and you try and diagnose their wallet or anything, you’re giving them the ideal solution, and you’re giving them the why related to them as why that is ideal. But it just you just might know that okay, instead of doing it all now, you spreading over time. So they still get the best care. I think that’s the best way to summarize them. [Paresh]Yeah, no, absolutely. And that’s what I feel. So, I mean, I’m sure you have cases right now, where it’s taking three, four years, because they’re going through a lot of work and, and sometimes you forget about you go Damn, I’m not doing it. And then all of a sudden, it’s like, oh, they just finished orthognathic surgery, or they just finished this. And let’s start going. And it’s kind of fun, because it’s almost like, Oh, I forgot about you. It’s great. And but the thing is it does it I don’t know, it’s I just find it more rewarding. And I’m sure you do too, at your stage now. I do feel it can be a little scary and daunting for a young clinician to look at all of this and go, Oh my god, that’s so much. But it really isn’t. Because if you really think about it, most dental schools you went through and had to do at least one or two comprehensive care cases, I would assume where you had a series of clinicians that you worked with, and that was probably the most intimidating because there was one doctor that you knew was going to tear you apart with questions and literature, but you did it. And it’s a matter of just okay, going back to that foundation and just almost doing an overkill of you what you feel might be an overkill of your exam, because that’s what you really want to do. So just do that, like go back to that fundamental. And the other thing that I would say is, find a mentor, find an experienced mentor, that will walk you through gathering the information, showing you if you’re doing analog, why it’s important to mount the cast rather than just holding it in your hand. And how to interpret this stuff. But actually sitting and listening like you said that young dentist, she watched you do exams and watch and observe because a big part of it is interpersonal communication when you have that information, and presenting it and communicating. So that it makes sense, and it’s not jumbled up and it is relatable takes time. It’s you can’t be technical with the patient. [Jaz]Amazing. That’s been really good. I mean, it’s a big topic to cover, treatment planning. But I feel like the themes that we’ve gone into is going to be quite helpful for young dentists as part of the back to basics series. Please you must let me know when your textbook is out I’d love to share it with the Protruserati and again if you’re not already following Paresh on Instagram, please do check it out. His sensational work are amazing. Aesthetic work, Veneers, Ortho-Restorative complex plans. Sometimes these just by seeing the work as possible inspires you as a young dentist, sometimes you know, you look ahead anything I you know, how am I going to complete that, but just by hearing Paresh’s story today and seeing his development, and he did Kois and he did that residency, it’s not something that happened overnight success, something that took time for you to build into. So as inspiration, I would encourage you to look at those cases. [Paresh]Thank you so much, Jaz. I really enjoyed the conversation. And like you said, it’s a very complex topic. And you know, I hope it wasn’t overly confusing or daunting, but hopefully just took a few the, you know, some of the audience took a few pearls out of there. [Jaz]It’s those pearls that you know, the way we communicate to patients or the way you present certain things. And so it’s about the conversations that we have on a day to day basis. And I thought this episode was full of those kinds of conversations and the importance of a checklist, a lot of very foundational things which we don’t talk about enough, I think so again, thank you so much. And I hope you have an awesome weekend in Winnipeg, Canada where you’re based. [Paresh]Alright. Thanks very much. I hope you have a great weekend as well. Jaz’s Outro: Well, there we have it. Thanks so much for listening or watching all the way to the end. If you’re listening on your podcast player please do hit that subscribe button so you don’t miss a single episode. If you’re watching on YouTube or on Dentinal Tubules hit that subscribe button. I’d really appreciate it as well catch you in the next episode of the series.

Want to upgrade your practice with dental photography but unsure where to start? I got early adopter and dental photography legend Dr Alessandro Devigus (the main man behind dentist.camera Instagram page) to share with us his fundamentals to make dental photography routine in for your clinical documentation. https://youtu.be/6WtCv9nb7HA Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental pearl: AACD Dental photography guide, have this document at hand when start taking dental photographs because it will help you to remember your settings before they eventually become second nature. AACD_2013_Photo_Guide And also be sure to check this video tutorial I made on how to take perfect Occlusal Dental Photographs (the trickiest shot!) https://youtu.be/PGTtZJnp9Pk “Every picture you didn’t take is a missed one…” – Dr Alessandro Devigus In this episode we talked about: Setting up the camera 12:37 The basic of taking photographs 14:19 Importance of magnification ratio on lens 17:48 Selection of materials ie mirrors and retractors 21:38 Making your own signatures on photography 26:39 Storing and Organizing photos 30:42 As promised, here are the basic dental photography camera settings by Dr Alessandro Devigus: Check out Dr Alessandro Devigus’ instagram page, the dentist.camera, to learn more about cameras. If you enjoyed this episode, you may also enjoy the ‘Which Dental Camera Should I Buy’? also with Dr Alessandro. Click below for full episode transcript:  Opening Snippet: So once you buy the camera, the second barrier I find Dentists have in terms of actually picking up and using it is because they've never devoted the time to actually sit down and learn what is the aperture? What is ISO? Why is this relevant? And then what they do is they just haphazardly put it on auto and they take photos and they get unpredictable inconsistent results, they get frustrated... Jaz’s Introduction: When I qualified as a dentist, and I got my first ever paycheck, the first thing I did was buy a camera like yes, it was used because I need save money. But it was the first purchase because I knew I was taught by some mentors that to take good dental photographs is so so important to your career development. And I cannot echo this enough. So today I’m joined by Dr. Alessandro Devigus, the chap who owns dentist camera Instagram page, he’s a world leading expert on dental photography. And we’re going to cover the basic settings, how to get consistency and photos, and all the best tips to help you get started in dental photography. So if you’re not already taking photos, you hopefully will be by the end of this episode, feeling more confident to start picking up the camera and taking more shots and becoming more consistent and a better dental photographer. Again, this is another episode as part of the back to basics series of August and this has been incredibly popular. I’ve been amazed at the comments, had one dentist, let’s have a look on the previous episodes, I had Brendon Parker comment on the YouTube channel saying “Hey, Jaz just found this series and love it. I wish I had this 20 years ago.” And honestly I didn’t know the impact of such a back to basic series would have been you know, it’s amazing. And thanks so much for for joining me in these episodes. I hope you find the real value from them. Now we’re going to give you the Protrusive Dental pearl. So if you’re new to the podcast, I give you a Protrusive Dental pearl in every main episode, and then we’ll join the main interview with Dr. Alessandro Devigus. So the Protrusive Dental pearl I have for you is that on the comments below in YouTube or on the website protrusive.co.uk under this episode, I will have you ready to download the AACD Dental photography guide and what this is, and I found this really useful back in 2013 when I qualified the first purchase I made was it was a camera because I valued how important dental photography was and to go along with it, to help teach me the settings I needed and what equipment I needed for every single photography shot, I got hold of the AACD photo guide. So I’ve attached that for you to download. And you should totally have this document at hand when you start taking dental photographs because it will help you to remember your settings and eventually that will become second nature and you won’t need to rely on any more but as a beginner’s guide I think is really good. And obviously with being the AACD is world famous, the VACD also have one but this is the real famous one. The other thing to check out if you haven’t already as part of the Protrusive pearl is the most difficult photo to take is the occlusal photograph. Okay? And one of my most popular YouTube videos is how to take an occlusal photograph. So if you haven’t already seen it, click below description or go website and I’ll make sure I link that YouTube video on how to take really crisp, really clear, really consistent occlusal photographs. Let’s join the main episode now with Dr. Alessandro Devigus, who’s going to help us become better at our dental photography. Main Interview: [Jaz]Dr. Alessandro Devigus, thank you so much for coming to the Protrusive Dental podcast again. We had you recently for a group function about which camera should I buy and you amaze me. You also surprised me with your recommendation for a mirrorless and I’m so excited to have you now for a two-part series. So this episode is about the basics like getting started with dental photography. It’s an episode the Ptotruserati have been asking for since the inception of this podcast and I know you will do it justice. How are you doing? [Alessandro]Yeah, I’m doing fine in Switzerland we are getting better and better and we start with the vaccination. We start to getting a let’s say almost normal situation and hoping to open up restaurants and do more what we used to do in the past [Jaz]and how is your clinic? Is it full flow busy again? [Alessandro]My dental clinic never really had a break down we just, we had a lockdown where we were forced to close our clinics for two months almost. In the dental work I don’t see any decline in work so people need and I tell you in bad times people look more after their health. And so health care, it’s they don’t look after serious diseases. Our son working at Rush, he told me cancer treatments have been postponed. People are not going to the hospital if they feel a little bit of heart problems, but overall people Want to be healthy because then you’re ready to face a crisis. [Jaz]This is why maybe the share price of a Peloton, there’s the sort of the spin at home has been climbing, climbing, so many people that are jumping on that. And I agree with you, I think people are looking at how to improve their physical health in whatever way they can. So that’s inspiring, I guess. Just so it’s been introduction for those people who maybe haven’t listened to that episode, the group function that we did, just introduce yourself, and why you are so knowledgeable on cameras in relation to dentistry and beyond? [Alessandro]Well, my history with dental photography started more than 20 years ago, I was an analog photographer in the early days, and in 1999. So 22 years ago, Nikon introduced their first digital SLR camera, and I was really happy. And it was a coincidence that I got one of the first cameras to try it out in the dental surrounding. It was not easy, because everybody was telling me ‘Yeah, it’s the same as the analog just mount your flash mount your lens. And instead of having a film, you have a sensor, and it’s everything is the same.’ But it really it wasn’t. So I was really struggling, I had to learn, I had to do trial and errors. But it was also interesting timing connecting with the Nikon company, talking to the engineers, professors from universities coming to my office, oh, this guy has something new that a digital camera. And it was exciting because it gave me opportunities to share my knowledge, my passion. I got in touch with the ITI, I was able to really travel around the globe, teaching people on how to use a camera, [Jaz]You were like a pioneer when it came to the use of digital dental photography it sounds like. Just a bit of historical perspective, how much should you pay for your first camera setup? I think that’ll be interesting to know. [Alessandro]I had to promise my wife not to buy a digital camera before the price was below 10,000. So I looked already before that. So Kodak in cooperation with Nikon came up with a digital camera was, I don’t know 20 a huge thing. But at 40,000. So my wife told me no, no, no, no, no, no, that’s too expensive, don’t. This is a gadget that I don’t allow you to buy. So and then in 1999, the Nikon came up with this camera at 9999 Swiss francs. And this was it. So this was the time to start and explore this exciting new technology. [Jaz]I think the number one objection or the reason why the newly qualified dentist or will not buy the camera initially is because of the expense. They can’t just fight yet. And what happens I believe, is that they don’t buy it for after year one, they don’t buy it after year two, and then they’re not taking photos, not used to it. And then to learn that skill is too much out of their comfort zone. So many dentists will go throughout, unfortunately, a large proportion of their career without taking dental photography. And I do think maybe it starts with this mindset that the camera is too expensive. But when you put that into perspective like you have today’s cameras are super affordable and super good. [Alessandro]Absolutely. But still I don’t know why the first question or one of the first questions I always get asked, What’s the price? And if you say Well, today I can tell you we you can have a decent dental photography setup for 1500. So with the camera, a good macro lens and the flash. But if you go into high end, then you easily spend 4000 – 5000. And I don’t know why dentists always talk too much about money in relation. If you buy a tool, and you know that this tool can help you, I would say you have to look on a longer term than just saying, okay, I don’t want to spend. It’s interesting dentists buy things that are less than 1500 on an emotional way. So if a nice looking girl comes into the office and says, “Hey, Doctor, I have some nice gadgets for you.” And the doctor asks the girl, “How much is it?” “Yeah, it’s 1400.” And then doctor says, “Okay, I buy it.” If the price is 5000, even if it’s a nice and convincing girl or a convincing, nice young man, then you say, “Oh, I have to think about.” So there’s a barrier and especially I don’t I think not only in dentistry, where you select, where you say yes to something. And where you say oh, I have to think about which is basically no it’s like maybe, the maybe that in some cases is a no. In other cases is a yes. But again, coming back to this, it’s worth to invest money into photographic equipment because it’s the other side of how to look at your patients. So we have X ray to look inside our patients, and photography to look from the outside, and diagnostics, diagnostics is so important. And it’s not only because of smile design and all these digital gadgets around, it’s looking at your patients, see what changes. And this extra oral documentation, I think is crucial. You don’t have to do it with every patient. You don’t have to take either people ask me, “hey, how many pictures are you taking?” I don’t take pictures all the time, the most important thing is, and we can jump into some important tips and tricks already. The most important thing is every picture you didn’t take is a missed one. That’s number one. So what I recommend this, at least if a new patient comes into your office, you don’t even need to do a full status. But maybe let the patient open the mouth, do an overview, then you see the gingivitis or you see the status of the patient when he first stepped into your clinic. And these are very useful information also in the documentation, in the motivation of the patient. And maybe one month later, the patient comes with a broken tooth. So you have the initial situation still there. So what we used to do today is we do a lot of intraoral scans of patients, because it’s very easy. So we take some, maybe if the patient allows we do a portray, relaxed and smile, then we do two, three intraoral. And the rest is done by an intraoral scan. So we have the 3d models, and we have everything. So this is also the future for me of the dental photo status. [Jaz]Excellent. Well, I think the people who listen to this podcast, the Protruserati, they already converted, most of them are good dentists who have already got cameras. But this episode is really for those people who are in that “maybe” category to just convince them. And maybe if you’ve recently bought a camera, maybe upon your advice, Alessandro recently from a previous episode we did, and they’re just unhappy with the settings because the settings once you buy the camera, the second barrier I find Dentists have in terms of actually picking up and using it. It’s because they’ve never devoted the time to actually sit down and learn what is the aperture? What is ISO? Why is this relevant. And then what they do is they just haphazardly put it on auto and they take photos and they get unpredictable inconsistent results, they get frustrated, and then the camera collects dust again. So hopefully with this episode, we can cover some fundamentals of how to get more consistent photography, and just the basics of the settings and why. So where should we start with this journey. [Alessandro]So the first we have we have bought the camera, we have the macro lens, we have the flash. Now the setup, I think everybody interested can visit my Instagram account or send me a message. And I can share my one slide with a set, with a summary of all the settings. So go for manual and all the settings, it’s really easy, it’s an easy setup. Look that your camera is able to save settings. So all modern cameras have like numbers or letters where you can save presets. So follow the basic settings I recommend or also others are recommending. And then save the settings. So if my, if you take your camera home, and you go back to your office that you just switch the button, and you have to go back to the basic settings. That’s number one. Number two, if you’re really absolutely a beginner and have no clue on what you want, I would recommend a short private coaching. A short private coaching, this can be done online, I can do some advertisement, I do that and very successfully. So you don’t need to spend hours. It’s a really, it’s a short thing. And I experienced this also in my workshops. The workshop is nice to socialize to do but at the end, you have to tell people now you have to go back to your office and practice. Some guy, some people are a little bit quicker. And it’s the thing, If you look through your camera, you have to visualize what you want to capture. So the basic message how to learn to take dental pictures is look through the viewfinder frame what you want to see and if you see in your viewfinder, what you want to capture, then push the button. It’s the same when you’re doing a holiday pictures, how many people are walking around and randomly clicking on their phones and shooting hundreds and thousands of images which is absolutely useless. I look through my camera and even if I take a picture with my iPhone, or my smartphone, I look at the subject I want to take a picture of, I frame it, if I like it, I take a picture. If I don’t like what I see, don’t take the picture. And it’s the same in dental. So you avoid this initial frustration. So this is one number one. Number two, the most common error people are doing is they don’t go close enough to the patient. And this brings me back to the viewfinder, look through the viewfinder. And if you want to take a picture from canine to canine, then if you don’t see canine to canine on your viewfinder, don’t take the picture, if you still have the half of the patients, the face on your viewfinder and think, okay, I take the picture, and then I do some Photoshop, this is waste of time, this is absolute waste of time. If you want to have fun with dental photography, do the right settings, and then do the click, click only if you see what you want to get. And these are the two key messages. And I can tell you if you follow these. And no matter if you are trying to take pictures with mirror or so. All this, some people say complicated stuff. If you follow these very simple rules, you will see that it’s fun, and it’s easy to learn. But at the end of the day, it’s really practice, practice, practice, practice. [Jaz]100%. I just feel like I’m such a so much better of a dentist from taking photography and reflecting on my work over time. And that’s a given. And also when I when I bought my first DSLR I started to actually use it outside of the clinic as well. And, you know, I think most dentists who are now comfortable in taking dental photography and doing well with that, they are also exploring the use of the camera outside of the clinic. And it almost brings another dimension to your life in a hobby. I know it affects lots of people, I’m sure you’re probably an avid photographer as well. And just so I can. So I don’t forget those settings that you suggested. I mean, I agree the way you said it, because we want to be able to refer back to that because people who are driving right now or listening, there’s no chance if we say oh f22, ISO200 you’re not gonna remember it. So it’s so much better to have like a PDF or an image. So we’re going to get that from your Instagram handle. What is the Instagram handle again? [Alessandro]It’s dentist.camera. [Jaz]It’s a great page. I love it. It’s everyone who is taking photos, sharing their story sharing their setup, every dentist has a story behind their camera setup and their photography. So it’s a lovely page. I’m a huge fan of it. So do check that out. And I’ll grab the settings from you as well and put it on the show notes. So you can click on to that and then go to a Alessandro’s page, so you’ve got the settings. So you’re going to the first homework you have is to find the settings. Okay, the second one is to practice and only take the photo when you are happy with the viewfinder. Now one thing that we can tackle now, which I think will help dentists who are beginning with photography is the whole concept, like you said about not getting close enough to the patient. So I think dentist need to understand that the magnification ratio that you select on your lens. So for example, for a crop sensor, it’s 3:1 magnification, which would typically be so that means that you, when you want to take consistent photos, you don’t mess with the lens anymore, you keep it to one place, and you move in and out. And what you find dentists, when the beginning is they’re doing this, they’re doing that you see them do this sort of in and out like a whole meter. But once you practice, practice practice, you’ll just know a tiny bit of adjustment will do. And so can you just explain why they need to do that to get the right photo? [Alessandro]It’s all about standardization. So what we are looking for, and there’s especially on social media, there’s a huge problem of too much artistic photography. I like artistic photography, because it’s fun, and it’s something to share and to enjoy. But this is not the daily work. Daily work is to trying to be consistent, to be standardized, to be reproducible. And that’s correct what you were saying all good macro lenses have a magnification ratio on top of them. So you can select already the magnification. So if you want to say okay, I just wanted two centrals then go to 1:1 and go out the further away you go from the patient. And then again, it’s if you have the same patient. it’s framing it’s the distance is given by the frame you want to capture. So I have like this includes the lips, just with the retractors in place, I want to see the full mouth, I just want to see canine to canine, I want to go closer to my patient and just go into having one or two teeth on that. And this basically gives you the standard views with the standard magnifications if you don’t change your equipment every other day. So that’s why it’s important to stay with the same lenses. So fixed lenses, fixed macro lenses and camera can be changed over time that’s not an issue. You can also change your light. If you want to be more creative, maybe we can talk about that in the next episode, there are different lighting options, but basically stick with the lens, which offers a 1:1 magnification ratio. So this is also questions I get asked, do I, why should I buy a macro lens? Can I, there are some zoom lenses out there where I can have macro options, but they don’t have these 1:1 magnification ratio. So this is one piece, the most important piece of the equipment in dental photography is the macro lens, allowing this reproducibility, quality and making it easier at the end to get nice pictures. [Jaz]I just thought it was worth mentioning because I have seen some lenses before using their cameras or first time. And what they’re doing is they’re standing at random distance from the patient, and then they’re moving their lens to put it in focus. But then the next time you do it, then how will you ensure you’re the same distance away and they never get the standardization. They never get the consistency. So that’s just like you know, a lot of people that are sound very obvious, but if you’re starting out, I’m sure that might actually help you to realize that actually you to set your magnification first, then move in and out. That’s at the very basics of dental photography. One question I want to ask is, I don’t know how to split it in terms of this episode and the next episode, because I really want to just hammer down the basics. So everyone’s ready for that next episode A month later, when we talk about the more definitely, lighting, we can talk about it next time because lighting, softer lighting, dual flash, ring flash, we can talk about that, that’s a bit more advanced, I think. But any tips that you can give to people in terms of selection of materials. So for example, when you get your camera set up, you also need to then invest in mirrors and retractors so which retractors and mirrors would you recommend? My personal favorite, Alessandro, is and you might disagree and that’s fine is the called Columbia retractor. So they’re the metal ones. I don’t like the plastic ones because I find that I can’t insert the occlusal mirror in with the plastic ones, there’s no space by like the ones which are just like the metal wire. And it’s like I think they call the Columbia ones. I’m happy to put a photo up as I’m saying this at the moment. But which ones have you found work for you and your students? [Alessandro]There’s a huge a large variety of mirrors and and retractors out there. I have posted some tips and tricks on that. And I’m reposting this because this is a question I always or very often get. So basically, I go for this plastic retractors because we use a lot of them. So metal retractors Yes and No. At the end, it’s really a personal preference. It’s really a personal preference. The most important thing is that you insert them correctly, that the patient is not pulling the retractors back. So to avoid that with the retractors you even get more lips and cheeks on your image than rather than taking them out of your image. With mirrors, I’m a fan of coated mirrors, not metal mirrors. So glass, basically glass mirrors, that have a coating from, there exists from different companies. So I was with Filtrop, which is a company in close to Switzerland. They’re producing mirrors for decades. And they have a mirror system they introduced in in the 1970s. This was done by a professor in Basel who was a periodontist. And when he wrote his book, he was looking for good mirrors to do his clinical photography. And these are very old, I have two or three kids in my office for over 20 years. So they’re very resistant. So but again, in this short time it’s too much information. So I would also here refer to some tips and tricks I have posted on my account. And at the end it really comes to personal preferences. What I do not recommend is don’t go for colored retractors. So if you choose retractors they should be almost let’s say transparent, or black. Very popular retractors are have a light blue. And you don’t, you know by the way, you know why they’re light blue? [Jaz]I don’t. [Alessandro]If you put the transparent retractor in the disinfectant, it gets yellowish so blue is the opposite color of yellow. So if something that is blue, gets in a disinfectant, it also gets more yellow, but because being that the opposite color you don’t see it that quickly so they look nicer over time. But at the end, it’s personal preferences. The only thing I don’t go because there’s some fancy colored retractors for children, and for bleaching procedures, they might affect the colors of your photography. So I found if you use this pink or whatever colored retractors, they have an impact on the color of your photography. [Jaz]Right. Well, I’m going to share, I’m going to show you, if you can see my screen in a moment. I’m going to show you the mirrors. Sorry, the retractors that I like using. They don’t have a, Ccan you see this Alessandro? [Alessandro]Yeah, I seen it. Yeah, I see it. I have them as well. The advantage is they they last a lifetime. There’s no problem, but some patients have an issue. And with this, especially if you have patient with a bit larger lips, the lips overlap the retractor. So the let’s say a final recommendation, there are two forms of retractors, C shape and V shape. So the V shape retractors allow much more retraction and are very common used in the orthodontist offices. Because then especially for children who have really soft, let’s say soft tissues, you can retract the cheek and do the lateral images without the use of a mirror. So that’s a huge advantage. And so they are very popular in orthodontics. So and then there are cheek retractors which have on one side, the C shape, and the other side the V shaped form. So you have both just in one piece. So this will be something that for a beginner, is something to take a look into. [Jaz]Brilliant. I just want to ask you, what are the other things that are, one of the questions I want to ask is how to make your photos unique. But I think to make your photos unique, that might be more of advanced technique. Now let me tell you why I asked this, right? Because whenever I see photos from dentists that I admire, dentists I respect, right before I even read the name on Instagram or on Facebook, I know whose photo it is, because every photographer, their photos, they have the signature sort of lighting, the signature colors and stuff, right? So how would you go about developing your own style of photography, because what you will provide us and what I will share with everyone is the standard settings. But then how do you suggest? Because if everyone did that, then everyone’s photos will look the same. Right? So how can we add our own signature to our photography? [Alessandro]This is a very good question. And my answer is the signature should only be in artistic photography. In everyday, in daily documentation, all pictures of all dentists should look the same. It’s like if you would ask me, oh, wow, I immediately recognize who did this x ray on this tooth. Because it has his own style. That’s his own style. Nobody’s talking about individual style on taking x rays. There’s a standard. And every now and it’s really important. That’s why this is a very great question. All pictures of clinical documentation of all dentists around the globe should look the same. If you want to stand out, clean the working field, avoid saliva bubbles, make it look clean. And this is the difference. This is the difference, you know, make it clean and sharp, crispy. This is it. But at the end, all images of all dentists should be comparable. And not say Ah, this is because I remember one dentist, one famous dentist from Spain. He started many years ago of using bouncers. And he created this Photoshop look in his images. And everyone say wow, this is amazing. And my answer as as editor of a journal was, oh no, no, I hate this. Because I want a clear documentation that is repeatable and looks always the same. So if I take a picture of a patient today, and in five and 10 years, it should look the same. We cannot repeat that enough. Don’t try to be artistic on your clinical daily documentation. There, it’s scientific photography, it’s documentation. It’s like taking an X ray, you don’t experiment taking your x rays. You know, and this should be how you use dental photography in the first place. This is 95% of your dental photography should be scientific, standardized photography and then the rest, the 5%, you can freak out and do some makeup, work with your patient and do shootings and.. [Jaz]Put a kiwi in the mouth. [Alessandro]Yeah, all this stuff. You’re free to do whatever you want. You can freak out but Again, try to be consistent, try to be standardized in your documentation because it’s a legal document. And it’s not fancy fashion photography. [Jaz]I’m so glad I asked that, because I wasn’t expecting that. But you’re so right. Honestly, I never thought about that way before. But you’re so right. Because like I said, when you take a photo from now, and five years later, you want consistency. But wouldn’t it be great as a dental community worldwide, that, patient now move somewhere else to a different country. And that dentist that takes a new photo will also be calibrated with you. And I think that there is a lot of beauty in that. And yes, we can have our fun for the 5%, for the after shots, for the you know, for the Instagram, for the gram, that kind of stuff. But I actually I like what you said that and I respect that a lot. Alessandro, my last question before we next time do a more advanced discussion is this, the storage of your photos, just tell us talk us through the software that you’d recommend the backup procedures that you recommend to actually store and organize your photos. [Alessandro]So basically, I started so there are different options. Option one is you have an office administration software, where you store your digital x rays and you store also your digital photographs their. Option two, what I prefer because I have so many pictures that I think it was like overloading my office administration, I started using a very simple folder structure. And I still have this folder structure. So name of the patient, number of the patient in my administration software and the keyword and you find everything. So and then, on top of this, I tried out all the different libraries or tools. And recently, two, three years ago, I started using a software from France, named Kitview. Kitview basically is this a software that allows the management of digital data, not only photographs, but also x rays, and whatever you want. And the beauty of it is that I can transfer my images wireless to the software. So I select the patient in the software, I push the button and the picture goes directly to the patient. But this is something a workflow that I have to explain in detail, maybe in another session or because a lot of people have asked, and if you have it in the database, backup is crucial. So we are using a network attached storage device, one in my office and one at my home. And all the data is synchronized. So this is in short terms. This is how I so, what my workflow of storage of my dental photography is all about. [Jaz]Brilliant. I think it’s going to help some people to give them ideas about how they could be storing it. Alessandro, thanks so much for covering some of the basics. I’m really keen to get out the sort of your recommendation settings because we are so great to have that from you. So I’ll reach out. I hope you have a good day at work today. But then we’ll catch up and I’ll get that out to everyone. And then also just where everyone’s appetite for the advanced one. And it’ll be great to have you on again. [Alessandro]Thank you stay safe, stay healthy. And don’t forget to push the button. Jaz’s Outro: So hope you enjoyed that episode with Dr. Alessandro. Thanks for listening or watching all the way to the end. I hope you found some good nuggets in there so you can get started in taking consistent dental photographs, something which I think is probably been the most important tool in my personal and clinical development as a dentist. If you’re listening on your favorite podcast player, do hit that subscribe button. And if you’re watching on YouTube, hit that subscribe button. So I’ll catch you in the next episode, which is all about treatment planning 101. Back to Basics guys, it’s almost finished because August is almost coming to an end. But don’t worry, I always have splintember ready for you. Catch you Same time. Same place. Next week.

When treating periodontal disease there is more to it than removing biofilm. Our role is to be a motivator and lifestyle coach – only then can we see successful periodontal outcomes in the longterm. What’s your spiel to patients to explain what periodontal disease is? Do you show diagrams, draw or use your fingers? Listen to how Dr Ian Dunn explains Perio and you will want to implement his way of communicating on Monday morning! Brought to you by the Back to Basics series of August on Protrusive Dental Podcast. https://youtu.be/KAGHaWyacZs Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Have some tools to be able to communicate via drawing (draw teeth, draw bone or periodontium etc) whether it’s digitally, on whiteboard or paper. There is beauty and magic about being able to draw something while your patients are watching beside you. “Communication has to be a two-way street. It shouldn’t be a monologue, it should be a discussion.” – Dr Ian Dunn In this episode we discussed about, Communication Masterclass between Dentists and Perio patients (12:38) How to communicate with more resistant patients (17:33) Referrals done by GDPs that could have been manage at their own practice  (21:22) Trying to get out of comfort zone in Perio (26:20) How to communicate risks in Perio treatment (32:08) Catch Dr. Ian Dunn’s Perio courses and be able to communicate to patients effectively about periodontal diseases. Do join us on our Facebook community, the Protrusive Dental community! If you like this episode, be sure to watch Finding Your Niche in Dentistry with Dr Pav Khaira Click below for full episode transcript:  Opening Snippet: So this is the bit where you explain to a patient that they're rubbish at brushing their teeth but you do it in a way that you don't offend them because that was the thing I find most difficult. Mrs. Jones bacteria builds up on teeth. It reaches your trigger points. Your body triggers inflammation, that inflammation damages the bone... Jaz’s Introduction:I’m Jaz Gulati and welcome to another episode in the back to basics series of the Protrusive Dental podcast. You are going to be blown away by today’s episode is with Dr. Ian Dunn of periodontist, on communicating. Communication in perio specifically, for example, how do you explain to a patient that they have periodontal disease like six significant things a chronic condition that could potentially live with for the rest of their life? It’s such an important thing for them to grasp so that they can get better outcomes. And you can get better success as a clinician. Like what’s your spiel? What’s your way of communicating that I think lots of Dentists have different ways of doing it. Now, you will probably get your way whichever way you’re doing at the moment. And Ian will show you the way to do it. I mean, his way of explaining to patients, how periodontitis works, and to get them on board is just the best I’ve ever heard. So I’m so excited to share these gems with you, we will talk about communicating risk of treatment with patients. And he does that in such a great way as well. And the relevant Protrusive Dental pearl I have for you today is to have something one-eight, whether it’s digital, or whiteboard or paper base, an opportunity for you to be able to draw certain things because certainly one of the tools that Ian Dunn uses is to draw certain things draw teeth, draw bone or periodontium. So therefore, I think it’s a really useful thing sometimes to be able to draw something. Yes, we have our intraoral cameras or DSLRs. But sometimes there’s a beauty and magic of being able to draw something while your patients watching, you know annotating as you’re talking to them. So that’s the main Protrusive Dental Pearl. I hope you enjoy this episode. Stick around for the outro and if you’re watching on YouTube, and if you haven’t already, I’d really appreciate if you hit that subscribe button. I know loads of you have you been enjoying the back to basics series I’m so grateful to for you to join me again in this episode. And now on hit the main episode with Dr. Ian Dunn, all about communication when it comes to periodontal disease. Main Interview: [Jaz] Ian Dunn, welcome to Protrusive Dental podcast How are you my friend? [Ian] Yeah, I’m very good, Jaz. It’s really good to be here. It’s nice to be on this and not be listening to it all the time if I’m on my commute to work. [Jaz] I’ve said it before. I’llsay again, I’m just amazed when clinicians are of your caliber. And I mean seriously, listen, honestly, he said it’s the highest praise for me. You are someone who I have seen as a brilliant educator, because you know, not only just the crown lengthening sort of workshop I did a few years ago, you’ve been on my radar, you taught my wife perio at dental school in Liverpool, and as a tutor you are you know, you’re a big favorite. I think I remember going to something very unique about Liverpool undergrad scene was this. We will shall not reveal details as per the contract. But it was that evening that you had lots of funny skits and whatnot. [Ian] Oh, yeah, the smoker. Yeah. [Jaz] The smoker that was just a brilliant experience, like into in Leeds and Sheffield and various dental school, we had the dental review, and you know, there’s like pre recorded videos and stuff. But what you guys put on in there. Live performances, and comedy skits was a level of wit I’ve never seen in dentistry before. So that was just amazing. So you came on my radar then. And then on the workshop, it was really nice. you’re logged into Dentinal Tubules Congress recently and you’re on the first workshops to sell out so it just speaks volumes about you as an educator. But for those people who might not know you, probably you know it outside in case someone hasn’t heard of you, for example, just give us an idea of the kind of your little background and what drives you? [Ian] Okay, wow. Well, I mean, thank you for that very, very generous introduction. My background believe it is a general practitioner, I never set out to do specialist training. I feel a bit like I listened to Amit’s podcast recently. And he sort of wandered into perio by accident and I feel a little bit the same. But I will I qualify in ’98, the specialist list we’ve just been established. So none of us knew whether they were going to be any good or not or whether they’re going to last for a long time. So I was a general practitioner for many, many years. But I also had this small role in the hospital that was basically just working in the A&E department and it morphed into a small perio teaching job. And from there I just I was bitten by the perio book, so to speak. And I just found that I really enjoyed it. I found that I think undergraduate perios a lot to answer for in the UK, though this is particularly dynamic, I don’t think we get access to the better patients. So I don’t know that undergraduates see what real perio is about. And I also think that people don’t understand that periodontist, don’t just spend all day scraping rubbish off people’s teeth. You know, we, Amit was talking about recession management, we also do implants, implants management. We do the sort of regenerative perio surgical stuff. It’s a very surgical discipline. And so yeah, I eventually got onto the specialist list about 10 years ago, after a 10 to 12 year career to GDP. And I sort of hope that I’ve never lost that general practice background, I hope that’s one of the things that keeps me relatively real. And I think the thing that drives me is, I just genuinely love passing on knowledge and trying to demystify perio. [Jaz] That is so evident in your teaching. Honestly, I’d say that is really evident the way you explain things. And then the passion behind it is oozing out of you, when you’re teaching. So please keep it up. Because, you know, we need this and in every desperate discipline, but especially in perio, to inspire the new generation of dentists, because as you said, it’s a great point you made about the type of patients I mean, literally, it gave me flashbacks to kind of perio patients I had as an undergrad, and you know, you don’t see that success when they come back. And then you wonder why and then you sort of lose hope in perio. And let’s not even get into the system of the UK and how you practice and how that might have been not not be conducive to getting the best results. But you raise a really good point there. But we need clinicians like you to inspire the next generation. [Ian] Yeah, well, I think you’re right, I know, Liverpool, one of the problems I used to see and I was the Perio in Liverpool for many years, was the type of patient we would have would be the professional patient, you know, the patients who’ve been in the system for 20 years. I mean, those patients were effectively maintenance cases not true disease management cases are so undergraduate perio was mainly blooming plaque and bleeding skills and six point pockets, yards and a little bit of debridement. But they never actually saw the juicy, you know, eight, nine millimeter bleeding pockets. And so people just get a real misunderstanding of what perio is and what it’s about. Not to mention the fact that as some of the academics make it very, very complicated, you know, you’ll have signed lectures on, I don’t know, hyperactive macrophages, and all these amazing host response lectures from wonderful scientists, but not necessarily real world perio on how you treat perio in practice, and that’s one of the things that when I, when I got involved with perio courses, in Phil Ower 12, 13 years ago, I’d already been on Phil’s courses as a delegate. And I just remember thinking, Oh, my God, that’s it that that Penny drop moment of, that’s all perio is it, some very simple concepts delivered very, very well. And for 70, 80 90% of the population that will do most of the time. And that passion surpass that simplicity on, is that one of the things that drives me, people overcomplicate stuff, as you well know. I mean, occlusions are classic, isn’t it? Occlusion is one of those massively over complicated subjects, when actually there’s some very fundamental principles that if you do that, right, most of the time, most things work, and it’s the rare cases where you need the, is my experience. [Jaz] That is the way you said that is I can completely know for those who are listening, I’m nodding all the way through. You’re so right. And I think the real world, like you said, is exactly what this episode is going to be about. It’s about the whole communication side. Because, like with every disciplined dentistry, especially my restorative background, it’s not so much about how good you are with your hand skills. It’s not about how good you are in delivering any piece dentistry is about how your patient perceives it and how the patient feels when they’re communicating with you. Like I’ll give you an example. Give those listening example. I used to do this [inaudible] Riverside communicators, it was Toastmasters. Even we were Toastmasters communication. So as a Toastmaster so almost like training for podcasting, I was trying to put myself in unfamiliar, awkward scenarios. So I can develop as communicator. So we used to do these talks in Richmond by the riverside communicators and it really you know, I remember first time our heart was pounding. And as the weeks came by, I was getting more and more confident it was a great experience. I highly encourage anyone to do that, to put yourself in an out of your comfort zone to try and become a better speaker, a better communicator. And we’re doing a one, telling one story or one communication pearl about I was talked about my son or something. When I won this little prize that evening, I put it on YouTube and everything. But later on, and he just knew I was a dentist. I didn’t really talk about dentistry at that much at all in presenting. But he came to me later this guy in the audience, he said, Wow, you are amazing. I want you to be my dentist and driving home that day and I was like wait a minute, I don’t understand this. He hasn’t, he knows nothing about me as a dentist. He just saw me deliver a speech very well because you know I polish it and I practiced it, and he saw me as a good communicator. And that’s what he, that’s why he wanted me to be his dentist. And that’s when I really realized, actually, it is all about the communication, which is what we’re going to make this episode about. But I suppose that’s been your experience as well. [Ian] Without doubt, I mean, perio is, I don’t know, probably 80% psychology and 20% dentistry. You know, we, the largest change that takes place in my surgery is behavior change. You know, we are manipulating patients, that’s not the right word manipulation, but we are, we’re manipulating patients to do the things they need to do that’s right for them. And we’re doing it in a way that they think it’s their idea, we want lasting behavior change, we don’t want that sort of join the team in January, not having been in February type approach, we want a lasting change. So the patient really needs to understand them and buy into it. And once we get that behavior change in our specialty, and in general practice, everything else clicks, everything else works, the simple stuff works, the complicated stuff works. But the behavior change takes place first, and that’s one of the things I really like, I like those. I like those even those difficult patients, particularly patients who think they know it all and they just want me to roll my sleeves up and get stuck in. I love the challenge of the communication of making them understand, I really enjoy it really enjoy. [Jaz] Dhru says, Dhru Shah says that his role, he’s seeing more and more as a Mr. motivator type of role, more than anything, more than anything behind what you got taught at perio, It’s a Mr. motivator. Also, you’re totally right about communication. And that’s why communications is a big topic. I’m so excited to delve deeper into this topic. So let’s go for it. [Ian] Yeah, Let’s do it. [Jaz] People need to hear, dentist need to hear the following. Right? I saw it must have been about couple of years ago now my first experience and a lot of people have talked about before but you the way you explain perio to patients, Ian is something that every single dentist in the world right now every single dentist, every single hygienists, every single therapist, everyone needs to hear this explanation. And eventually, all our patients need to hear this, because I’ve tried it various ways when you cover this, well, you explain perio in various different ways. I just thought your way of doing it. Something that you’ve inherited or something that you’ve modified over time was just brilliant. Would you mind sharing that way? I think you’re familiar with what I’m talking about, right? [Ian] Yeah, it’s a fairly big part of my day, and it’s fairly repetitive. [Jaz] Your nurses must roll their eyes every time. [Ian] She know. I feel sorry for the poor girl. She’s just sits behind me rolling her eyes. She could deliver this speech herself all the time. [Jaz] Please, I really want to, I want to hear this. [Ian] Okay, well, the first bits a bit of a chat. And then there’s a picture that I draw on them. I’m going to try and draw that picture on the screen. And I remember watching your canine risers bit. I’m watching your drawings, I’m hoping my drawings are a bit better than yours, Jaz. [Jaz] It’s very difficult. [Ian] So we tend to these, we sit the patient back, we do the examination, we sit them back up. And we start the conversation along the lines of ‘Mrs. Jones. I’ve just looked in your mouth, and I can see that you have some gum disease. Do you know anything about gum disease? And we always ask the question because we want to engage, we want the patient, the communication has to be a two way street. It shouldn’t be a monologue, it should be a discussion. The beauty of asking that question is also that you get to understand their misconceptions, anything they don’t get, or they’ve got wrong or you know, the classic Well, I lost the tooth for every baby I had or you know, just that the classic old wives tale. ‘So, Mrs. Jones, I’ve looked in your mouth, I can see you’ve got some gum disease. Do you know anything about gum disease? Once they’ve had the chance to speak? I say well, that’s not quite right Mrs. Jones. Gum Disease is a disease of inflammation, your body produces inflammation and that inflammation damages the bone that holds your teeth in place. Do you know anyone with arthritis, Mrs. Jones?’ And often they’ll know somebody who’s got arthritis. I said, Well, well that patient they have inflammation that damages the joints and the bones in the joints. You have a similar disease where your body produces inflammation, that inflammation damages your bone. Mrs. Jones the one thing we know about gum diseases that’s a bit different to arthritis is why gum disease starts Mrs. Jones gum disease is triggered by bacteria. Bacteria builds upon teeth, it triggers inflammation, and that inflammation damages your bone. So this this is the bit where you explain to a patient that they’re rubbish at brushing their teeth, but you do it in a way that you don’t offend them because that’s that was the thing I find most difficult. Mrs. Jones, bacteria builds up on teeth, it reaches your trigger points. Your body triggers inflammation, that inflammation damages the bone. Mrs. Jones, it sounds a little bit like we’re criticizing your cleaning. I’ve looked in your mouth Mrs. Jones and your cleaning would be about a seven out of ten. And if everybody walked around with seven out of ten cleaning, I’d be out of a job. Mrs. Jones. [Jaz] Brilliant. I love where this is going because that little bit is so good because it tells them that No, they’re not likely 2 out of 10. Sevens. Okay, that’s not bad. I’m doing okay. But it puts you’re about to put in perspective that they are different, right? There’s something unique about them. [Ian] Absolutely so yeah, I mean, it’s the, I think Professor Youngson at Liverpool used to call it the poo sandwich, you’re delivering some horrible information wrapped up into nice big bits of warburtons bread. So Mrs. Jones, I’ve looked in your mouth and your cleanings about a seven out of 10. And if everybody cleaned that seven out of 10, I’d be out of a job. Mrs. Jones, unfortunately, your seven out of 10 cleaning is not enough. Because your trigger point is much more sensitive than most people. Mrs. Jones, is it okay if we spend a little bit of time looking at your cleaning, and seeing if we can get you from a seven out of 10 to a 10 out of 10. So that we can get you the right side of this trigger points. And we can switch off this inflammation. And so that’s essentially the opening spiel that develops the concept of bacteria triggers inflammation, inflammation damages bone. And off the back of that we’ve also explained to them that, that this is concept of one size doesn’t fit all because you’ll know yourself, Jaz, you must have seen patients with very clean mouths and very aggressive periodontitis. And then you see patients with filthy mouth and no real disease mild gingivitis. So we know, as professionals, we have this spectrum, we’ve got to get that across to the patients that there are a spectrum, the more sensitive ends and whilst it might be. I mean, you could tell Mrs.Jones a 7 out of 10, you could be thinking 3 but you don’t tell a 3 you tell a 7 you’re trying to meet, you’re trying to break down barriers, you’re trying not to offend.. [Jaz] This is why you’re genius, this is what we’re saying is absolute genius, because you’ve made it palatable for a patient and not to dishearten them because what people wanted to see what we want to us to do is like, Okay, this is, you know, really a bad scenario here. We got plaque here, plaque here, we need to, you know, use the cracked end of the toothbrush. Yeah, it’s something that’s really not motivating the patient anyway, but what you said is, okay, we’re seven. So that gives them a little bit of hope that okay, because they obviously have been giving some you know, they care enough to be there at your surgery right now. So you need to give them that validation. And that’s why so it’s amazing this way of explaining because it essentially teaches them the concept of perio disease, via inflammation in such a way that it’s just absolutely beautiful and engaging way. So that is phenomenal. I’m so glad that you share that. Any challenges. Have you ever had anyone who’s, what do you do with that patient that that bloke in there, you know, bloke or the arms folded, who’s just not engaging? But what if when you say, when you ask that question, Do you know anything about Perio? And they say no. And then they say one word answers? How do you manage that? More complex patient? How do you get how do you draw blood from a stone? [Ian] Blood from a gum? I think that the next Well, probably before our conversations happen. The first question that I think most dentists will ask is, why are you here? What brings you to us? What is, I always ask what is it you want from your teeth in the next in the next 5 to 10 years? Because I need a buyer, I need a motivational tool or an emotional buying effectively is what I’m after somebody that I can go back to and use against them. So I need to know, they want to avoid dentures, they want to get rid of the halitosis, they want veneers for their son’s wedding, they want to start their orthodontics. I want to know what their motivator is. Because once I’ve got that motivator, everything can teach in them relates back to that motivation. And that there is behavioral science on this, there’s good evidence that shows that behavior change takes place more readily if the information delivered is perceived by the patient to be relevant to them and not just generic. So, you know, the minute I get the patients who said, Well, you know, I, my dad had dentures and I don’t want dentures. Well, that difficult patient you can say to them. You told me at the start of the appointment, Jaz, that you wanted to avoid dentures. But the things that we’re going through now are about avoiding bone loss, avoiding tooth loss and avoiding that transition to denture wear so we need you to understand the following before we can get on with any treatments. And so I think the challenge is always finding the time. And I’ll be honest, if the people always think from a periodontist point of view, that we have this sort of elite group of patients who you know, do everything we say. They do, and they don’t and I also spent many years working in the hospital service where we provide a treatment for free. So it wasn’t just high value treatment. And you do get patients who just don’t care about their teeth. Some people are waiting for the day that they moved to dentures because that was the best day of their parents lives. Everything was great after their dentures and with those patients. You might find that they’re unmotivated? Well, I think you’ve got to find their emotional want, and relate everything back to that, because then they’ll perceive it being relevant to them. [Jaz] Protruserati, I just want to highlight that what Ian saying here is not just relevant to perio. This is Dentistry 101. This is something that I wish we were really emphasize more as an undergrad, because it really really is such a big deal on every communication course I’ve ever been on. But that is the takeaway message that you have to relate everything back to the goals of the patient. And if there’s one thing I learned during dental public health, believe it or not, the only one thing I learned was that when you give someone knowledge, we used to think it changes their attitude, which impacts their behavior, but we know that that’s a false model, and it doesn’t work and just arming someone with knowledge is not effective enough. And that’s what you know, in Perio, if you just tell someone about gum disease is not enough, you need to then just like Ian said, we need to relate it back to their own individual goals. So whether you’re planning for perio stabilization, or teeth straightening or veneers or whatever you need to really, really, really make it tangible for the patient with relevance to their goal. And you will see a massive uptake on the treatment that they should be getting done. A massive change in their sort of general attitude and the towards dentistry. And I think what you’ve highlighted there, I just to highlight myself, it is the very crux of communication dentistry. So that is brilliant. Next question I have Ian is referrals, you get referrals, you are in a referral space practice. And I thought this question whereby perio is one of those things whereby you might find that you you get an out and there’s me just postulating because I’m thinking about them when I used to refer a staff and as a dental student, and all these sort of what were the challenges my colleagues face is that you might be getting some patients. And you might think, hang on a minute, all you’ve done is the basic oral hygiene, non surgical drive, and you’ve got the patient a good result. And you think, why couldn’t the GDP do this? Now, obviously, in the environments different like when you’re going to when you get referred to someone, and the patient is coming, or when a patient come to me for a splint must be referred by local GDP. They’re already bought in a little bit. And they already think that this guy’s awesome, because he’s an easy solution. So there is a bit of a change, right? When someone refers someone on, they always think that Okay, so I think people when they come to a specialist, the take up, the buying is going to be more just because that factor. But do you think a lot of your, what percentage of your referrals you think could have been managed in GDP? And where do you think it went wrong in communication? If that’s a fair question that led to them being at your chair rather than being treated at that practice? [Ian] Okay. Yeah. Great question. I remember reading that when you sent it through difficult question. [Jaz] It is sorry. [Ian] If we take away the mucogingival work and the crown lengthening and that type of work that we do. If we just sum up disease management? I would say it’s probably as high as 70 to 80%. Could it be managed in general practice? In the right practice with the right clinicians? And I know, you mentioned the dentist there. But we’ve got to remember our hygienists colleagues and therapists colleagues, did a wonderful job. You know, I have some brilliant referrerals, hygienists and therapists who send these patients to me, with nowhere else to go other than surgical intervention. It’s not that they’ve under treated the patients, it’s, they’ve reached the end of the road. So we, I think, probably Yeah, probably 70%, at least could be could be managed in general practice, because I would say that 70 to 80% of our patients are managed nonsurgically on referral. So you maybe just maybe we can do treatment better than some people, you know, it would be wrong, you know, anything you do all day, every day, you get good that, don’t you? That’s so there are some times when just that little bit of extra skill or knowledge or something makes difference, or the patient Penny dropping communication, but I think there’s no two ways about it. And we don’t want to be too political here. But the system in the UK has devalued Perio. And I don’t just mean I mean, the NHS has devalued it, they’ve never understood it, they’ve never paid for it effectively. And the time allocated to perio is just insufficient. That you know, the communication alone takes me 20 minutes half an hour, that’s before we even treated the patient you’re not going to do that for three days. But even when you take that across the private practice, because of you know, if you spent a decade in NHS practice, you will have the skill both in the perio communication and in your perio treatment skills. And you know, even patients going to a private practice we see them sometimes on the treated on demotivated, and I think it’s the hangover of that NHS mentality, which is desperately sad because it’s the number one reason for tooth loss in the UK in the half of population. It’s essentially a preventable disease. And with the exception of the really lack field, the old fashioned aggressive periodontitis patients, you know, most of the stuff is, like we said at the start of this, the basics been done well, and when when you get the patient’s doing their bit, and when we do our bit to a reasonable standard, most patients would get better. [Jaz] I was Yeah, I was thinking that you would say this, you know, because it’s something that I thought that a lot of our patients just need the basics done well, and it starts with the communication. But I think now that everyone’s listened to the way that you communicate, if like you said, it takes you 20 minutes to really make that connection to figure out what is that patient’s prime motivator, the prime goal, and to be able to listen to them, when you ask them that question, What do you know about perio, and to give a tailored response, and I should go walk through that process, make your diagram. I think if you are in a practice, where you’re not getting enough time, that I still think you can take something away from this podcast episode, and apply it. Just tweak your communication. And I think that itself will get you great results. And if you are, you know, amazing that you mentioned about the hangover from Manchester, if you’re in private practice, and and you feel as though you’re feeling not so confident in your perio skills, and now is a time to upskill through education, through courses, which actually reminds me, Ian, when you started to get into perio as a GDP, and you starting to get into Perio. Here’s an interesting thought I’ve just had, back in, you know, the early 2000s, maybe when you were starting to do these perio type procedures, through mentorship and trying to sort of get out of your comfort zone with procedures and whatnot. Do you feel as though that perhaps in today’s climate, to be able to do these sorts of procedures, I know you teach GDP crown lengthenings, you taught me crown lengthening and stuff. And still I’m happy to give it a go. But it takes me like in a micro steps, baby steps. Whereas perhaps in you know, when you were a young dentist, you were able to maybe go take leaps out of your comfort zone rather than micro stpes because now we’re perhaps practicing in a defensive way. And that might then hamper your development or development of interest in to perio. Because then really, then the only people going to perio is when they go into whole-hog, the specialist pathway. Maybe we’re seeing a dying breed in the special interest in Perio because you’re not able to go out your comfort zone. Does that make sense? The question? [Ian] No, it really does. It really does. So basically, what you talk about is the old days you’re telling me that I’m old? That’s what your saying, Jaz? [Jaz] NO. [Ian] I’ll tell you that. He’s talking about communication guys. That’s a masterclass in, not offending the patient? No, no, it’s I think it’s very valid. I think I definitely see young graduates terrified of litigation. And it does, it paralyzes them in terms of moving on and progressing. And I think it is a more difficult time. And I think we do have to be very confident when we move outside of our comfort zones that we’ve got both the knowledge and some basic skills, there are never going to be enough periodontists. So we do need special interest GDPs in perio. And there are lots of courses out there that develop that now. And I think what people need to do is probably take a leap out the Implant World Book because look at the implant world, those guys. They go from nothing to big surgical stuff, drilling holes in people’s bone. And what do they do? They invest time, they invest in not just courses, but they invest in mentoring. Mentoring is just a standard across implant dentistry. Well, you know, why do we not have that in perio, or in occlusion or in restorative. Go on a course, develop your skills. And when you’ve got your first couple of cases, I mean, I offer this to all of my delegates, they can bring a patient to me and we’ll do the case, the first case together and we can work on the fees and everything else, but at the same time, they can bring that patient to our clinic and we’ll do the first surgical case together or the second or the third. Because sometimes you just need somebody there even though you know it inside out to just hold your hand on the first time you do something. I have the luxury of having that experience within the hospital setting. I was lucky to be taken under the wing of a lady called Eileen Thiele, many of many old Liverpool grads will know Eileen and I just spent a day a week doing perio surgery onto her provision for about three years. It was just amazing. And my surgical confidence grew. I mean one week she’d nurse for me, the week one when I’d guide nurse for her and watch her. The week after I’d be doing the same procedure. She’d be nursing the week after I’d be on the clinic doing that procedure. She’d be in the room next door and it was just that, it was a steep steep learning curve. But I think mentorship is probably the way to go because the implant guys have got that nailed on and we probably need it across the board in dentistry now. [Jaz] I really like that parallel you drew with with implants and their pathways and I think if you are a young dentist who’s trying to find? Okay, what is it that they want a niche into? And if perio is looking exciting to you, then yes, find a mentor. And yeah, upskill, go on those courses. And yeah, you’re totally right. Look at what they’re doing in the implant world and see how we can model it in endo, model it in perio, modeling all these disciplines as a modern contemporary way in this scenario we’re in, to be able to progress and get out of your comfort zone and try and take those leaps again, rather than just restricting yourself to little micro steps and really suffocating your growth in a way. So I really like that a lot. [Ian] It’s sacrifice though, Jaz, isn’t? That it’s the thing that I see with some dentists is they don’t want to sacrifice time or income or profit. And, you know, the, we have some great young clinicians who come and spend the day with us and just just to watch what we get up to. And you know, that they’re giving up a day salary or a day’s holiday. And in five or 10 years, I know who the superstars are the next five years or 10 years are going to be because they come and spend the day with the people in our team in five or 10 years time they’re friends, they’re dental school mates to be saying to them, oh, it’s all right for you, you’re dead lucky look at where you are today. And it won’t be luck, it won’t be luck at all. It will have been, it will have been planned, it will have been time, it will have been sacrifice. You’ve done it. I’ve done it. You know anyone who’s anywhere has made that sacrifice. You can’t well, can’t say enough, it doesn’t happen overnight, there’s very little luck in life, most of this stuff is planned. [Jaz] That is absolutely brilliant. I think that’s gonna be a gem I’m gonna play in the beginning because you’re so right sacrifice is something that, it’s so true, I just can’t say any more than that is is so true that you have to put yourself in these scenarios where you’re not earning for a while and you’re making these big financial decisions, because you’re investing in yourself. And even just time away from the clinic or, or taking that leap of faith that okay, this is what I need for the next step. That is amazing. I’m not talking about the next thing is just being mindful of time. Because while we can talk for forever, you might have to do a two part here. We touched on this with Amit a little bit on the recession episode, but I sort of hear your take on it cuz you know, you’re so great in the way that you communicate, the inflammation process to a patient, how do you, Ian, communicate to the patient that there are some risks involved inherently in Perio treatment, when in terms of blank triangles, recession, sensitivity, to make the patient truly understand the importance of it and what they’re getting self themselves into, and why the juice is worth the squeeze? [Ian] Yeah, it’s probably the most difficult sell, isn’t it, because most of the time, I am making the patient’s look worse, but also at the same time making them healthier. This is where I tend to do two things, I draw a picture and I have a bank of photographs that I use for patients. So I can, if patients say what’s gonna look like? I can draw a picture, but I can also open my laptop and show them. Because I mean, I know you’re big into photography, a picture tells 1000 words and so if you can show them, if you’ve got a mild perio case in front of you, you can show them mild black triangles. If you’ve got an advanced perio case, you can show them a picture of an advanced disease management case with lots of recession. The most powerful thing I do when it also fits in with the medical legal aspect is a draw a picture. So I’ll try and draw it now I don’t know how well this is gonna work, but we’ll see. So and I’m going to draw it back to front so I say I say to patients, teeth have (it upside down as well, by the way) teeth have roots in the crown. I say your gum should be up here. And when the gum gets a tooth, it’s supposed to do this. It’s supposed to form a little seal on the roof. And that little space Mrs. Jones, we call those pockets, underneath the gum when it’s healthy this should be bone and the tooth on the bone, never touch. There’s a little ligament, the whole tooth against that I’m thinking of like a shock absorber. Mrs. Jones, I’ve just looked at your x rays, and I can see that you’ve got some bone loss. Mrs. Jones, sometimes the gum shrinks and follows the bone. I’ve looked in your mouth and you’ve got a little bit of shrinkage. But you’ve also got these bigger, deeper pockets. Can you see a problem with these bigger deeper pockets, Mrs. Jones, and you’re hoping that she says ‘How am I going to keep those clean?’ And she doesn’t say.. [Jaz] The penny drop moment. [Ian] Yeah, no, I would say that is the, this is the biggest Penny drop moment patients will say to me, ‘Ah, that’s a pocket’ and they’ve been under someone’s care for a decade and never actually understood what a deep pocket meant. And so we explain to patients that they’re going to clean up here like an Olympic gold medal winning toothbrusher. And once they do that we’re going to clean the space. Now this is the bit that answers your question. I say Mrs. Jones when you’re doing your bit and we then do our bit and we clean the pockets, we’re going to switch off the inflammation. Can you think of anything? Mrs. Jones that’s inflamed like a spot or a bruise? What happens when you switch off the inflammation? And they say, well, it shrinks. So yeah, it does, it shrinks. Mrs. Jones, the good news is the gums are going to shrink that way, they’re going to shrink and form a seal on the root of the tooth. The bad news, Mrs. Jones is the gums goes are going to shrink that way, the gum is going to be a little bit lower, there’s going to be a bit more of the tooth exposed, but your pockets are going to be smaller. If your pockets are smaller Mrs. Jones we can keep on top of it, the trigger, and we can keep that inflammation away. Now if they then say, I don’t want my gums to shrink, there’s a really old everybody’s heard it really cheesy line that we all use. And we say Mrs. Jones, it’s better to have a longer tooth and the tooth no longer. And I know that’s cheesy, but it.. [Jaz] I love it. [Ian] The research tells us that 70% of pocket healing is recession. So we know we’re going to get recession when we treat perio. And they either, you know if they want to save their teeth, they’re gonna have recession. And they’re not a choice where we’ll have one or the other or. Success will mean recession, because that is just the nature of the beast, the thinner the biotype, the bigger the recession. But about 70% in pockets over six millimeters is going to be shrinkage. If they want to sit on them, we then, the first thing they’re terrified of, as you you will well know is the aesthetics of that. So we tell them, Look, we’ve got to get things stable. Once they’re stable, and we can establish how much recession is happened. We can then look at managing the aesthetics, we can. But the line I use I say, Mrs. Jones, you’re worrying about the decorating when I’m worrying about the subsidence. You’re redecorating, or you’re thinking about what curtains you’re going to put up or what wallpaper you’re going to use. But you’re footings are insecure and the house is going to fall down. Let’s get everything secure and stable. [Jaz] Genius analogy. Ian that is a genius analogy. I’m so glad you said that. Everyone pinch that. Everyone’s writing that down. [Ian] Because then I mean, you know we’ve got things like you know, we can do black triangle closure with direct composite bonding. In advanced cases, we’ve got really fabulous gingival veneers that we can use. There’s lots of ways, even Perio or ortho these days, you know, some of the stuff that I’m doing, some of my specialist, ortho colleagues, he’d be surprised that how adventurous we are with some of these ortho advanced perio cases with the ortho we do. There’s a lot we can do to make these patients look better. But we can only do it when we’ve got stable basis. And so they’ve got it, they’ve got to buy into that. And if they didn’t want it. Yeah, their alternative will be things like dentures, extractions, and all on fours, you know, but then we have to educate our perio patients that implants have an increased failure rate in because of the history of perio. So implants are not always the answer to the question. [Jaz] Ian you’ve covered that absolutely, brilliantly. I won’t have time for my new classifications and perio case because you’ve just covered. So honestly, we covered it so well. I mean, I think this is the, this is what I wanted in the back to basics month in August, I think there’s going to come away and people may feel refreshed and recharged and be able to be excited to implement some of these new communication skills in our daily practice cuz I think this is one of those episodes we record now that people can use on Monday morning straight away. Ian, I want people to be able to know about the wonderful work in education that you do. Please tell us about where they can go to learn more about you know, being able to shadow you, being able to go on your crown lengthening courses, being able to learn from you as a mentor in Perio. [Ian] That’s very kind, Jaz. My teaching brand is perio courses. So the website is www.periocourses.co.uk. And all of our teaching is on there. And we are available all over the country. We do everything from one day courses through to a four day masterclass that includes surgical training. My practice, I’m an associate, I’m based in Liverpool and in Wilmslow to Super practice run by great, great people. And yeah, we have people come to spend the time with us just to see what we get up to and see if they, you know, we get a lot of young dentists who are thinking, you know, do I want to specialize in perio? Is it for me? And even just to hear the communication that we do with patients, we have a lot of people come spend time with us. So yeah, just get in touch through the website. Have a look at the courses. We do a lot about communication on the courses we really delve into that a bit more because it is a big part of the psychology we get we delve into a bit more of that. But yeah, it would be great to see some of your occlusion geeks on some of these perio courses. [Jaz] I’m sure they’d love every moment of this and i thought i think you know this is the way forward if you’re someone who’s thinking about an interesting Perio. People like Ian are just amazing. I’m so excited to meet you again at two bills in Brighton. Catch up in a drink with you may. So thank you so much for coming on today and you’re absolutely amazing. I can’t wait to get this out in a week or so. And I’ll look forward to catching you in Brighton. [Ian] Yeah, thanks, Jaz. Keep up the good work. And if anyone we go for tubules get joined up. It’s the, it was the best two days of 2019 when I went It was just an amazing two days. So get signed up. [Jaz] I’ll put the link on the website you guys if you haven’t like I said you haven’t been to a tubules Congress before it is not a normal conferences. The vibe is just amazing. So I’ll make sure I put that link protrusive.co.uk under the episode. Ian, have a lovely day today. And thanks so much coming on. [Ian] Take care, Jaz. Have a good day. Jaz’s Outro: There we have it guys. I told you his way of explaining periodontal disease to patients is just amazing. And I hope you listen to the relevant chapters. Again, if you if you head to YouTube, if you’re watching on YouTube. Now there’s a highlighted bit we can watch that exact moment where Ian explains the way that he speaks to, I think it was Mrs. Jones and Mrs. Smith. I forget who it was now, but it’s just beautiful. It’s just beautiful in every way. And I think it’s going to really make a big difference to your periodontal outcomes. Hope you’re enjoying this back to basics series. Do join us on our Facebook community, the Protrusive Dental community, I’ll put the link below and of course hit subscribe if you haven’t already and I’ll catch you in the next episode.