Protrusive Dental Podcast

Dr Zak Kara, an oral surgeon, helps dentists regain confidence in extractions by discussing the importance of sectioning and elevating teeth. They also cover topics such as reassessing difficult extractions, effective communication with patients, overcoming equipment limitations, and tips for successful tooth sectioning.

Do your ID blocks work all the time? How about your management of the dreaded ‘hot pulp’? As a part of the Back to Basic series this August, I asked Dr Pynadath George, who practices advanced surgical and implant dentistry, about dental hacks for success with every dimension of local anaesthesia in Dentistry. https://youtu.be/F6l9glsEbuc  Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Give painless local anaesthesia (aside from topical anaesthetic, we know that already!) by massaging the mucosa and the lip with your index finger and thumb. Get just a few drops of LA first and give it a minute to work. Then you can go back in and deliver your anaesthetic much faster and the patient will love you for painless anaesthesia! “If you want good success with the ID blocks, you need to look at and study the anatomy, even if it’s on a skull, and then relate that to your patient..” – Dr George In this episode we discussed about: Is Lidocaine/Articaine enough to numb patients as a GDP, or do we need to stock other anaesthetics such a Mepivicaine? (15:09) Avoidance of Articaine for ID block in some countries – if that really necessary? (18:35) Shift of mindset with young dentists practicing defensively (20:38) Tips on achieving successful ID blocks (27:04) Hitting bone during ID blocks – do you HAVE to hit bone? Can that be harmful? (33:38) How to manage the dreaded hot pulp! (36:39) Moderate and advanced local anaesthetic techniques in Dentistry (47:31) Tips on getting painless palatal injections (especially on ultra nervous patients) (51:05) Want to learn more? Check out this Advanced Implant Training by Dr George Pynadath I hope you are enjoying this Back to Basics series of episodes! If you liked this episode, you will also enjoy Basic Implant Occlusion and Work Life Balance – PDP012 with Implant Ninja! Click below for full episode transcript: Opening Snippet: As i gave the intra pulpal, I didn't realize the sound was being recorded but as i gave myself an intra pulpal, as i was reviewing back the videos all i could hear was myself grunting going 'ah because it was that painful I had to keep my mouth open while i'm numbing myself up through the pulp but honestly after that was done it was like magic i could you know i found all four canals, extirpate it, done... Jaz’ Introduction: Now to answer these questions I’ve got George. His first name is far too complex from around so we shall call him Dr George, who is a very well known name in the UK. He actually does lots of advanced surgical dentistry, pterygoid implants, zygomatic implants, full arches that kind of stuff. He also does some general dentistry as well but that’s his real niche that he’s known for and along with that he does teach on very advanced local anesthesia techniques like how to give extra oral blocks for example or how to give anesthesia in areas where you’re not really taught at dental school but we’re gonna really bring it back to basics in this episode to go through how to get success from the more basic techniques like what are the the factors involved in getting success in anesthesia and right at the end we even cover the top tips in getting painless anesthesia for palatal, those dreaded palatal injections.  Now it’s interesting when i was in Vietnam on my elective, I was with these dentists who are 25 years qualified and they were celebrating like having a reunion and we’re on this charity project in a village near Da Nang and it was a school. So were at the school. We were about to do restorations extractions and basically any sort of dentistry these children needed and there was a queue of children and before they’d have their treatment like for example a restoration or a tooth out, we would numb them up. I’ll never forget how these children were given id blocks so inferior alveolar nerve blocks before they had their restorations on their lower teeth for example right? But the interesting thing that the leader of the group he said that 50% of id blocks failed. That’s what he said “50% of ID blocks fail so let’s give these kids two id blocks each before they have dental treatment just in case they had this language barrier and they were actually having pain and they weren’t just expressing themselves so just to avoid that possibility of a child feeling pain” They gave two id blocks that always stuck with me i know 50% is quite a strong number and maybe it’s hopefully it’s not very true. I’m hoping that our ID blocks are more successful than 50% time but it’s an international issue that we all face on a daily basis.  So the Protrusive Dental Pearl I have for this episode is a local anesthesia one and it’s very simple. If you want to give painless anesthesia, give the topical anesthetic enough time we know that already but the other thing is that when you start giving your infiltration for example you want to first very slowly just give a few drops, just a few drops and you will get these drops ever so slowly and you want to distract the patient the way i do this is by massaging the mucosa massaging the lip with my between my finger and my thumb as I’m doing it. So they’re really feeling this massaging rather than concentrating on the anaesthetic. So give very very slowly just a few drops and you come out give those few drops a minute to work and then you can go back in and deliver your anesthetic much faster and you can actually see the ballooning or swelling of the mucosa which you usually do that’s fine but it the whole point is that if you give the first few drops pain-free very slowly after topical anesthetic the patient i trust you has already had a painless experience and then the second or the main dose of anesthetic you can give much faster without hurting the patient. So hope you enjoy this episode back to basics with George on local anesthesia techniques I’ll catch you in the outro.  Main Interview: [Jaz] All right we’re going to call you Dr George because as you said in the before part when we’re offline and people struggle but just for the flavor do tell us your full name. how your mother tongue was supposed to pronounce it.  [George] So it’s Pynadath. I’ve heard all kinds but it’s Pynadath and that’s why everyone calls me George because people forget how to pronounce that and it makes me cringe every time i hear it pronounced incorrectly.  [Jaz] We will definitely stick to George. Welcome to the Protrusive dental podcast, my friend. How are you?  [George] I’m good thanks. I’m very good thanks Jaz, i’ve not seen you in some time it’s been a long time since i i think we last saw each other and when i last saw Simran as well. [Jaz] So your course you know you used to teach my wife, yes you used to teach my wife she was an undergrad at Liverpool and she spoke very highly of you so that’s when you first came my radar maybe 10 years ago now and i remember you are as a dentist back in the day when i was a student i was going like on online on dentinal tubules and stuff and reading the thing that struck me most about you was that you’re a dentist who wasn’t afraid to speak your mind and i liked that and i hope it was a i wouldn’t say controversial but i enjoyed the fact that you were you’re calling a spade a spade so i think this this will make a very interesting episode. Actually I’m actually quite excited to cover the topics we’re going to cover today now with you coming on we could have spoken about so much because obviously I’ll let you do a formal introduction about the kind of things you do but in my eyes like you’re the Pterygoid man you know anytime that you know anyone needs any fancy kind of implants no one else can sort it out, they’re going to send it to you as the implant guy to have some sort of fixed solution. So that’s in my mind that’s who you are but please tell us about the kind of things that you do, where you’re based? So that those who haven’t heard of you can learn more about you.  [George] I don’t know where to start actually Jaz, i think most people i think you’re right i think most people know me as a person who does implants and sometimes people know me as a person who tends to just do complex implants, so Pterygoids as you said I obviously do zygomatics, trans-sinus nasal lift as well as complex bone grafting so maybe not small grafts I’m kind of more associated to more complex work or it may not even be the work it may be a medically compromised patient. I’ll get referrals for that but I’m not sure if people are aware that I also do restorative dentistry so my background is restorative dentistry and I still like doing removable dentures, complete removable dentures I still like doing implant over dentures I think there’s a little bit of a bias to what you see on facebook and people know me for very set procedures but actually i do the full range and i still do the odd fixed conventional prosthetics so think fixed bridge work. I still do the other Endo single canal endo that is. I don’t touch multi-root. There are other people much better than me doing that i teach surgical Endo. What else, so I’ve got a bit of a range i think the only thing i don’t do is ortho grade multi-root canal endo i think that’s the only thing i don’t do but otherwise i do a fair range of oral surgery implants and restorative dentistry.  [Jaz] I did appreciate that i did think like a lot of people would think that you just limited to one aspect but it’s great they do a bit of everything so i suppose it gives you a foundation that you’ve built on over the years.  So what i want to know is what got you into the kind of advanced things that you do now? Who are your mentors? Who are the people that inspired you to do the kind of crazy complex surgical kind of stuff that you’re into now?  [George] Oh god you know what i probably fell into it by accident i went i started doing implants pretty early on after VT to be honest it was probably not a good idea to do that and then i ended up doing more of a formal course in Birmingham with Tatum. Hilt Tatum and i went down that pathway and on the course it was very much Eastman lecturers on the course. So there was Ben Aghabeigi who was a Eastman oral surgery consultant but on that course we also had someone called Richard Tucker who was a periodontist and he headed up i think at the time he headed up the the perio employing dents at The Eastman i don’t think he’s there anymore and when i spoke to him about more perio surgery and more refining restorative work. He suggested i come down and do the msc restorative dentistry, the MSc restorative dentistry at the Eastman. So i went down that pathway because i looked up to these guys but before that i also spoke to Callum Youngson. I’m sure you know who Callum Youngson is. He was still dean when Simran was a student in Liverpool.  [Jaz] Really charismatic chap like the way the story of Sim would tell me about him he just seemed like the coolest guy on earth.  [George] Yeah and you know i would echo that he is an unbelievable man he did a hell of a lot for the university i still look up to him he was one of the big inspirations to me as well as Ben as well as Hilt Tatum. There are a few other guys who have also mentored me as well there’s a guy called Vijay who’s also meliali like me who originally started off EVO dental.So i started Evo dental I think 2012/’13 and we started working together obviously i was already doing implants at that point but there’s been a number of people who have inspired me also people who have inspired me from a distance so not necessarily people who I’ve met but i used to speak to the late Jamal Tanna who was a quite well-known implant dentist over in Romania. He’s passed away due to covid quite sadly but yeah there’s quite a few people who have inspired me but then also non-dentists and my dad. I always looked up to my dad he was a was or is an oncoplastic breast surgeon so his background was general surgery then went into breast cancer large reconstruction and then when it kind of the role changed and this title became oncoplastic breast surgeon but he showed me a lot, taught me a lot about suturing, surgical skills, assessment of patients. So i think that’s everyone really isn’t it?  [Jaz] I mean that makes a lot of sense to me i mean that makes a lot of sense to me George because i often think how does one without following a maxfacts pathway get to raise these big flaps or or get to you know how many dentists will get to see a pterygoid in their lifetime right and then doing you’re in those areas of anatomy all the time so i was thinking where was your surgical real inspiration sounds like your father being a surgeon himself was a big role in that.  [George] Yeah absolutely i mean not just from a surgical point of view but also from the point of view you know i wasn’t born in the UK, i was born in India i went back to India for schooling i came back i think when i was 10 and when we came over in the 80s it was quite it wasn’t as you know as it was now there weren’t that many of us in certain areas of the UK, my dad didn’t know how to speak english so he came over as a medical doctor, had to pass the PLAB while not knowing english so he had to learn english at the same time. I think he failed the first PLAB exam then learn english a bit more fluently then sat it the second time round, passed the exam and then he early came to the UK so he could sit his FRCS, his fellowship in the royal college of surgeons, he did that and then he wanted to stay on really for both my brother and I are our kind of education, he felt at the time good education from the UK would be better than in India so he ended up staying here and i think it then came to a point where he realized he couldn’t go back to India, he had stayed out of the country even though we were going every year to see family he stayed up the country a little bit too much and adapted to his surroundings and i you know even when my parents go back now for long extended visits for maybe two three months at the end of the two months they’ve had enough they can’t cope with the heat, with the mosquitoes, with the service you know Kerala is a very very laid back state in India, it’s not you know it’s not a busy hustle bustle type of place and my mum when she wants things done, she wants it done. Yesterday and she can’t cope with the way the Indians do stuff.  [Jaz] Amazing. I’d love to go Kerala one day is the place in India i want to go to. I’ve been to Delhi as you know my wife is from Delhi and i hate the place i’m sorry to offend anyone but i hate going to Delhi i like Mumbai but Kerala is definitely on the map for me. What a beautiful country i will be for state even i’d love to go Karela one day. Interesting you mentioned about your father not speaking uor not knowing english like my father when we came in the 90s from Afghanistan, my father he still doesn’t read the right english actually he’s just about to get away because he owns a corner shop you see so it’s interesting the sacrifices are our parents make you know to the next generation which is it really touched me actually.  So amazing well let’s head to the main part of this episode which is the back to basic series we’re doing and it’s about local anaesthetic because as I was saying that because with you George we could have spoken about Pterygoids, we could have spoken about all sorts of advanced things you do but I really do think as a first episode if you just get some foundations some most common things that or the most foundation thing that we need to be able to be good at as a dentist is painless dentistry and that’s where local anaesthetic comes in but it’s a daily struggle like we know lots of situations where we haven’t been able to successfully numb a patient. It happens to me not too often nowadays but still it does catch me up now and again like it does all good dentists. So let’s start with a very basic question, in my armamentarium I pretty much use two or three things it’ll be articaine, 90% of the time. It’ll be lidocaine when I’m doing an ID block and even then I’m doing less and less of those and then sometimes when someone says that they can have adrenaline, I’ll have a adrenaline b or alternative. So that’s it now this is I believe and correct me if I’m wrong George but i believe that this is the state of GDP’s generally. Are we missing a trick or do we is that all we genuinely need to get 100% success in anesthesia? [George] It’s a really difficult question isn’t it? I wouldn’t say it’s the only thing you need but I would say 99.9999% that’s the only only stuff you need you don’t need anything more and it’s the 99.9999 percent of material I use as well articaine Lignocaine I of course have Citanest and you know all the other types of local with adrenaline free but i hardly use it and often it’s a case of educating the patient you know I do big procedures really big procedures and patients coming in saying they can’t have adrenaline in their local anesthetic it’s really going to compromise like massively it will compromise the work that i can perform and do and a it’s a case of re-educating the patient and explaining you’re not allergic to adrenaline, you’ve got adrenaline in the body you can’t be allergic to it, you may be sensitive to it but often that maybe the previous dentist who may have given an injection or infiltration or a block and they put some of that local into avascular you know region and they felt the palpitation mixed with anxiety, it may have set off a bad reaction. It’s very rare to have a patient who is truly allergic to anesthetics of course there are patients who are allergic to anesthetics often that may be the ingredients, the other ingredients, the preservatives within the anesthetic it’s not really going to be the adrenaline and if those patients are truly allergic you would know even before you see them because they’d know the full history and they would have got tested in hospital and all kinds because they would struggle with routine dentistry let alone some of the more advanced or complex stuff that you may have to do like extractions or root canals and things like that.  So yeah generally I use Articaine and Lignocaine now if you imagine the stuff that we do we generally do full mouth stuff. We’re going into a much bigger type of surgery than your average general dentistry that you would expect in primary care and all we use is Lignocaine and articaine. I do use the odd time Bupivacaine and that’s more of a longer lasting type of anesthetic it can last for four to eight hours so really quite long. The onset takes a long time as well but most people who use bupivacaine use it as a pain relief. So maybe after removal of all four wisdom teeth or we’ve done zygomatic implants and we’re putting it as a post-op pain relief so the patients have a certain level of pain relief for when they get home and for a long period after that so yeah other than that, other than removal of all four wisdom teeth or a very deeply impacted wisdom tooth or maybe zygomatics, the odd time I don’t use Bupivacaine so it’s just articaine and Lignocaine.  [Jaz] Good because i really didn’t know what you would say to this you know maybe you’d give like a recipe of 7 different 8 things that you you’d be using but I’m actually pleased to hear that you’re achieving great results with the stuff that we all have in our drawers so that’s amazing. Now this question I didn’t actually tell you in advance but just came to my mind the whole thing about avoiding articaine for id blocks. Now some countries that’s not a thing, in this country it seems to be a thing George, is it a thing?  [George] To be honest i don’t think so but and although i don’t disagree with using articaine in for blocks and it doesn’t have to be id blocks it could be blocks in other parts of the mouth. I don’t believe articaine is an issue I think the issue is normally down to trauma of the nerve because you see the same kind of complications with lignocaine or it could be certain preservatives.  Now some countries who also have articaine like Germany or other parts of Europe. There articaine makeup as in the other ingredients or preservatives are slightly different but in reality I think the the real issue and the issue we’re talking about is more nerve damage or nerve related issues especially associated with id blocks I don’t think that’s due to articaine i think that’s due to trauma and the technique and so on however in saying that i still use lignocaine for my id blocks and the only reason to use lignocaine is because i know if anything goes wrong in the case and it goes in front of a medical or a dental expert. I’m sure there will be one dental expert witness out there who will on the side of prosecution put that forward as a problem but no other reason so it’s purely down to medical legal reasons.  [Jaz] It’s true and actually I’d love for you to to share what you were telling me before we actually started recording about we were talking about the kind of things you do and you surprised me and said yeah it’s a little bit of General Dentistry as well and i thought you limited to the pterygoids and stuff and then you said I was talking about the fact that i now in a situation where i work in Reading I’m trying to consolidate everything here not having to commute so much and you said actually don’t have that luxury because you’re traveling around the country, mentoring people, implants and advanced techniques but we need that we know we still need that someone there to help us hold our hands when we’re doing these advanced techniques and then you said something really interesting about how there’s been a shift in the kinds of experience that young dentists are getting can you just elaborate on that i really enjoyed that.  [George] Yeah I think obviously i used to teach as an undergrad lecturer i don’t do that anymore i still teach as a postgrad lecturer so i will teach half a day at Liverpool uni teaching the post grad the specialist trainees with the undergrads and I’d also say the post grads the guy you know the guys and girls coming through they may not have experienced the same amount of clinical work and complications as we would have done 20 years ago or even 15 year or 10 years ago so that means you know the number of cases they do not just at university but also at VT and not just that VT but also at you know DCT one, two, three. I’m not sure if the newer generation are are seeing the same number of clinical cases as we would have on a day and even if they were to i see a lot of medics and dentists it’s not just limited to dentistry but medics and dentists are surgeons, medical surgeons and dental surgeons limiting the type of work they do because they’re practicing defensively which is a real shame so with the increase in medical legal or dental legal complaints and the lawyers out there, there’s a lot of us practicing defensively I mean a few minutes ago I just said I don’t use articaine for an ID block even though I believe it’s fine because of the medical legal consequences I mean it’s a real shame so we’re all practicing defensively however you know my generation 10 15 years ago we could practice and get mentored in complex work knowing that if there were any complications the patient would be often very reasonable except the risks of the surgery even you know because they were told in advance and knew that you know it’s failed and we can either try and fix it or you know that’s it and while these days it’s really quite difficult i mean we’ve got consent which you know even though we consent to patients for whatever in the world even the work that i do a lawyer will always be able to find a hole in that consent paperwork and you know there will be dental expert witnesses who will always be able to find a hole in our clinical notes, it’s really quite tough for the new generation and I really feel for them i don’t know what the solution is for them which is why I also try and mentor as much as possible because it’s quite difficult to learn advanced and complex work without some sort of mentoring pathway. [Jaz] I think that is a solution George i think it is finding it if you’re the young dentist who is feeling like you have a lack of clinical exposure or you are practicing defensively the only way out is through mentorship i think and i think it’s great that you do that and i think it’s great for the dentist to put their hands up and say yes i do need mentorship for this like we all know that comfort zones are a nice place to be but nothing ever grows in them so as even as a dentist i’m always looking at that next opportunity to go it’s just slightly now before maybe you make it but when you know in your colleagues that when you were learning you could have taken giant leaps out of your comfort zone i do feel now we’re taking baby steps but yeah but you know but it’s still good to take those baby steps out of your comfort zone.  Yesterday i did my first ever in practice by myself i did my first ever and the patient knew was my first time and we hadn’t you know had this conversation beforehand stuff palatal functional crown lengthening case. I raised a massive for me massive flap upper three to three okay and my mentor for that was Amit Patel who you know very well.  [George] Which Amit Patel because there’s a couple of Amit Patel.  [Jaz] The perio chip guy.  [George] The periodontist in Birmingham?  [Jaz] Yeah.  [George] It’s okay so he mentored you for that crown thing case, did he?  [Jaz] He did but the way we did it nowadays you know we we i sat down with the photos and he described the protocol to me he drew it for me, sending me a photo on whatsapp saying this is what i do then i sent him back to my thoughts let me exchange some voice messages and then he sent me some Youtube links to watch from the university of Michigan so it was a great like remote mentorship of that but i have enough surgical background that i was able to to know didn’t need hand holding on the day I was able to crack on with it but I’ve taken some photos I’m not gonna send it back to him and he’s gonna give me some feedback so we have that thing going on but again it’s a whole thing about taking small baby steps for for me and it’s taking me eight years to get this point where i think okay now i can do this kind of stuff you see. So this is the kind of stuff that we need, we need more mentorship and you gotta identify any way you can to to get that so I’m really glad you mentioned about you know whole defensive dentistry because it’s true it happens all the time. Now we’re talking about exactly ID blocks and it’s interesting how you also practice defensively like i do because i also believe that in other countries they use articaine on blocks and it’s not an issue so i do tend to stick to lidocaine for my id blocks just like you for the same reason. Any tips you can give on success for id blocks?  Interesting story when I was in Vietnam on my elective right? I thought you’re going to say in the army when I was in vietnam during the war or something that’s how that story started. There was this group of dentists who were from Canada who were celebrating 25 years out of dental school and we were all doing this a big charity project so we went to like rural village in near Da Nang an hour away and we went to this school and we set up a base there we did all their restorations, fissure sealants, a lot it was a great experience as a student to see these experienced dentists are teaching us and and one thing is before these children had any sort of restorations done they’d be in one queue they’d be given an id block so you’d go around give an id block to them okay then they’d go to the next queue and they’d be given a second id block George from the same place because the rationale of the lead dentist yeah these kids he was like you know nine ten years old okay and the rationale this was maybe 12 years ago right George or maybe less, maybe 10 years ago?  So the rationale there George was and this is what he said really lovely guy great dentist but this is what he said to me he said 50% of all ID blocks fail, so let’s give these kids two id blocks so by time they come to have their restoration because what they didn’t want is that their language barrier right? They didn’t want these little kids to be suffering and the language barrier and not be able to communicate, so what they did they just gave them two id blocks and then they sat down they had their dental work. It was like a whole factory operation just a cool story they’d tell you in terms of an interesting experience i had but that just highlights the fact that in general dentistry you know id blocks they can be a little bit hit and miss so where are we going wrong any tips that you can give us for success?  [George] Yeah so in reality the only time it goes wrong is it’s not because of it being an id block it’s because of the technique isn’t it?Often it’s a mixture of the technique and the anatomy and i don’t actually see anything wrong with giving two id blocks but on kids you know it’s quite difficult to give an id block on a nine-year-old anyway you know I’ve got a nine-year-old son, I’ve got a five-year-old son, I’ve got a twelve-year-old daughter that eleven-year-old sorry daughter and to give id blocks on that kind of age group that’s difficult especially if you can’t communicate although I’m sure the Vietnamese kids were rock hard they just had to get on with it and you know if their parents were there they’d probably get a slap if they messed about with the dentist helping them because i know i did in India, we were here you know it was quite harsh punishment if we didn’t sit still but yeah it’s technique isn’t it and i do see a lot of colleagues and not just dentists I’m talking about therapists as well maybe hygienists they’ll shy away from the id blocks because they feel oh you know what it’s not a reliable technique and so I’ll move on to other techniques like intra-ligamentaries for dentists, it could be other techniques like intraosseous although I’m not, I don’t think intraosseous is as commonly used but it’s a very, it’s an excellent technique but colleagues shy away from id blocks because they you know they feel they’re not very good at it and unless you’re doing more and more you won’t really understand the anatomy or the feel or where that needle needs to go i see sometimes colleagues often freshly and not just recent qualified but you know people who have been 10 years plus they don’t actually know where that needle and the tip is meant to go.  So if you don’t know where the needle tip is meant to go you can’t visualize where you’re meant to be going with the id block and if you can’t visualize where you’re meant to go with the ID block it’s always going to be hit and miss because you just don’t know what you’re trying to achieve so i would always say you know if you want good success with the id blocks you need to look and study the anatomy you know even if it’s on a skull and then relate that to your patient you know to a living patient.  [Jaz] George on that note because one you know i know you’re gonna you’re gonna give us a guideline for success of course learn the anatomy but two things to reflect on what you said there on the patient in front of you because i had this thing in the beginning where if someone was overweight versus someone was super skinny that anatomy difference how it presents to you can can really throw you off when you’re learning the technique and and i think every dentist maybe has this George i mean correct me wrong but you sometimes go through a bad patch of your id blocks not working i certainly had it a few times in my career in my you know eight years so far where i just went through a bad patch where for some time my four id blocks in a row were just not successful i was giving three of them to get to work at that point obviously it’s definitely technique at the time and a lack of skill, lack of expertise but I’ve heard this from a few dentists speaking to them actually they just been through a bad patch sometimes and obviously it’s the same mistake that you’re making over and over again.  [George] So when that happens it’s important what you do next if you’ve got an issue you would, you should ideally then reflect on on what the issue is and how can you improve it so look at your anatomy books look at the skull look at techniques even you know this day and age we’ve got Youtube and a whole bunch of things showing correct techniques of id blocks that’s what you should do sometimes colleagues will think you know what this isn’t working for me I’ll move on to another technique or keep trying three times or four times instead of looking at where they’re going wrong and it’s really having that thought process of where am i going wrong? How can i improve as opposed to not actually finding out what the problem is and that’s the most important message here you know everyone will have failures everyone but then if you have a failure what do you do? Are you the type that just doesn’t you know reflect and try and learn from it? or are you the type to learn from it improve and then move on going forward? So yeah it’s always a technique thing as well as anatomy don’t get me wrong you could have a perfect technique but then you’re assuming that the nerves are where they should be and they’re not always where they should be. So you know there could be a difference in anatomy.  The other aspect is on the patient i mean you just mentioned a skinny patient and a patient who could be a little bit more larger in size and often if you’ve ever encountered patients who are really quite overweight you know they’ve got a large amount of fat in the cheek you may not get into the area where you want or the mouth opening may be limited or you know for whatever reason… [Jaz] Or you may need to actually advance the needle all the way into the hub actually goes just by the mucosa which obviously we’re taught not to do and that is scary when you have to do that but that’s the only way you’re going to get through that fat tissue. [George] Yeah, unless you’ve got extra long needles which you know they’re standard needles but I mean even with those kind of patients to get through the tissue you know the patients who can’t open if they have trismus or whatever you know have you looked at Gow gates? Have you looked at akinosi? These are all variants of achieving the same outcome as an ID block they’re just different techniques I’d probably say they’re moderate to advanced techniques they’re not your standard id blocks they’re not as commonly performed but if you’re doing more complex stuff or patients who are a little bit more trickier or differences anatomy I would look towards those techniques as well.  [Jaz] I mean the standard thing I do is if I have a block that’s not work my default thing that was always taught is just go again just maybe a sending me a higher and that’s my default is that an accepted practice. [George] I think that is i think if you go you know a little bit higher sometimes it depends on where you are right i mean if you go if you’re already high and you’re going highest well that’s not going to work but if it really depends on where you started off so you could say you could go higher you could go more further back in the mouth you could go you know more outside you know a bit more closer towards you or a bit lower down but then you won’t know if you need to go higher or lower or wherever you need to go if you don’t have a basis of where the correct anatomy should be in the first place if that makes sense?  [Jaz] It does so i guess the main message here is If you’re going through that bad patch as described really hit the natty books again related to your patient, go back and watch those videos like you said then they’re widely available I’ll link a few in the blog post below for those who to click onto there’s some good ones that we can share for sure. Hitting bone yay or nay?  [George] I don’t routinely do it. I was taught that but that was a long time.  [Jaz] Nor do i by the way but I was gonna hear your what why you think? What you do? So you don’t hit bone because?  [George] Because theoretically whether it’s true or not but theoretically there’s a small deformity to the tip of the needle and as you withdraw it back out you can get more trauma and you know especially on a patient who may be you know on certain blood thinners or whatever it is that can cause more of an impact so I don’t tend to do it and to be honest I’ve not done it for a long time my id blocks are pretty successful so if i needed to do it i would be doing it but I’ve not needed to do it. [Jaz] Yeah exact same reason so I used to do in fact when i was a new grad it was like i love the feeling of hitting bone because i know I’m there kind of thing it was a hip bone because that’s what we were taught right and then i stopped doing it because I’d seen a few slides i think it might have been Radoslaw is that polish implant guy what’s his name?  [George] Yeah Radoslaw. I can’t i know who you’re talking about. I think a lot of people know he’s quite well-renowned Europe though for implant dentistry and i believe he shared a a slide and showing this and used like gloves or something where when you have a needle versus when you’ve hit bone and it does damage that needle a bit and then that can cause more trauma so that’s yeah same reason for is why I don’t hit bone anymore so that’s some food for thought there I mean. That’s not to say I do use the tip of the needle to hip bone and other techniques so other more advanced local anaesthetic techniques so something my dad taught me was a thing in plastic surgery called hydrodissection where they use some sort of fluid to separate tissue and i tend to do that for not for blocks but for infiltrations especially if I’m raising a flap. I will ensure that the needle has hit the bone because at that point i know that the tip of the needle is under the periosteum and then as I inject it will lift the periosteum off the bone so even before i start cutting i know that periosteum is going to fall off the bone.  [Jaz] That is genius.  [George] Yeah so it makes my flap raising extremely simple so anyone who’s done my courses or who I’ve mentored will often use that technique. It makes the local anesthetic more effective as well because obviously the local anaesthetic is close to bone something like articaine needs to diffuse through the bone so I know it’s not going to just be in the soft tissue well away from where I’m going to work as well so it depends on what I’m doing so I will use the needle tip and hit the bone for those kind of techniques but certainly not for ID blocks and it’s not just ID blocks obviously we’ve got infraorbital block and other blocks you know mental nerves and things like that I would never advance the needle to try and hit the bone around the nerve because I know it could potentially cause trauma.  [Jaz] Brilliant. I’m so glad you shared that, amazing. Now we were talking earlier now obviously in the theme of back to basics let’s talk about a really common scenario the hot pulp, the lower molar that’s in severe pain and it’s difficult to numb and I’ve been that scenario where you try everything you first try the id block then maybe you give a second id block then you give an articaine infiltration buccally then you do a bit of periosteal then you put some in the attached gingiva then you go a little bit lingual right? And you’ve like injected in every single site possible yet the patient is still not numb right? So you were telling me an interesting story about a patient in Reading just share that with everyone please. [George] Yeah, I completely forgot you’re based in Reading i should have sent him to see you to have a go before he came to see me. So this patient had a hot pulp lower six your classic hot pulp lower six but it could also be upper molars as well it kind of you know it’s the same learning outcomes or points that we can learn from so a patient who had a hot pulp on the lower left six he had seen as dentist to attempt extirpation, dentists couldn’t get anywhere near this tooth. They had tried double ID blocks infiltrations all the way around you know as you said lingual and intra-ligamentary and all kinds still couldn’t touch the tooth you know even the gentlest touch of the drill sent him off in pain and he saw another GDP in the same practice who had a bit more of an endo interest again same scenario multiple ID blocks, multiple local couldn’t touch it. They gave him antibiotics, anti-inflammatories you know for a number of days i think it was for a week to try and see if it settled down, attempted again still no joy.  So this is his third attempt, they then referred him out to endodontic specialist and again he went there the endodontist attempted still no joy. As his mum who was a patient of mine and I’ve treated for advanced restorative work reached out to me because she lived in the I think she lived in North wales you know explaining her son lives in Reading, he’s had i think it was coming up to three weeks of no sleep. He couldn’t work, it was really affecting his quality of life. Now she knew i don’t do root canal especially multi rooted teeth I certainly don’t do root canal but would i be willing to see him to try and help i said fine and I spoke to the patient you know checked medically fit well and all the rest of it and he came up to see me while I was working in a clinic in Manchester again same thing man, if you know when a patient comes to see you start to get a little bit cocky you know i can manage this patient, this is fine you know I’ll easily do it look at the work that i do anyway patient came in double id blocks, intra-ligamentaries, mental you know the full works lingual everything. Started to drill the tooth it was going okay I was getting you know i was getting much further than the previous dentist and then I got to the pulp and yeah again just couldn’t cope with this extreme extreme pain. Couldn’t go anywhere near it and unfortunately you do come across these situations it doesn’t matter how much local you’re using and I had already given an intraosseous as well.  So I’d given him double ID blocks, I’ve given him intra-ligamentary, had given an intraosseous which i don’t often do but i do that in the odd occasion still nothing touched it and you do get these kind of cases and and sometimes i think colleagues think well you know these people can do it and it’s magic actually it’s not.  It’s a case of then setting the patient up and saying “Look this is not going to be comfortable whatever i do is not going to touch it but if you give me a few seconds i can sort this out for you but you will be in discomfort for the one maximum two seconds, are you okay with that?” Now this trap he was an adult you know he’s had pain for well over three weeks and we’d already got further than you know at this point i was already beyond the main pulp chamber I was going to the different canals he was more than happy to give it a go because he knew I’m doing the main bulk of work here and it literally is a case of putting that needle in the pulp chamber down those canals and for that one second maybe two seconds really you know pressing into that canal with the local anesthetic it’s not actually the local anesthetic that just does the work it’s also the pressure you know just ripping that nerve apart and at that point it’s fine and that’s essentially what I did so I got to the point of you know removing up to the pulp and that’s when you know he could feel the pain and that’s all i did, it was an intra-pulpal you know for that one or two seconds and once that was done he was fine, no pain and i could continue to carry on with a full extirpation put the calcium hydroxide down there, temporize and sent him away and you know he was in he was so appreciative over the following days that he you know gave a really nice hamper because it was the first time he could get sleep for you know for three weeks and that’s really you know if anyone’s had toothache that’s really quite debilitating.  [Jaz] I have had severe toothache my friend my lower incisors, all four of them root failed, tooth fractured so we think orthodontics cause my lower four incisors to necrose so first time present first year of uni severe throbbing ache i was in tears, first year uni dental school in Sheffield. We go up randomly to take a pa and this is huge apricot pathology all around my lower incisors. Anyway so yes I’ve definitely been there the worst thing ever but you know what i was smiling throughout that story you were saying George because i was actually expecting you to say he came up to see me and we got him numb through one id block and this is how i did it right? But I just love the human side that you showed there the real, the reality that you know what no matter what you do the hot pulp is a hot pulp okay and you get, you do the best you can and then it’s about getting that intra-intra-pulpal so I’m actually really pleased and i really appreciate the humility and sharing not a failure in any way you know you’ve got hamper, you got someone out of pain but in an ideal world you would have loved to given one id block and you know pull up your collars yep done that but it’s sometimes just not possible.  So it’s great that you share that because a lot of young dentists listening we’re gonna encounter this scenario every six months or something on that or maybe more frequent if you’re emergency setting or you know whatever depending on what kind of practice you’re in but it’s a scenario we must face and that communication gem you gave George is key that you just have to say to the patient look this is a situation give me a little bit of time we will get you out of pain but it’s not going to be a joyful ride for those 10, 20 seconds in that scenario a painless experience unfortunately it’s just not possible.  [George] Yeah exactly and you really do have to sit the patient up. Give him the you know give them the options look this will take literally one to two seconds it will be uncomfortable but it will sort you out or i can just stop here put some leather mix or whatever where I’ve gone up to temporize you know give it another week or you know this patient had already been on a week’s worth of ibuprofen in advance just to settle things down before my attempt as well but you know it works you know there’s no real magic technique, it’s just a case of look this is what we need to do this is the reality we can either go down this path or this path and that’s it and you know I’ve had really bad toothache as well so during covid i don’t know if you know this but during covid i had severe acute pulpitis from my lower left six and that was on good Friday during covid.  Now i knew that i knew the guys in the Liverpool dental school treating the covid pulpitic you know that service all they were all they could offer was extraction at that point because of covid. It’s very early on so dental treatment was very very much limited to take teeth out that’s it and i didn’t want to burden them i know quite a few endodontics i work with quite a few endodontics. I’m really really slick operators this was this was 7 p.m on friday because i thought i’d just persevere with it just got worse and worse and worse and by 7 p.m i couldn’t actually close my mouth it was that bad it was it was severely affected because i had to get my wife get the kids in the car drive to my practice. I’ve got a practice as well i put them in the waiting room and then in front of a mirror i had to give myself an id block i had to give myself i had to give myself an interligamentary.. [Jaz] An id block not even like an infiltration? You gave yourself an ID block?  [George] An ID block, intra-ligamentary started to extirpate it was a hot pulp so as soon as i started getting into near the pulp chamber I experienced exactly what this lad I treated experienced which was acute pain you know as i was getting close and again i had to give myself an intra-pulpal and I’ve recorded this because I was using my phone as the mirror while i was treating myself amazing i know yeah and as i gave the intro but I didn’t realize the sound was being recorded but as i gave myself an intra-pulpal as i was reviewing back the videos all i could hear was myself grunting going because it was that painful to keep my i had to keep my mouth open while i’m numbing myself up through the pulp but honestly after that was done it was like magic i could you know i found all four canals, extirpated done.  [Jaz] You obturated with obtura, you did your own crown prep.  [George] I did put a decent enough restoration over the teeth but honestly that night i had the best sleep that i’d had for about a week because this constant like acute pulpitic pain that was experienced you know it was coming in waves of pain you know that classic textbook you’d experience waves of pain that’s what i was experiencing and it was it was horrifying  [Jaz] I mean I can’t believe you gave yourself an idea blocking. You did all that hats off to you and i was thinking in my head wait i couldn’t even bring yourself to do that but you know what i do remember the time when i had the severe pain we’ve only just been taught as entering second-year dental school at that point in Sheffield, we get early exposure to extractions and we’ve only just been taught how to extract your teeth and you know what i it crossed my mind you know that i have some pliers dental pain as you experience is the worst thing ever as we know as we experience. So it’s great you shared that story I’m actually amazing at that’s really impressive. So final question George i think a lot of a lot of great gems, a lot of varied gems we’ve covered today i think everyone find this really useful but just give us a flavor of you know i said to you earlier when we’re planning this episode like you don’t know what you don’t know and i probably have no idea that these advanced techniques even exist but what kind of moderate and advanced techniques do you do to to use utilize to be able to do the kind of density you do what do you teach on your courses in terms of technique wise?  [George] I suppose because of the surgical techniques that I’m teaching or implant techniques that i’m teaching require really good adequate anesthesia like ultra good you know a lot of the times we’re doing this just with local anaesthetic alone, we may have some Midazolam mixed in there but you know sedation is not a substitute for achieving local anesthesia. If the patient is not numb and they’re sedated it can actually bring them out of the sedation and make the procedure even worse because they’re not comfortable.  So it’s really really important to have really good you know adequate anesthesia achieved and a comfortable patient and these kind of techniques that we we tend to use will be for example we we teach blocks to the posterior superior alveolar nerve blocks, for the middle superior alveolar nerve, the blocks to anterior superior alveolar nerve, the nasopalatine block or incisive nerve block, a greater palatine block which is really quite important for things like crown lengthening on the palatal aspect to even just reduce bleeding or harvesting connective tissues or lifting up large palatal flaps you need to now to you know adequately achieve anesthesia there mental nerve blocks of course but also lingual blocks. So these are the kind of range but then also extra oral techniques i think as dentists we’re commonly taught how to numb up the patient from the inside of the mouth and not from the outside of the mouth so i tend to do a lot of blocks from the outside.  So if it’s an infraorbital block that I need to achieve I will do an extra oral infraorbital block if we’re doing work on the zygomatic, we will do extra oral blocks for the zygomatic region sometimes we do a full maxillary block so you can achieve a block for the whole one side of the maxilla in one go and you can do that through two methods, you can go through the greater palatine foramen and achieve anesthesia to the whole maxilla through that root or you can go extra orally into the Pterygomaxillary fissure and deposit the local through the extra oral approach. So these are quite you know a bit more advanced complex techniques. It’s not just a case of you get your normal dental local and start sticking things wherever you can do some real damage doing these types of techniques incorrectly as you can you know as you can imagine you know for example if you’re incorrectly taught or shown how to do an extra oral infraorbital block you can cause blindness to the eye so you can really do some damage but these are the more advanced techniques that we would cover in our courses.  [Jaz] I mean maybe I’m just showing my ignorance but yeah I just didn’t appreciate them the role of extra oral blocks. I’ve never seen one being done before. I have seen and I’m on a course learning about it at the moment extra oral TMJ sort of anesthesia and that kind of stuff that’s my kind of interest I’m developing but I’ve never seen it for maybe because maybe you see this on maxfacts positions and I didn’t hold one for long enough to see that kind of stuff but yeah you kind of forget sometimes in dentistry that there are extra oral blocks available and as well as all the others that you said so that’s really fascinating i can’t believe i didn’t ask you this my friend any tips on getting painless palatal um injections now what i do at the moment lately here i do at the moment i just put i just push really hard with the handle my mirror is there anything above and beyond that that i could be doing. [George] Yeah, I think that’s probably the best way i would also suggest not just pushing really hard but making a little bit of vibration to it as well um so it’s not just pushing hard but pushing and and vibrating in a remote area where you’re providing the local anesthetic i would also while at the same time if you’re going to do that just deposit a few drops of anaesthetic first so you don’t give the full cartridge give a few drops then come out give it a minute or a minute and a half and then you can go back and then slowly give the local when you know when we’re talking about techniques I you know I’ve seen dentists where they’re pressing really hard and giving the local but it’s everything isn’t it? It’s not just pressing hard, it’s also giving the locals slowly you know I’ve seen people just pump that local and often the pain is not just a needle tip going in it’s the expansion of the tissues and if you’re expanding the tissues very quickly and stretching it very quickly it will cause pain and why you know if you can avoid it why would you why would you not look to avoid it so I would suggest pressing hard vibrating on the handle of of your mirror remotely in a different area and then dropping a little bit of local anaesthetic in the palette you know a good a good small amount but enough to achieve uh a decent amount of anesthesia withdrawing giving it a minute or so then going back in and and slowly providing that local you know very very slowly the slower the better actually depending on what you’re doing if it’s a single tooth you’ve got all the time in the world the other alternative is you’re giving your buccal articaine first then after the buccal articane you can then go in politely because often the buccal articaine can go through the bone onto the palatal side but what i tend to do is I’ll give the buccal out articaine first and then I’ll numb up the crest with articaine and then once the crest is numbed up you can then slowly go down the palate while moving the mirror and doing all the other stuff. [Jaz] I think in an ultra nervous patient that’s how i know you’ve got the luxury of as much time as you can yes i would be doing it i think that way as well buckle then papilla area then the palatal of the papilla area and then progressive that’s the the you know the way i’ve achieved the most painless palatal that’s the best way and i do well with all that as well. I think this has been a really valuable episode George but at least if you’ve got anything else to add?  [George] Yeah I was going to say if you’re really looking at the the full process if you’ve got a patient who’s really nervous about numbing up um and you know they’re still not really suitable for or you can’t provide station for whatever reason obviously give the topical on the cottonwool roll on the buccal aspect once the topical’s been there for you know a good three four five minutes then take it out and you insert the needle by only one to two millimeters only within the mucosa not the gingiva, not the fixed gingiva but high up in the mucosa give you know again like the palate give a small amount of local wait for that to kick in then you can go back give it a little bit more local again with articaine, wait for that local to kick in this is all in the mucosa once that’s kicked in you should be able to anesthetize the the papilla and the attached and once that’s kicked in, you can then go to the papilla on the lingual or palatal aspect wait for that to kick in and then on the palate.  So you know there is a progressive route now in saying that i would often do that in single teeth type work or maybe multiple teeth type work you know when you’re doing things like zygomatics and full arch and you know a whole bunch of more complex stuff often the patient may be sedated but generally you don’t have that time because the local anesthetic has a certain period of time that it’s effective for so once the locals in you know you you’re really starting a you know a bit of a countdown that that brings me on to another subject as well often colleagues will put the local in give it a few minutes and then crack on with the work and that’s not how things should be done you know you put your local in whether it’s an id block or infiltration that local anesthetic takes a specific time for it to diffuse into the tissues adequately and often more often than not dentists will start doing the work doing the treatment before that’s fully kicked in and ideally what you should do is you give your local check the time so for example you know the times 3 30 you finish your local i would then on my clock even for big mouth even for zygomatics more, so for zygomatics but i would start a timer i want 10 minutes to have passed before i start treating the patient, before i start cutting the patient, before i start drilling the patient you’ve got to have adequate time for that anesthesia to become you know to be effective because if you’ve not given adequate time it could still be in the soft tissues it may not have diffused into the bone into the nerves or wherever you’re going to you know you’re going to work so that’s a really important aspect of trying to provide successful local anesthetic.  [Jaz] So a great point and often something that the easiest thing to skimp on is the time like if you’re in a rush or you’re trying to you know be you know the time is the easiest thing to just skip on and yeah a couple of minutes later you started but whenever i do have a a particularly nervous patient or someone with a history of being difficult to numb for whatever reason they’re the kind of patient I’ll be booking in just for anesthesia and then see a checkup while they’re waiting outside because they need that time because not often the technique is just about giving them enough time as well and you you’re so right with that George please tell us for you know if we you do lots of implant courses and stuff a lot of the the audience that listen and watch this are various various levels of their career what kind of a dentist, the kind of dentist who’s going to be learning implants from you and what kind of stuff do you have available for them what kind of resources courses do you run?  [George] I’m not sure where to start so i suppose most people know me for courses on more complex advanced techniques so generally my courses involve learning zygomatic implants and i’ve got a great, so for every course i have a great co-instructor so for zygomatics i have someone called Guy McClellan who teaches the zygomatics on that course i teach the pterygoids we both will teach the trans-sinus so that’s one course but it’s not just implant courses we teach bone grafting so big bone grafts we teach gum soft tissue grafting and you’ve mentioned Amit Patel. Amit Patel runs a course with me and we teach on cadavers because we feel pig’s heads aren’t really appropriate to learn true techniques you know pigs soft tissue or bone or anatomy bears no resemblance or similarity to a human so why learn from a pig when we have you know really good quality cadavers about these days.  So Amit Patel heads up the soft tissue grafting course. We have Sanjeev Bhandari who heads up the apical micro surgical course and again that’s on cadavers. We have Sami Stagnell we’re talking about local anaesthetic so Sami Stagnell is a consultant oral surgeon he heads up the local anaesthetic course and again that courses on cadavers and we will be teaching more advanced intraoral techniques. So whether that’s Gow gates or akanosi or just normal good quality id block techniques or mental nerve block techniques or good quality infiltration techniques and then if if there are some advanced practitioners out there we will teach extra oral techniques to those colleagues and then of course I teach full arch implants and that’s a hands-on course so all of these courses are hands-on they’re not theory again i teach a hands-on course for large implants and so that’s not just for fixed bridges we have a new course coming out in next year that’s with someone called Harpal Chana who’s a restorative consultant based in London and that will be again another hands-on implant over denture course. So there’s a number of courses that i run quite a few i think next year there’s something like 24 courses they’re all hands-on busy. All with various specialists in their field teaching that subject but yeah so yeah.  [Jaz] If you can just leave me your if you can email me the website because you know every episode I like to share what presenters have because a lot of time people resonate with what you said and they’ll usually message me on instagram saying, how do i get hold who? What’s the email address for this person? How do I get on to learn more from this speaker? So I know that what you spoke about today will it’s such a fundamental topic right and then those who may need help with grafting whatever may be looking for a course like yours so if you send me the website I’ll put on the protrusive website for those to see how they can learn from you George. So I really appreciate if you do that.  [George] Yeah I’ll definitely do that I mean most people i think find me on Facebook as implant dude but that friendship number has it has kind of maxed out so I’m a bit behind the times. I’ve just kind of started Instagram I’m a bit rubbish at Instagram but again you know I’m trying I’m on there as implant dude but the courses are under the website advanced implant training but I’ll put it up, I’ll send you a text where you can.  [Jaz] Actually share it with me and I’ll stick it on protrusive.co.uk for everyone wanting to see Protruserati, thank you so much for joining me and George today I hope you found that as useful I did. George thanks so much for your time that was really awesome I think lots of from communication gems to patient management to a cool few stories in that which I enjoyed. Thanks so much for giving up your time today.  [George] That’s great. Thank you so much for having me on Jaz. Jaz’ Outro: There we have it guys. I hope you enjoyed that episode with George lots of stories exchanged there, lots of bigger themes you always like to focus on the bigger picture on these episodes. I hope you found value from that hope you’ll find that the next time you’re going through a bad patch of giving id blocks or the next time you’re struggling to anesthetize someone’s molar which is a hot pulp you’ll just relax and just explain to the patient what the scenario is what’s going on and you won’t always be successful. Hot pulps are one of those things you will not always be successful so don’t beat yourself up over it if you can subscribe on the Youtube I really appreciate that and I’ll catch you in the next episode back to basics. It’s gonna be a huge one, it’s all about extractions you absolutely cannot miss the next episode it is gonna be probably the most profound episode I’ve ever done. So I’ll catch you in the next one with Chris Waith

A daily dilemma in Dentistry is deciding when (and HOW) to restore that extensive MODL amalgam restoration that was placed over 30 years ago! We go deep in to this, looking at single-tooth factors but also a full mouth ‘bigger picture’ view with Dr Andrew Chandrapal who has been trained by world-class clinicians including Dr John Kois and Dr Didier Dietschi, https://youtu.be/lulpENm4swo Check out this full episode on YouTube. Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How to make sure your equipment doesn’t keep getting lost? Use color coded tapes on your own equipment and tell your team that stuff is super important because it belongs to you. https://www.instagram.com/tv/CNUi20EJ9Pk/ “Using things like air abrasion to then try and remove the apical amalgam whatever you can do to try and be gentle in your removal of that material is a good way to go” – Dr Andrew In this episode I ask Dr Andrew Chandrapal,  When to classify the large restoration has failed (12:45) Risk factors of a tooth with large restoration would undergo necrosis (18:33) About restricted anterior restriction or constriction (22:21) How to prevent yellow stains and if you should intervene for a long time restorations? (29:16) Little tip on special burs to use when cutting out caries (31:21) Cutoff point whether to cap the cusp tip or not (33:26) When to decide if you should intervene because of marginal staining and communicating to patients (37:44) What factors to consider moving from direct restoration to indirect restoration? (39:59) Treatment plan to reduce the risks of fracture (42:31) As promised in the episode, if you want to learn more of Composite courses by Dr Andrew Chandrapal – IndigoDent Education If you enjoy this episode, check out this Composite vs Ceramic with Dr Chris Orr Click below for full episode transcript: Opening Snippet: I've shied away many times I've made a treatment plan for a patient for quadrant but I will just work around that upper first molar we've got that behemoth amalgam because I don't want to touch it. Any help you can give me? We should not be responsible for owning the clinical problems that the patient presents with... Jaz’s Introduction: Most of my patients are above the age of 60 actually nowadays and when I look into their mouths I see these huge amalgam restorations you know like it’s MODB they’ve got very very thin cusps you can see the amalgam shining through. You can see craze lines, crack lines but they’ve been there for so many years, they’ve been there for two three sometimes even four decades i mean you look at these studies about longevity of amalgam and composite and you know my patients are the heavy metal generation patients are a living testament to longevity of amalgam however when things go wrong they can go catastrophically wrong like remember when you find secondary caries around amalgam it can be a huge huge mess and of course, we know that in time cusps can fracture around amalgams and that’s like the most common emergency we find which is when someone just broken off a cusp and lo and behold there’s a huge amalgam left behind. So when should you look at amalgam and say you know what I’m gonna decide now is a good time to crown this tooth or now is a good time to remove this amalgam because I worry about secondary caries or I worry about microleakage because if they’ve been like this for 30 years 40 years and I can’t really justify enough a good reason to drill into it then why am I drilling into it okay? This kind of debate that I have with myself. So to help answer this as part of this back-to-basics series for August, I’ve got Dr. Andrew Chandrapal from the UK, who is just such a gifted clinician.He’s well known throughout the world actually and I think he’s done a really good job of covering these basics of you know when do I need to remove the stained composite like is that staining around a margin, how can we prevent it but then when it happens, do we need to actually drill into it or not? So we covered that kind of thing but also we talk about that patient who’s got these amalgams everywhere, these flat amalgams that they’ve accumulated over the time and how we need to manage those patients but an interesting thing that Dr. Andrew Chandrapal discussed which I’m going to share with you now as like a teaser for the rest of the episode is these patients who have a flat amalgam like you know they go from having beautiful cuspal inclines to having this flat amalgam thumb inside the cavity right and then they have another one and then they have another one, they have another one, eventually because you’re losing the anatomy and the dentist obviously because it’s flat it’s very unlikely that that restoration is finely tuned into the occlusion. So what you get is that every time a restoration is placed it’s out of the occlusion right? So slowly but surely you’re losing occlusal vertical dimension just imagine all your molars getting these flat amalgams and eventually each one is out of occlusion and eventually you lose vertical dimension and it’s interesting how Andrew Chandrapal, who’s been very influenced by John Kois talks about this constricted envelope that can form, now if you don’t understand what that means don’t worry Dr. Andrew Chandrapal will cover that. So yes this is back to basics theories but some of it does get a little bit into the bigger picture which is good we need to appreciate we need to look beyond the single tooth and appreciate the bigger picture. So much to look forward to in the rest of this episode I hope you stick around also for the rest of August for the back-to-basics series. I’m hoping if you’re watching on youtube or dentinal tubules or whatever I hope you like my new setup I’m standing no longer seated I’ve got my biggest green screen mounted behind me so I hope it’s coming out okay. For those of you listening I appreciate you while you’re running, jogging, chopping, onions, or gardening whatever you’re doing right now thanks so much for joining us today. If you’re a new listener to the Protrusive Dental Podcast, Oh my gosh, welcome thank you so much for joining us and sticking around. Check out some of the old episodes and just before we join the main meat and potatoes of the episode I’ve got my Protrusive dental pearl for you. So Raghav Munjal recently on the Protrusive dental community Facebook group. That’s facebook.com/groups/protrusive. He asked an interesting question he said ‘Jaz, you posted a while ago on Instagram about color coding your burs or dentists that buy their, or associates that buy their own equipment and how to make sure it doesn’t keep getting lost? Like that’s a huge bug bear of mine you know you spend your hard-earned money on buying this equipment or these burs or this you know composite brush or whatever modeling resin right and then it gets lost misplaced broken whatever it’s really you know it’s really sad because there are these associates who are buying their own equipment that they’re growing but they’re few and far between i think it’s a great thing to be able to buy your own stuff sometimes to elevate your dentistry and then hopefully find a principal that appreciates you enough to buy you the stuff that you want to use but anyway when you do, when you are that associate and you are buying that stuff one way I found to make sure that things don’t keep getting lost is to color code that equipment now obviously you can’t color code your mirrors because that’d be difficult but you can color code the cassettes that they go into or let’s talk about I’ve got like this little sword this interproximal saw is if I’ve ever bonded composite on the adjacent teeth together so I’ve stuck the two teeth together i will use that this little saw that itself could be a Protrusive Dental Pearl actually. Anyway use this saw but that little saw has got a handle which i’ve got like this yellow and green tape so what I’ll do is if you go to protrusive.co.uk and if you click on this episode then I will put a link there to the instagram live i did showing you exactly the tape that my nurse uses so i know that if something is color-coded orange and green and everyone knows that that belongs to me okay it always comes back to my surgery. I’ve got some handpieces that are color-coded orange and green so I know that hey these are Jaz’s handpieces they’re going to go back to him and when it comes to burs, this is the most annoying thing the easiest thing to lose is burs right? So why did i buy my own bur blocks from like eBay or something right and the color they could they’re colorful but I also color-code them with the green and orange banding which again like I said if you check out the website i’ll show you exactly where I get that from and then the bur blocks themselves are color-coded so any burs are put in will always come back because they’re part of that block and you take a photo of that block. So the decon nurse knows what which burs are supposed to be inside that block so essentially the pearl is to start getting a little bit savvy with your equipment look after your equipment and part of that is actually color-coding it but also telling your team that hey this stuff is super important because it belongs to you. So hope you hopefully we can elaborate more on the website when you check out the full Instagram live I did some months ago. Raggy, thanks so much for asking that question on the Protrusive Dental Community and let’s finally join Andrew Chandrapal on what’s a very interesting episode about the very fundamental question of when should i drill this amalgam? Main Interview: [Jaz] Andrew Chandrapal, welcome to the Protrusive Dental Podcast, my friend. How are you? [Andrew] I’m doing really well, thanks Jaz. Thanks for having me on here. [Jaz] It is amazing to have you on finally it’s something that people have been asking for. Mohammed Sharjeel asked for you. Loads of the others of the Protruserati have asked you because obviously we’ve been infected by your enthusiasm in the past. I first saw your lecture at the BACD, you did a little workshop with a microscope and you’re teaching us how to do these beautiful life-like composites and I saw you again lecture this is like one of those evening things in the BACD again this is at the BDA on behalf of the BACD and honestly your work is always inspiring. So it’s great to have you on to, really I’m gonna try and suck as much knowledge out of you and share it with everyone as possible today. [Andrew] Yeah go for it I mean it’s very complimentary what you have to say I mean it’s just you know it’s one of those things that I’m very lucky to be in the position that I’m in. I’m thankful to people who see you know what I can do.What i can offer to the profession and those who believe in me. So I’m privileged to be here. [Jaz] And to just give us a little bit about your journey because I think you qualify from Birmingham right? [Andrew] Yeah, I’m a Birmingham graduate. I qualified 2001. I took a year out and concentrated on trying to focus on what I did as an undergrad doing music and stuff like that because I was a bit of a performer back in the day and yeah so I qualified in 2001. I worked in West Bromwich in the black country for a couple of years developed the accents they thought would be time to leave. Moved down to oxford to mix practice there and then joined a pretty well-known and high-end private practice in Banbury and then basically moved to Buckinghamshire which is where I have been ever since. I’ve been there for 16 years now so I spend my time there and teaching as a do-all over the place and then also in specialist practices in Central London now. [Jaz] Who inspires you? Who inspires Andy? [Andrew] Oh, that’s a good one. So I guess there’s kind of mind, body, soul inspiration. So I guess the first inspiration I can’t lie it’s got to be my dad who’s not with us anymore but he was a massive inspiration to me we quite alike both grafters, both trying to do our best to be people, persons, as it were. The next one is a guy who taught me as an undergrad. His name is John Davenport, an amazing guy and one of the first things he said to me said ‘Andy, you want to make sure that whatever you do professionally because I can see that you’re quite focused on your profession always have a sideline, always make sure you do some stuff on the side to give you a complete separation from dentistry otherwise it will have this ability to kind of suck you in a little bit’ and with that, there’s a local park in Birmingham that I was going through that weekend and I saw him bear in mind John Davenport that time was probably in his mid-60s and I saw him rollerblading just like rollerblading across the park i’m like wow this guy’s for real. So yeah, he was probably the mind-body-soul mentor and then clinically I guess the first time I met Pascal Magne was in 2006 and he changed the way I performed dentistry. He’s been massively influential for many many dentists and I know you know him and know of him well and then John Kois, who’s been my mentor in sort of restorative dentistry I suppose since about 2008.  [Jaz] You’ve been to Seattle a few times to see him in the course program? [Andrew] I have. I’m a graduate of the course center having done all nine modules and i teach the principles on some of my courses so I fully buy into his approach. It’s not a philosophy so it’s not like ‘oh yeah you know I do things that Pankey or the Dawson way or anything like that.’ It’s based on metric science and he manages to weed out all the rubbish and keep the good stuff within the science over the last 50 years and so I love that philosophy and so he’s camper fear and thought is always changing and modifying so I find that makes sense in my little head. So i love that and then finally Didier Dietschi is a great friend and mentor in Geneva.He has supported me throughout my career to this point and he’s a wonderful clinician and an even better person he’s that type of person that i strive to try and base myself on professionally and you know and have the integrity that he does. So those are my people. [Jaz] You have some amazing mentors and friends wow that is so inspirational. That is just so good I love it. Well today, we’ll be talking a little bit about we’re going back to basics so august is all about back to basics and I could have picked anything because I know you do teaching on all varieties within dentistry, beautiful composite restorations, the management of tooth wear, and everything in between and wide all that but the main thing that Mohammed Sharjeel, who just specifically i don’t know why he thought of you but he said ‘Look I want to learn this topic and I want to learn it specifically from Andrew Chandrapal. I said okay go what is it and he said I want to learn about the management of our day-to-day patients who like my patient base is average patients about 60 years old plus and they have these huge amalgams, right? And he just wants to hear from you and he wants me to bring you on an interview and ask you questions about how do you manage these big restorations and when they have subjectively failed because we do see a lot on social media and we’re in a blessed position as young dentists who want to learn that nowadays. You couldn’t do this maybe 10 years ago where you can just go on and look and observe and learn from full protocol cases and there’s so much to learn but there’s also something you appreciate that this some things that you would do or some things you wouldn’t do other clinicians are doing or not doing. So the classic example is you know that restoration that you would have never touched or replaced and other dentists are replacing that’s the classic thing so essentially though I’m beating around the bush one of the first crux of a question I’m getting to for you, Andy is these patients with these large restorations, when do you classify them as failed and when do you have that what’s going through your mind when you’re discussing about okay has it near the end of the restorative cycle? [Andrew] Okay, great question. Thank you, Muhammad. I think let’s take a step back from this Jaz for a moment, and if you look at the whole sort of dentition in a single individual for a moment and you look at someone who’s in the age group that you said that is typical for my kind of age group in general practice as well you’re looking at someone that typically has gone through a restorative cycle of dentistry that means that there was perhaps a little bit more heavy-handedness for intervention in the areas that have gone before us.So let’s look at perhaps the 70s the 80s or maybe the early 90s typically these people would be pretty heavily restored and to give testament to the practitioners of that time they were doing amalgam restorations bonded or pinned that I could never do. I have no idea how these massive MODL amalgam restorations have stayed in place for 20-plus years because i simply could not do that and so there is a degree of kudos to them to practitioners, before we start to then change the rhetoric a little bit but what I will say is that when you have a patient that has a mouth full of these there is a cycle that’s gone before them and this sort of cyclic fatigue, to me is the bigger picture so if we go back to Edwina Kidd publications and her textbook she was then referring to the fact that amalgam restoration that is unleashed or ditched to the degree of perhaps 0.5 of a millimeter or more should be then be replaced because you’re going to get that sort of creep of material over time which is going to then plaque trap and bacteria et cetera. So that’s one indication but that’s fairly historical. What I’ll say is this if I’m looking at a large restoration that’s got facet marks in it or has got a wide occlusal footprint as I call it you know so in other words something that shows you that occlusal contact is wide and flat. One then the potential for that to be adding especially when you have multiple restorations of that nature the potential for having loss of posterior guidance, loss of point contacts, loss of posterior bilateral simultaneous contacts is quite high, and what that will do… [Jaz] As what you mean is if you intervene in that scenario then the risk is high? [Andrew] Well, what i’m saying is that if the risk is high if we let some of these things go. So the point is of intervening on a single restoration like that is that you have to then conform to that occlusal scheme and the difficulty with that is you’re adding to the problem. So this kind of cyclic restoration cycle means that every time a restoration like that wears or every time a restoration is flattened in that sort of way you lose a little bit of vertical dimension and that cyclic that’s typical phase means that you lose vertical and then you increase anterior guidance and increase anterior contact, in other words, get to a point of anterior constrictions being a much higher risk than they would usually be and that in turn might give you anterior wear as well as the posterior wear that you see so, in short, I’m sorry I’ve gone around the houses on this but my indications for replacing something like this is if i start to see fatigue early fatigue of a restoration, singular or multiple. Then I’ll have a look, I’ll step back and have a look at the dynamic and the static occlusion as a whole. If I’m suspicious that we’ve had a loss of vertical as a consequence of that, I will keep a watch on that perhaps for six months and I’ll say to the patient keep an eye on this. Let’s take a scan of your teeth, let’s take photos of your teeth, or let’s take silicon indixes and then let’s see if this problem is dynamic in other words let’s see if the tooth wear is increasing and then decide to make a pathway to then replace your worn and flattened restorations. Now whether or not that’s amalgam whether or not that’s composite the principle is the same because whenever you’re replacing a single restoration you are having to confirm that’s the first thing. I hope that makes sense. [Jaz] It does. I’m just going to probe you further on that but I’m gonna let you finish the two-three points here saying because I’m fascinated by this and i love the angle we’re taking it but I have got some things to try and clarify for listeners about the decision making tree but please do carry on so if you’re like I said you might monitor it and see if there’s a dynamically deteriorating situation. [Andrew] Yeah, there’s the second thing is that if I see a restoration within a dentition that does show wear or high occlusal contacts or quite flat heavy occlusal contacts, I’m always going to be suspicious of fractures within the actual coronal tooth tissue itself and one of the main things that I am worried about with amalgams that have been present for a long time is what Cameron stated in 1964 and that was, there is a massive concurrence of fractures subrestoration when you remove amalgam restorations and that’s because the amalgam restoration in itself is harder than the tooth substrate by which you put it into and so that cyclic fatigue that you get on amalgam restorations the casualty is not the amalgam off and it’s the tooth and so when you unearth these seeing internal fractures, cavity fractures are for me are a real commonality and sometimes that can be a problem is that if we leave it for too long you’re then dealing with problems that could potentially be terminal for the tooth. [Jaz] But how can, you know, obviously we can’t see through the restoration I mean yeah it’s very common you and i both see we remove these big amalgams and we see this massive crack line and we take the obligatory photo so we can explain to the patient afterward our findings in case it does go necrotic or needs a root canal but yes that’s one factor but then how do you, how can you predict that or is it just a high percentage chance and you go with that in mind? [Andrew] Well, i think if we rely on the percentage chance of probability I think that we’re on shaky ground. I think that’s probably you know because I’ve got an inkling, can we do this? I’m not sure that’s going to fly and so actually what I do is I try and look at the evidence over some time I’m lucky I’ve been in the same practice for many years and so if I’m noting that tooth wear or tooth surface loss is progressive for example or this patient presents with lingual or buccal tori or they have masseter hypertrophy as an example, I’m thinking okay we’re building a case for someone who’s higher risk and what we’re trying to do here is do a risk assessment on every single patient that comes our way. We’re trying to be predictable in terms of that treatment modality. So that we don’t have a crystal ball but we can look at the risk factors that would associate with the risk to be higher in one individual than another and that in itself might legitimize the course for this individual requiring their amalgam or restoration to be removed plus a little bit of fatigue that we see on the individual tooth versus another one that doesn’t show any form of dynamic tooth surface loss, shows normal muscle tone and this type of thing. So there are differences but you’ve got to step back from it a little bit and look at the evidence that stands before you. So the term that I was gonna point to on my first point just so you know Jaz it’s called a combination syndrome and combination syndrome is that thing where you’ve got a heavily restored patient who’s had you know most of their posterior dentition treated directly most of the time or indirectly on some other time and over that period the teeth is fatigued the restorations are fatigued and we’ve had that general loss of vertical over that period. So every time you do an amalgam restoration or a direct composite restoration you know what it’s like if you leave it if you sculpt it in the way that you think or believe is morphologically correct the patient be like you know what I just can’t bring my teeth together on that one side, yeah it feels a bit odd. So what do you go in and you remove or you adjust as you need to and then yeah no that feels better but what you’ve done right there is conformed or even you’ve even infra occluded the restoration and you’re contributing to that combination syndrome. So done over some time repeatedly what that does is further reduces your vertical dimension and that is one of the main rationales as to why a lot of the age older restorations that happen to be an amalgam need to be replaced but you’ve got to look for the risks sights so you’ve got to stand back and look at the and risk assessment that individual patient. Now I’m going back to the third point it’s a bit more obvious if I start to see signs of fractures underneath the amalgam restoration so a lot of the time on premolars as an example you might see the palatal wall or buccal wall hairline fractures. Some of the time on class 2 restorations that have amalgam restoration particularly upper fours you can tend to see these little hairline cracks in between the buccal cusp and the floor of the cavity. So these types of things might be rationals as to why I’d be interventionist and choose to suggest to a patient you’d remove the amalgam restoration and perhaps then choose to lay the cusps with your direct composite after that. [Jaz] That’s a clear one to see and that’s a clear one to show the patient as well. One thing I’m going to come up with again in the first time is that it’s a much bigger picture issue to convey to a patient let alone another dentist as well which you know we tend to think tooth by tooth single tooth dentistry you know you place these restorations. So when you’re having this kind of conversation in the future about the flat, how flat the tooth is, the functional risk and being able to convey that to a patient and a timely manner be able to rehabilitate them to an improved vertical dimension, less constriction anteriorly so for those maybe dental students listening if you don’t mind clarifying exactly what you mean by the restricted anterior restriction or constriction even. [Andrew] So the idea is that we can introduce interferences both posteriorly and anteriorly. Now we know when we learn about occlusion at an undergraduate level we’re talked about the fact that posterior contacts can often be a working side interference or a non-working side interference and that is often occurring when you excurse and so as a patient ruminates or masticates their food as an example or even protrudes. If you introduce an interference on the posterior teeth depending on the direction of where the mandible moves you will introduce a working side or a non-working side interference. Now as a consequence of that this is where these working side interferences or non-working side interferences need to be removed adjusted or modified appropriately. Now that can be done subtractively or additively. Now often the theory stops there but in fact, when we’re talking about interferences, the interfaces can also be anterior. So if you can imagine the path of closure and the path of elevation of the mandible as it comes into full closure, into full maximum intercuspation. The issue sometimes is that you can have and this is well proven throughout science is that you can have a situation where the mandible elevates into position has a micro contact onto the incisor ledge of the upper incisor teeth and then shifts back as the mandible shifts and what you get there is a situation where you can get localized incisal edge wear or palatal incisal edge wear of the uppers and labial incisal edge wear of the lowers and if you think of a class two div two type situation where you have kind of frictional wear caused by teeth that are retroclined, if the mandible actually if the path of closure of the mandible which is controlled by the CNS and that’s well-proven equally apart from trauma or pathology. If that closure means that your anterior teeth interfere on that path of closure then you’re going to have an anterior interference and effectively the mandible is going to be shunted posteriorly distally and that is known as a constricted envelope of function because what you are doing is you are constricting the envelope of function which is the methodology of how the mandible elevates into its home position as we call it. [Jaz] Definitely can hear the Kois running through your veins, Andy. I love it I mean here’s an interesting debate I’m gonna throw with you that there are some of my mentors and friends who actually I wouldn’t say they don’t believe in it but they see it in a different way. Let’s just talk about that so that there is this you know restriction let’s say anteriorly or a frictional chewing pattern as is also referred to which is am I embarking on the right tree that is the same sort of philosophy? Now some people say that actually when we’re chewing and were that the teeth generally do not slide, they don’t make that contact and then the way that some other people rationalize that accelerated wherein a class two div two is rather than it being a constricted envelope of function they say it’s a constricted envelope of parafunction i.e when that patient does parafunction because of that sort of setup that they have, all the force is transmitted and accelerates the wear anteriorly. Do you have anything in the literature or from what we know that could counter that argument in a way or is this something that we still aren’t sure about? [Andrew] So from what I have learned and from my mentor the whole definition of. parafunction kind of differs and there is a differentiation of parafunction versus a constricted envelope of function or a frictional chewing pattern. A frictional chewing pattern is not known to necessarily be a parafunctional movement.Parafunctional movements are tending to be classified in my eyes as non-functional movements and that’s the massive difference between those two forms of wear and so the issue and if let me give you another example when orthodontics back in the day, I for one, I was a class two div one case and I have my upper fours removed what you end up doing as a consequence of that is retracting in the upper anterior labial segment but often what you can end up doing is bringing the upper and lower anterior teeth to a minimal or tenuous overjet and when you have a tenuous overjet the problem being is that you cannot change the arc of closure as that mandible elevates into position. There are only three determinants of that arc of closure there’s the CNS or your skeletal neuromuscular system this pathology or this trauma and so as a consequence of that, that doesn’t necessarily change and so if the teeth effectively get into that position or they interfere into that arc of closure that is an anterior interference. Now the problem being is that if we are in a situation where our jaw or rather more TMJ can ascertain a position of neutrality within the condyle when our teeth are discluded. So as we are moving our jaws and not in contact if they’re in that position of neutrality all of a sudden that position of neutrality is then in discord when the teeth meet and when the anterior teeth meet, well then shunted and that therein causes or causes the incisor-edge tooth wear that we’re talking about. It’s a phenomenon that you know it is has taken I guess a lot of credence, a lot of belief I suppose in the more recent years but actually when you look back in the literature it’s been there for many many years more in Amsterdam in the 60s was talking about this as an example. Pete Dawson was talking about this for many many years as an example and so i guess that you can create an anterior constricted envelope of function by the sheer fact that vertical height can reduce thereby bringing effectively your anterior teeth closer together. It’s the same reason why when we open our vertical height the mandible postures distally it’s the same so it makes sense that when you lose vertical, the mandible can posture anteriorly rather than distally when you open it that makes sense? [Jaz] Brilliant and I think that does help to clarify those listening who’s never come across this term that’s great. Now you’ve said the three points so far was there a fourth one or can I go to the next question? [Andrew] No that’s it. That’s my rationale really. [Jaz] Perfect and I love that so much and I want to just be able to jump to the next common scenario that you might see. So I think you’ve gone way over and above what I was expecting I love that and you really and I’m so glad you converted what is a single you know it can be interpreted as a single tooth question but you know helped everyone to explain that actually, you’ve got to take a step back and look at the chewing system, look at the functional risk so all these great things you’ve introduced into this dilemma is fantastic. The next question which maybe is a bit more single tooth based is that when we see posterior composites and they have the yellow-brown stain okay that dreaded stain that you see at the margin, A) how can we prevent that any protocols and B) when these restorations have been there for some time and there’s no radiographic evidence of secondary caries is that in itself a reason to intervene? [Andrew] Great question. So i think in terms of what we’re looking at is marginal microleakage so when you start to get a breakdown of the margin of your composite restoration we are getting a reduction in the hybrid layer effectively in the adhesion between that thin part of your restoration and the underlying tooth and so there are a couple of things that are anecdotal there’s a couple of things that are scientific that I can suggest. The first thing I think I will say is that anecdotally is that rubber dam is such an important part of this, isolation in some way shape, or form to enable the tooth substrate when it’s prepped to not get hydrated to allow the tongue not to contact you know the cusps tips let’s say of your tooth before restoration is such an important thing and i think if you’re looking at a lower six or a lower seven and you’re talking about exactly what you’re talking about there which is the marginal breakdown, the chances of that being the case are slightly greater if you’re not going to be using any rubber dam isolation that’s the first thing that said no evidence in the literature would support the use of rubber dam and so it’s such a subjective thing so it’s all anecdotal but there are ways to then apply rubber dam that are simple, that are predictable, that are quick. It’s just a case of learning it as we go along and with the confidence of course. So the second thing I would say is that your prep design is also quite important just like something like Emax is an indirect restoration. Composite doesn’t really like sharp edges so you need to make sure that you’ve got beveled edges or that you’ve got soft edges so that when you have a finished point it’s not necessarily just a butt joint equally if you’re sort of overlaying cusps you need to make sure that that cusp tip on the internal line angle isn’t sharp it’s not a butt joint it needs to be rounded. So things like that will make a big difference.. [Jaz] Any before you just jump onto the next one, just a little tip that you can give us when you’re cutting your cavities removing caries, is there a special bur that you use to try and create that sort of bevel or the sort of the correct emergence out into the cavity from the proximal surface? [Andrew] Sure. So, I’m old school and so I would still tend to use steel roseheads to remove my caries where i can proximately I sometimes like to finish the proximal boxes with sonic handpieces NSK do a great sonic handpiece and the proximal attachments that go with them are great for removing a prismatic enamel for ensuring that you don’t harm the adjacent proximal wall as well. So we also like using those but i tend to use rose heads more than anything i use them with water so they could be ceramic or they could be steel but i tend to just go for steel because [Jaz] What about for beveling that enamel so you’re not ending up with a butt joint of the composite at the proximal? [Andrew] So when it comes to the actual prep of that of that particular part they tend to stick with the 20 micron red band composite finishing burs and in particular i quite like the rugby ball pear-shaped i tend to sort of try to eat flatten that out and then have my hand be sort of curve over a smidgen so that you’ve got the bulbosity of that rugby ball that then sort of makes a concavity at that point so i quite like doing that i have no hesitation with overlaying cusp tips either and Didier Dietschi did some research that would suggest that posteriorly your composite needs to be at least one millimeter in thickness on an occlusal layer so as a consequence of that if you’re gonna overlay your cusps tips you do need to take that down by at least a millimeter in an effort to then overlay and get strength of your composite material. So together with the red band 20-micron finishing bur and at least 1-millimeter reduction on the cusp tip, I’m quite comfortable doing that. [Jaz] Brilliant and just leaning on from that, at what point do you numerically or otherwise are you going to decide to cap that cusp or not? So what’s your cutoff point, do you think okay now this cusp is thin enough that I’m going to now remove a little bit to allow one millimeter of composite to cap that cusp? [Andrew] Great question so I’m going to answer that and I’m going to go back to the last point that I was going to raise on your first question. So the answer to that is I look at Pascal Magne’s research from 2009. He did some finite element analyses on different types of posterior cavities I’m not sure you’re probably aware of this particular piece of research and surprise what he figured out is that the weakest or the highest stress of would be the MOD and now that stands to reason because of course what you’ve got is a channel going straight through the middle of the tooth and then you’ve got these unsupported buccal and lingual walls and so he supported obviously the motion to then say okay well if you don’t have to do a MOD and if you don’t get rid of that middle part of the isthmus then don’t and then sort of you know to get rid of your GV black kind of classification and just do what you need to and then adhere to that which makes perfect sense. Moving on from that however is that what makes me decide whether or not I cover the cusp tips or not is whether the distance between my cusp tips and the width of my isthmus that’s been created is and the ratio between those two distances, so if the distance between my isthmus that I prepped is over half the distance between my cusp tips then i will overlay the cusps if that makes sense. If I’m less than that then I’m quite happy to not overlay the cusp because i know that the thickness of my buccal or lingual proportions is going to be decent. The only time that changes is if we’re diverted onto one side more than the other and in which case if i got buccal that’s real thin but my estimate is still thin I’m gonna then still overlay that particular cusp tip because it’s very thin indeed that’s the only exception but I will rely on the science to guide me there. [Jaz] Brilliant. I knew you’re going to be coming on with references and stuff and I’ll try and put as many of these on for the Protrusive Dental Community Facebook group as well so people can geek out and you’re going to talk about isolation and you’re talking about the correct cavity form and that led nicely to all these accessory questions and i think there was one more point you were going to raise right in terms of staining. [Andrew] That’s correct. And the other way and the other thing that we’ve got to look at is the quality of the bonding that we get and one of the main things that we often miss out on is that we think that because the cusp tip is a relatively accessible area in terms of cleaning and hygiene we think that that’s clean and the difference is actually if you were to use something like GC plus and triple paste to then highlight your biofilm or some of the plaque. You’d be quite surprised with how much plaque indeed builds up and so actually what i tend to do is use particle abrasion. Particle abrasion is so important in making sure that your cavities are disinfected or as at least the biofilm has been removed as best as possible and I’ll overlay that onto the sides external sides of the buccal lingual cusps equally so that when I do perform either a custom overlay or I have a finishing point of my composite resin i know that that’s free of biofilm the same principle will apply from like a class 5 restoration, they look clean but to the naked eye they would look clean but you’ve got to make sure that you sandblast those areas to make sure you can remove that biofilm and I’ve found that since I’ve been using that and that’s been about 10 years now that has revolutionized the level of marginal leakage that I then get on the periphery of my composite restorations. [Jaz] But I was having a chat with Marcus Blatts and he was just coming out with all these you know the evidence for and against air abrasion and by against air abrasion I mean that there’s the lack of efficacy for it but there’s one in terms of bond strength that is how much does it improve your bond strength and there are some papers for and some papers against but there’s one thing that cannot be denied and that’s a removal of biofilm which is why I will routinely use it and i completely agree with you that you know once you scale and then you disclose you’ll still find plaque there but only after you use the air abrasion unit can you find that you’ve got a truly clean surface that is ready for bonding and recently David Gerdolle came on the podcast and he just blew us away about the two most important things about bonding being clean and rough so I’m glad you’re echoing those are those same sentiments. So talk about those three main areas of how to prevent having that staining and you know how air abrasion has revolutionized that.So now let’s come to the fact that okay at what point are you gonna see these stained composites probably not yours probably from your predecessor and now decide, okay, now I’m gonna intervene because of this staining or this microleakage. [Andrew] So that’s a tricky one and i think that there is so much subjectivity that builds into whether or not to decide to intervene because of marginal staining and it may well be that we have to then communicate effectively with our patients when we do this because it may well be that certain situations don’t look complicated or infiltrated with caries but in fact when you open them up they are rife and it may well be for a host of different reasons it may well be because the bonding protocol was either old not so good, perhaps the quality of the bonding agent wasn’t ideal back in the day, perhaps the composite wasn’t cured in completeness. There are so many factors that can contribute to whether or not you get propagation of that delamination going all through the tooth. So I guess in answer to your question I would do this if I see microleakage that can either be polished or gently smoothed down by means of either air abrasion or by use of rubber cups for example the chauffeur one glosses is a popular one in my hands or composite finishing burs and you see a finish that then is not stained or delaminated then perhaps that’s a good place to stop if however you see that then propagating then obviously you’ve got to go further in and you might end up having to then suggest to the patient that you have to remove the whole restoration. The key in the answer this is really and truly communicate with your patient because the truth of the matter is that you may not know until you’re in that in that zone and so you have to then make sure the patient has the expectation they’re going to have to have that restoration removed and the solution presented to them alongside with the time and the cost and the risks to that patient and if it’s then ever more limited in terms of what you need to do then that’s only then a bonus and that’s a good way to look like the hero. [Jaz] Brilliant and we always appreciate these communication gems and that was one right there so I really appreciate that and one thing that we did also touched on obviously that you mentioned about, the cusp cupping which leads very nicely to the next question which is something I discussed on the podcast at great length with Chris Orr as well, it’s about at what point do you Andy want to go from the beautiful direct work that you do to say you know what I’m going to now move to indirect lithium disilicate or whatever for those big restorations? So what is it because you’re so gifted with these composites, for you to recreate the functional anatomy of composite comes easy at what point do you say you know what I’m not going to just cusp cap with composite I’m going to now consider an indirect restoration. What parameters go through your mind in that decision-making? [Andrew] Yeah, again I think the answer to that lies by stepping back and looking at the dynamic and static occlusion by which you’re treating. Look at how long that restoration has perhaps been in the position in place and how well that’s performed in the time. look at the level of fatigue that’s in place there, look at the opposing dentition is there anything that you can do to limit the further fatigue of a more simple direct restoration by for example removing that of a plunger for example, little things like that. The next thing that you need to look at is the ratio of the restoration to the tooth, if you’re in excess of about sort of 50 to 60 percent then I think there is absolute legitimacy for going for a semi-direct or an indirect restoration i say semi-direct because these days we’ve got more options than ever when you’ve got things like semi-direct composite works or pre-cured composites or ceramic hybrids when you’re dealing with milling and CAD CAM solutions. So I think that that world has really opened up in terms of using more robust harder materials that have great ability to protect the tooth moving forwards so if I was in excess of perhaps 50 or 60 percent of the ratio of the tooth to restoration and I was dealing with a static and dynamic occlusion that had the potential to worsen in a short time i would definitely go for a semi-direct or semi-indirect or an indirect. [Jaz] Amazing. That’s such a nice clear guideline and I think a lot of people find these guidelines helpful in their decision making tree and again I appreciate the fact that you’re looking at the opposing dentition, the functional risk of the patient, and the fatigue that you mentioned as well of the restoration as well and that’s fantastic and that leaves beautifully to our last big theme which is how do we manage, and these restorations which are these huge amalgams? Now we’re talking maybe you said 50-60% I’m talking about these amalgams that are 80-90 okay let’s go for 80% of the tooth, right? So upper-lower molar 80% of the tooth is an amalgam it’s been there for a long time but we can see signs of fracture, we can see some ditching and you want to reduce the risk of fracture or catastrophic failure by intervening the problem is by intervening you’re not going to have many teeth left and really sometimes you think okay am I going to remove the whole restoration and commit this patient to a root canal treatment and then put a cusp post in this molar. Are there any other ways around treating this or some things that you some guidelines that you use for decision making because I have to tell you, Andy, I’ve shied away many times I’ve made a treatment plan for a patient for a quadrant but I will just work around that upper first molar we’ve got that behemoth amalgam because I don’t want to touch it any help you can give me? [Andrew] I think the first thing is communication as we said before, Jaz, we’ve got to look at communication and have our patient on board we should not be responsible for owning the clinical problems that the patient presents with okay so it’s really essential to every patient that comes our way that we say look we are here to assist we are here to help here is the problem at hand. Now we have a couple of options here but here are the risks that are the first thing because very very very quickly it can turn on you and I hate to go off topic I apologize but I think that that is so so important to make sure that you as the clinician don’t own the problems that the patient possesses first thing… [Jaz] That is key I love that [Andrew] The second thing is that by removing that restoration as you say when it’s 80-90 percent you run the risk of there being so little to that there’s not anything to work with so you are already telling that patient that root treatment is a possibility and if that is the case how are you going to then restore that too with an indirect restoration when there’s so little tooth that remains. So there are a couple of ways to look at this and I guess some of the more contemporary core build-up materials and I’ll include composite within that are probably a sensible way to then seal the underlying dentine and is as good as anything these days as the researchers suggested when properly treated. So again if we were to then carefully and sympathetically remove the amalgam restoration that doesn’t mean going in with the fast hand piece until you see dentine or worse yet until you see pink what i do mean by that is perhaps sometimes using ultrasonic hand pieces to then try and blast off bits of the terminal part of the apical amalgam if you like i also mean using things like air abrasion to then try and remove the apical amalgam whatever you can do to try and be gentle in your removal of that material is a good way to go and then because you’ve used something like air abrasion you’re in a good place to then try and hybridize that dentine as well as predictably as possible pretty quickly I’m gonna get etch on there and leave it on there for no longer than about 10 maximum 15 seconds and then use a good fourth generation bonding agent like Kerr OptiBond 1 and 2 FL which is gold standard and then put a core in place I’m quite happy to build up a composite core in good nano hybrid composite because that’s nice and strong i know then it’s well sealed to the underlying pulpal area and then perhaps you can carry on your your prep from there that’s all done pretty quickly. You’ve got to be in a situation where you can engage the margins of your restoration. So whether that be by using deflection or retraction cord and whether that be sort of some form of deep marginal elevation whether it be some form of crown lengthening you’ve got to try and make sure you can get onto sound margins where possible especially with direct restorations and I think that if you’re not, if you can’t visualize, if you can’t see your margins then you need to put yourself in a position where you can and that means either doing one of those things we’ve just talked about or then perhaps bouncing it off to someone who can perform some crown lengthening for you or something like that. [Jaz] I think the main takeaway there in those tough scenarios is all about the communication because the dentistry we can do, we can remove and then get some great tips in terms of atraumatically if you like removing these amalgams which is such a great thing to consider and then proper protocols in bonding under isolation to build your core and then considering something indirect from there but it’s all about that conversation in these big amalgam cases so i really appreciate you not digressing but really putting the foundation of that entire topic in its place. Andy, you’ve answered all my questions I really appreciate it so much. So the main two things want to ask now is any final words on this big topic that we covered and where can we learn more from you I know you run some courses and I’d love to know about this because I always get flooded every time I got a really interesting guest like yourself people always message me saying hey where can i learn more about, Andy. So I want to put your stuff on my website but also where you know what kind of where which countries do you teach in now? [Andrew] So I guess the first thing to say is that in terms of trying to then make sure that we adhere to good principles in terms of you know what the subject matter we were just talking about it’s really really important you train appropriately to get to that point where you can prepare the tooth in the most appropriate fashion. If I can just add one more point really quickly, Jaz is that and there’s a lot of evidence that supports the use of something like RelyX™ Unicem as almost like a base if you’ve removed that amalgam restoration then sandblasted. The reason is is because that self-etch is also cured you mustn’t let the dual-cure operate by itself because the exothermic is quite high so you want to light cure it quite quickly but then you can bond to that because it’s self-adhesive so from that perspective that’s a good material to use and then you can then… [Jaz] So like an indirect pulp cap? [Andrew] Basically, exactly that. So to your question, I own and run a company called indigo dent it’s been around for about four or five years now and what i do is teach in composite restoration anteriorly and posteriorly. I’ve been doing composite education I’m so lucky for in my I mean my 13th year of education now with composites and I’ve seen the layer of the land change hugely i’ve seen some wonderful talent emerge in the UK which you know which is just an amazing thing I really like to see that young talent emerge through and so I do anterior and posterior courses. I launched a tooth wear course about four years ago which has been as I’ve been told kind of one of a kind in terms of teaching a lot of the course.. [Jaz] People have been raving on about that my friend Maria Godfrey, she’s always banging on about how awesome that was i think you do it with Govinda right? [Andrew] Yeah, it’s one actually that I’m taking by myself these days but yeah we started off doing that but yeah it’s taken a long time to get the course into what it is now and we, you know, I’ve teamed up with Ashley Burn, who’s really helped me out on some individual exercises and things like that but there’s it’s a pretty heavy going course and I want every delegate to come well rested because you’re not going to be when you come on the course and there’s a lot of theory in it and there’s a lot of hands-on and it breaks through a lot of the mystery demystify a lot of the stuff that’s there and it makes it work systematically in a workflow that I can understand and I can then put across to the delegates. [Jaz] Well, please do send me the website and stuff so I can put that on for everyone to check that out. [Andrew] I will do, I’ll send you the link it’s www.indigodent.com so and then yeah I also offer photography I’ve done that for the RTI and such like so that you can actually get to grips with taking restorations document your work appropriately and do ethical marketing. [Jaz] Fantastic, Andy. It’s been an absolute pleasure and I love that you took this seemingly single tooth issue and I’m so glad you brought these. I’m so glad i wasn’t expecting to talk about constricted envelopes of function but I’m so glad we did because that’s another thing that is something that we don’t really touch on at dental school but this basic series in august that we’re doing. I’m so glad that you touched on it and the role of this episode or role of any podcast is never to give you the complete info. This is just 45 minutes so take Andy, what he’s saying as an inspiration to go and read more. Look up John Kois in the works of John Kois. There’s so much out there that you can learn for free and even when you consider going to Seattle or one of andy’s courses, the learning never stops. So thanks so much for sharing that all with us. [Andrew] It’s worth saying that you know just because we look at the whole dynamic occlusion and dentition as a whole it doesn’t mean we have to treat the whole dentition as a whole. You can still remain to be single tooth dentistry without having to treat the whole arch or all of the restorations there so it’s just a matter of stepping back and looking at the bigger picture. [Jaz] And classifying your patient in terms of risk and failure and having those communications. So great conversations with the patients which you really help with as well. So Andy thank you so much and i look forward to catching you at the dental events, my friend. When they go back up again run again. Jaz’ Outro: There we have it guys the first episode of the back-to-basics series of august with Andrew Chandrapal. Thanks so much for listening all the way to the end. Hopefully, it didn’t get too complex around the whole occlusion and the loss of vertical dimension leading to a constricted envelope if you didn’t understand it, message us let me see if we can help you to understand that and now and again we’re making some helpful infographics you might have seen that recently the protrusive team has expanded we’ve got Erika, Krissel helping me out. We’ve got the producer John, myself. So the team’s getting bigger. So the announcement really I want to make is that if you signed up to my splint course early on and one of the promotions I had hey if you sign up by this date then you’ll be part of the protrusive premium. Well something really awesome is coming to your inbox very soon just give me a few weeks and a really important announcement is coming very soon but anyway check out the next episodes i’m super excited for in two episodes time the episode will be titled ‘Regaining your confidence in extractions’ This will probably be the most profound episode I’ve done to date so I’m really excited for you to listen to that one but anyway I hope you enjoy the rest of august. As always I really appreciate you listening and I’ll catch you in the next one.

Recession is one of the those diagnoses we make all the time – lots of our patients have recession. I always struggled to decide when we should be proactive with recession and suggest surgery – it is very easy to monitor recession through photos and measurements. Specialist Periodontist Dr Amit Patel discusses his decision making when it comes to recession defects. He also discusses his journey which is very encouraging as it teaches us that you DON’T have to have it all figured out from the start…. https://youtu.be/A1b0sL4rJUk Check out this  full episode on YouTube Need to Read it? Check out the Full Episode Transcript below!  Protrusive Dental Pearl: What do you do if your patient is bleeding after an extraction and you’re struggling with haemostasis? You can try placing a hot tea bag on the socket (no, really!) – the tannic acid in the tea bag will aid blood clotting. So next time you have a bleeder in the chair, remember, ‘time for a cup of tea!’ In this episode we discussed: Knowing when to refer recession to a Periodontist for surgery vs monitoring (23:39) Communicating to patients whether to have some treatment done now or later (26:02) Miller’s classification (30:05) Why can we get 100% root coverage (32:36) Do GDPs have a role in carrying out Perio surgery (42:53) Advice for patients to prevent recession to get worse (48:30) Realistic expectations to patients about what kind of aesthetic complications to accept as a compromise (52:01) If you liked this episode, you might also enjoy the episode, Should you specialise? Click here for Full Episode Transcription: Opening Snippet: I've got to be honest the referrals that I've had, the patients don't want to have the surgery okay which is interesting because you know they've obviously been told that they've got a problem, they've got recession but they're just thinking i don't want to go through this hassle, right? So which is fine but what i have noticed during lockdown, I've had a lot more patients contacting me about their gum recession... Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome to PDP 082, all about the management of recession defects not like the crazy like you know get the scalpel out let’s all start doing root coverage. More like how to assess it as a GDP because i find that recession is one of those things right? Where it’s like tooth wear in the sense that it’s common but that doesn’t make it acceptable, that doesn’t make it something that we don’t write down as a diagnosis because i find that you know people ignore tooth wear and people ignore recession because why we see it all the time of varying degrees. Some patients will take it really seriously whereas others will have recession for years and you might be the first dentist to have that conversation with them about recession and it can obviously lead to sensitivity and aesthetic issues So it’s a huge issue and i think soft tissues as a whole is something that needs better coverage i guess if that’s a pun I’m allowed to use.  This episode, I’m joined by Amit Patel, who is a I want to say youthful like. This guy’s like got a baby face right and he’s such a good guy. He’s one of the nicest guys in dentistry very knowledgeable and he’s been on the lecture circuit for like years and years and years. Although you wouldn’t tell from his face he like i said he’s a baby face. He’s going to talk all about how he assesses as a periodontist specialist the tissues and how he manages the cases that get referred to him with the recession and it’s amazing how a lot of these cases, he’s just reassuring patients he’s not actually picking up a scalpel and it’s great to know when we can reassure patients and how far we can go that versus when we actually kind of need to intervene or refer so that the situation doesn’t get out of hand so we cover all those things including prognoses and the beginning we also cover the journey like Amit Patel’s journey and it’s another example of how and why you don’t need to have everything figured out straight away Sometimes things happen, signs come your way, you meet people, mentors and that leads you to a certain path. So hope you enjoyed this episode all about recession as a GDP with Amit Patel. Oh i almost forgot the Protrusive Dental Pearl, so on the theme of recession, recession coverage i guess which is bloody. I’m gonna give you a bloody pearl okay? The bloody pearl is if you’ve got a bleeder right? What i mean by a bleeder is if you’ve got someone carried out an extraction and they’re not settling and they’re bleeding profusely, okay? Here’s a little trick okay? You get the nurse to boil the kettle and you’re gonna make a cup of tea okay except you’re not gonna drink this cup of tea you’re gonna pull out this hot tea bag okay and you’re gonna put it on the socket okay? This works wonders okay? This is something i got taught as a student on an oral surgery seminar and it’s always stuck with me and i saw it recently again on a Facebook group where someone was talking about this trick i was like yeah that’s an amazing trick. So if you’re ever stuck okay then just remember time for a cup of tea. Let’s join Amit Patel and I’ll catch you in the outro.  Main Interview: [Jaz] Everyone knows you in the UK, right? and i don’t know if you know this or not but you were the for me the poster boy for perio chip, right? Like I’d open my cupboard and I see a poster of you, I see you with your little mop and be like five millimeter pocket, think periotive. You and that white shirt and the hair and stuff, so that’s why i think everyone in the UK knows you but for those who don’t know who you are, can you tell us a little about yourself, Amit?  [Amit] Thanks yes, well I’m a specialist in periodontics and I’m from London originally, I went to Liverpool university in ‘92 and worked all over the country and then I decided to do Perio training at Guys in St Thomas’ for four years and that included a bit of implant training and then again I worked all over the country until I moved to Birmingham and started my own little practice here in the city center, Birmingham Dental Specialists and it was going really well until 2020. So because we were going to expand we now just have to wait a bit longer before we do that.  [Jaz] Well let’s see, it’s all hard and I hope things pick up for you again I mean you totally deserve that but how soon did you know after qualifying that you wanted to pursue Perio?  [Amit] Man, that’s a good question, Jaz, that’s a really good question. Let me tell you a secret. So i’m not the best student really bad. I would have left school at 16 become a plumber or join the military or something and just you know been quite happy but my mates went off to you know to do the a-levels that they’re all tagged along and then I went to a careers day the teacher said look you’re good at woodwork maybe you should be a dentist and I’m like okay fine that’s what I was going to do. So then the problem was i went for my interviews and I didn’t get a place because my interviews were so bad because they kept asking why you want to be a dentist I didn’t have an answer then I filmed my levels because i wasn’t the best student in the world i had to reset and then I went again when it came to my university interviews, i went back to some of the universities and they reject me and the only place that was gonna offer me a place was Liverpool that was the last place, the last interview and they sort of said I, we suppose we have to offer you places you haven’t been given any offers and I’m like yes please. That was it they gave me they gave me and then it was i mean there was three Bs you know for the recess but before the resets it was a b and two c so it was it was a bit easier to get in then at that time i did pass my a levels and then went to Liverpool. So the question you asked was why did I, how did I want to do perio? [Jaz] No. But after admitting that you weren’t the best student yeah after saying that you weren’t the best student and then you end up doing a whole perio program what was that about?  [Amit] Yeah, so the thing is again it goes back to you know I realized when I went to uni went to Liverpool within the first term you know we did an operative tech you know op tech and I realized I can’t do this rest of my life you know drilling and filling i was like this is really not going to be for me and but I’d committed myself to the five years and i was having a good time at university so i wasn’t gonna walk away from it. So I carried on you know just scraped through I wasn’t the best student. It wasn’t you know yeah wasn’t liked very much but you know and then in the fourth year we were doing a week at a hospital called Walton and I turned up and on a monday morning and these dentists were doing head and neck cancer operations and I’m like what what is this right and then they said yes we’re dentists but we’re also doctors and I’m like okay so then what was really good about that week was because i was really enjoying it and really enthusiastic they kept dragging me back in to do zygomas and all this stuff to let me do lots of stuff you know plating and all this sort of stuff as an undergrad and i thought I’m gonna do medicine right?  So then the plan was that i was going to go do meds after i qualified and i got my house office job, SHO jobs MFDS and then i also applied to medical school and i got into a three-year medical course at Leeds so yes that was good something now you know I’m, I mean trumpet or whatever but you know i do feel quite fortunate that you know i got that place especially a short course and then i also could make an informed decision that maybe this isn’t the career for me do you know what I mean? and i think a lot of people who do Maxfacts, I’m not again I’m not criticizing their career choices but you know how many of them actually go on and do head and neck cancer surgery? Most of them will become GPs when you look at the questionnaires and all the studies have been you know been published on the doubly qualified clinicians what do they end up becoming? It’s red you know it’s not all of them will become Maxfacts surgeons  [Jaz] So that’s a very very good point for anyone thinking about doing medicine after dentistry i think you’ve raised a good point though.  [Amit] Yeah i mean it’s you know because you look at majority of them they’re either GPs or they go off and do ENT or plastics it’s like well so.  [Jaz] Other specialties skin or whatever yeah exactly  [Amit] Yeah so you know like i know here in Birmingham I’ve met a Maxfacts guy and he’s like niche this is like you know you’re actually a dentist so you know do they dislike dentistry that much? I didn’t really dislike it but what i learned was because i did VT, i did VT for one year and what i realized there i started to enjoy just talking to patients you know i mean having a laugh and stuff like that so i just realized it wasn’t you know i could have done anything because in VT i did we spent one day with an endodontist in Manchester, David Cohen and he works with a guy called Phil Green who’s a Periodontist and David Cohen was just so enthusiastic about endos and i was like i could do this because i realized that i only need to be around somebody who’s got so much energy and i think right i could do that and you know i mean it’s really sad you know i mean you know you know for example i am digressing quite a bit but i went to a lecturer in London a few years ago with a guy called Frank Spear he came and he gave a lecture and i just sat there and i thought if I’d met him 20 years ago i would have done his course and i would have been you know a restorative specialist or something like that you know what i mean and so it’s just it just depends on whoever  [Jaz] Frank Spear is like you know god’s status in this podcast  [Amit] But you see i never heard of him until then and i thought i like this guy you know he’s amazing and you know the same time there was other other people who spoke there and some well-known people that you’ll know and they just did not impress me in this life but he did. He just simplified occlusion and and cosmetic dentistry and there’s all these other people talking about it in a very complicated way and i thought no but he was very good and maybe because he had age on his side and you know he wasn’t you know hasn’t had got anything to prove or something like that but it was good but going back to the reason why I did perio so I met this endodontist and then they took me out for dinner Endodontist, Periodontist and they sort of said i said right i’m not sure i think i’m going to become a specialist because at that point the specialist training pathways were put forwards and the register was already set up at that point just like a year before and so the periodontist said ‘are you good with the scalpel?’ said I’m all right with a scalpel because i did loads of oral surgery right and he says well then do perio and that was the only reason why I did Perio no other reason so then i rocked up at Guys in St Thomas’s for my interview and like i said before my interviews are really bad right and that was one of my worst interviews ever. So my CV said you know Maxfacts, SHO here you know there or whatever and he’d done this publications and all this sort of rubbish and the restorative guy there I’m not going to mention his name who i dislike quite strongly and he knows how i feel about him because I’ve had a conversation with him  [Jaz] Maybe he’s the same guy I dislike, actually we’d love to have the chat about. We’ll have a little chat about who that is after the podcast ends to see if he’s a mutual person that we dislike  [Amit] He’s a very prominent individual and he will now walk the opposite way because he knows I’m not going to take any conversation from him but so he sort of said so your CV says you should be doing Maxfacts and I’m like yes but I’m making an informed decision because i want to do i said you know i really enjoyed dentistry and you just wouldn’t give it in and I wanted to turn and say do you realize that i have a place at medical school and you never did so (beep sound) I had to keep my mouth shut you know what i mean which is fortunately they did turn around I mean the the head of department turn and says you know essentially we’re going to offer you a place because you’re the only British candidate and so I got in otherwise there’s no way on this planet it’s so competitive you know there’s so many you’ve heard of all these some of these on social media  [Jaz] You’re being way too harsh on yourself i mean getting way too harsh yourself  [Amit] No, it’s the truth it’s honest truth because you know there’s all these social media periodontists and and you know they have you know they have worked very hard they’re very very you know academic and and you know they’ve got there because you know they’ve ticked all the right boxes there’s no way you know if I applied against them I would get in you know what I mean but what’s funny is that someone will ask me saying you must have been a a-star student or whatever it is and I’m like no really I just scraped through you know and it’s a really really bad story because essentially when I did the first year so I deferred medicine for one year really and that was a that was just because i was trying to play the odds you know and I did the first year and it was I was just we were just cleaning teeth and i was thinking this is what am i doing this for for another four years? So then a really good lecturer his name is Dr City, Allen City, he works on Portland place in Central London and I just said to him listen, I have I’m thinking about dropping this course and going back to leasing to finish just doing medicine and do Maxfacts and he goes listen have it come to my practice and see what I do.  So I just rocked up at his practice on a on a monday morning and it was it was so good you know he sort of you know yes you know we clean teeth but he showed me bilateral sinus lifts and he let me you know assist in them quite significantly more than you know you know as in I would do the lifts and he’d do block grafts and all this sort of stuff he did so much in that day and I thought actually this is really good this is lots of surgery that would keep me interested and then i just turned down the place of medical school and carried on with perio really and I’ve never regretted it you know. I’ve really enjoyed it and what I’ve learned  [Jaz] That’s really cool that Allen City that he almost took you under his wing right he almost took his ring and and he if it wasn’t for him you you may have dropped out that perio program so i think sometimes to identify these individuals in your career to trajectory whatever you end up doing and and they sort of swing you and they and they take you and they really change the course of your career so i think it’s great that you’ve identified someone like that and it’s great that he’s part of your story  [Amit] Yeah, he was, you know, he’s such a good friend and you know I always used to ask him for advice and stuff and whenever you know if I’m in London I’ll go and knock on the store i just love hanging around with him because again he was just enthusiastic but he helped me make a good decision you know it wasn’t because i mean for example if i was doing i mean I’m 48 years old now right, I’m 49 gonna be 49 soon but essentially you know i would be a maxillofacial consultant at this age right and i would have probably been a consultant by the age of 44 and you know i would have been anywhere in the country and then I’d be working with it within the NHS constraints because essentially you can’t have so many specialties doing head and neck cancer. You can’t have plastics, ENT and Maxfacts in the same hospital doing the same sort of surgery so you know the funding is reduced. So it’s like you’re so highly trained and then i might be just taking out wisdom teeth or fixing fractured jaws which is not an issue you know but you know I’m really happy and actually what’s been good you know talking about you know people who’ve you know helped me guide me in a really good way because there’s another individual. So when I came to Birmingham Prof Chapple. Iain Chapple offered me a job working there because I had no work you know just trying to you know but Birmingham is very NHS there’s very few specialists here to be honest there’s only three periodontists in the city and you can see why because most the specialty training is in London so you’re to build a network there and you’d stay there and so Prof Chapple, who is just an exceptional individual you know two years ago he won the best scientist award in the world you know that’s pretty impressive you know what i mean and so he’s taking me under his wing and he sort of let me do what i want and he you know he sort of because of him, I’ve been able to get onto the international circuit, Lecturing circuit, you know because he’s part of the EFP, the European Federation of Perio and I’ve lectured twice at Euro Perio where we get like 13 and a half, 14 000 people at that event once every three years. So it’s because of him that you know maybe you know my name’s a little bit more prominent I’d say yeah but going back to the Perio training.  [Jaz] That’s great it’s it speaks volumes about you as well Amit but it does speak volumes about you the fact that Iain Chapple, Prof Iain Chapple, I mean what a huge name in the world of Perio and you know he saw something he knew that he liked. So there there is a lot to be said about that my friend so that’s awesome yeah please do tell us because because what this episode is evolving into is your journey which is important and i like that and so tell us a little bit more about your journey and then I’m going out to the more clinical bits so this episode will have almost two arms, the journey part which will be really useful inspirational for a lot of people and then when i get to the nitty-gritty of recession  [Amit] Yeah, okay cool, so going back to the Perio side about it so you know i did the four years and the training I’ve got to be honest the training within the UK maybe it’s changed now i don’t know but it was quite limited in my mind because you know I looked you know you look at all the colleagues around the world doing so much more and it was like it was very limited I’m not sure why it was limited but I mean in four years i placed only 13 implants and that’s not very good for someone who’s coming as a specialist you see so so obviously when i came out i knew my limitations i didn’t you know just because i had the word specialist didn’t mean i was going to be you know thinking I’m the best and that’s you know and still not it’s not the case. So i went and then sought out other dentists around the country there’s like a friend of mine called Paul Stone, who’s an exceptional implant dentist I’ve been watching these you know there’s some people like him and a guy called Jonathan Ziff you know placing implants and i realized actually you know these are general you know they’ve been doing it for such a long time and it built my confidence about what i could do and then i went abroad for a month to Milan with a another guy called Giulio Rasperini, he’s a professor there in periodontics and i met him at a lecture in London, i don’t know now maybe 11, 12 years ago and we hit it off really well and he then set up a course that i could attend and learned loads about periodontal regeneration because the techniques that we were taught in the UK were very limited in that and the surgical aspects of periodontal regeneration have changed massively in the last 10 years, 10, 15 years so i spent four weeks with him and became part of his research group for a bit so and that network then allowed me to  [Jaz] You doing research, Amit? Sounds very studious to me. [Amit] It’s not they give you products you use and you have to then you know you know take the correct measurements, correct photographs, the correct surgical techniques and then they’ll be publishing that within a year or something like that yeah so yeah i still do some of that also within the practice with companies like Geistlich and i’m actually in the middle of doing one now but obviously the whole COVID situation made that slowed it down significantly but i’m going to get my friend (Julia Russellini) and his team involved in that as well now . I was working with that with the Professor in (burn) but things are just complicated now. So it’s been good it’s been good actually i’ve you know i’ve met some really lovely people on my journey.  [Jaz] Amit, should we dive into the recession aspects  [Amit] Actually can i digress again? Is that okay? So go back to my journey as you put it. One of the things because you know essentially you know when a dentist meets me they’ll say well I’ve had a few dentists when they especially when they’re a bit drunk would turn around and say how’s it going with the cleaning of your teeth and I’m like he’s going fine and you know but it doesn’t bother me in the slightest right because i do see myself in the glory you know. I have no insecurity about my what i have done, right? I don’t care about anybody else really, okay? But so going back to you know so when i lecture i still say I’m a glorified hygienist, it’s not an issue right? you know I’m quite content with what I do. So you know all the aspects that i thought was going to do all this surgery and stuff it’s not really the case because what I’m finding out is well found out early on as soon as you give the patients the right oral hygiene techniques and and the motivation you know. They fix the problem and that’s just the best fit and that’s what i enjoy about my job because essentially all I’m doing is just talking, having a laugh with my patients and just saying you know if you do this you’re going to be fine you know and okay there are cases when you need to do surgery or whatever but it’s not that often you know and what I’ve learned now that what i like about dentistry is you know the relationship that you build with the patient you know and the way you communicate with them and you know it’s just fun you know it’s you know the work isn’t hard you know it’s just there to build a relationship and you know that yourself you know and that’s what’s gonna give you longevity as a clinician isn’t it?  [Jaz] Well I bet your patients absolutely love you, Amit because you’re such a you know a likable guy, your a character who’s just so easy to talk to and the very few phone conversations we’ve had you’re just hilarious so very like straight up real. I think people are sensing that already you speak your mind and that’s exactly what i what i like about you so we could you know speak your mind about recession now because what i want to know essentially, Amit and feel free to tell me I’m an idiot and that I’ve been doing it wrong is that i come across a recession a lot. General practitioners we see in our patients, right? And it’s this mentality that we have sometimes that A) you know what it’s not painful you know Should we just watch it. Should we just watch and wait? So i think i am kind of proactive in the sense that I put it in my diagnosis I inform the patient is there i know about the Miller’s classification to some degree but i want you to just touch on that a bit later i take photos and I kind of follow it up but i feel as though because I don’t do soft tissue surgery myself and i don’t do these procedures that maybe i you know you could say that I’m doing supervised neglect so what i want to know from you is at what stage is just watching and waiting and or and just observing the recession neglectful? At what point do you think GDPs should be referring recession to periodontist?  [Amit] Okay so it’s a really good question. It’s got multiple facets hasn’t it really I mean, see the thing is if you look at all of the historical studies based on you know for recession so for example there’s a guy called Klaus Lang and he looked at you know when, how much attack, how much crystalline tissue, how much attached tissue should you have around a tooth so you can stay healthy? So he sort of came up with a number of two millimeters. Now, there are other studies that almost show that you may not need any keratinized tissue or attached tissue around a tooth because essentially it shows that yeah okay it looks like the tissue’s inflamed but they’re not right? Histologically they’re not. Okay it’s just the way they look and that was the study done by Mia Sato but but the reality is when you think about it in our own patients you know you see patients with you know a loose bit of mucosal tissue around the tooth they can’t clean it, we know that you know what i mean so all these studies are great right? But you need to look at the patient individually and think hang on, you know if they have to pull their lip right out to clean that area they’re not going to do it are they? You know so i think, so i get when i get patients referred to me for recession i mean obviously i can fix it it’s not an issue but i look at it and i think does it actually bother you and if they say, No, I’ll say right fine clean it well, if there’s a problem come back to me in a year’s time and then we’ll look at doing it, do you know what I mean? As long as there’s a lot of there’s you know there’s some band of attached tissue there  [Jaz] But sometimes patients don’t know because a patient may be referred by their general practitioner who’s concerned about the level of recession. Let’s say you have an upper molar and you notice there’s you know a four millimeter of recession and you haven’t got any attached gingiva left so you refer to periodontist. Now for you as a periodontist if the patient says look my dentist is concerned if you say that, if you ask the patient are you concerned the patient might not know what’s around the corner if they don’t have any soft tissue you know treatment i guess so. What’s the best way to communicate to a patient to find out whether it’s in their best interest to have some treatment done now or later?  [Amit] So okay so the way i look at it is so let’s say you’re talking about that upper sixth okay i mean we see loads of recession around up to six and they’re not always the easiest to repair, okay? But the good thing about those is they usually have a quite a good band of keratinized tissue. Now in those cases i would you know just tell them how to clean the teeth and then monitor it enough not for a long time just for like you know for six months or a year and then maybe have a look at it. I’ve got to be honest the referrals that I’ve had, the patients don’t want to have the surgery okay? Which is interesting because you know they’ve obviously been told that they’ve got a problem, they’ve got recession but they’re just thinking i don’t want to go through this hassle right? So which is fine.  But what i have noticed during lockdown I’ve had a lot more patients contacting me about their gum recession and it’s interesting because I’ll say to them if it doesn’t cause you problem that’s cool leave it alone but i think it’s only because they’re looking at themselves on these sort of platforms right and I’ve done far more mucogingival surgeries in the last six months than I have done, you know, all last year right and there’s multiple especially the ones here okay, in the lower anterior region and i think and it’s what’s interesting is you know I like you know I’m very honest with my patients i say to them listen .you’re going to have a lot of bruising while swelling after this. you won’t be able to eat hard foods or brush that area for at least three weeks because we don’t want the gums to be, you know, to be pushed down and you know it’s not that’s not a pleasant thing to go through for three weeks right but now all the patients are quite keen to go ahead with it but I’m going back to the question you sort of said how does the GDP sort of explain to the patient that this could cause a problem  [Jaz] But the urgency of it?  [Amit] Yeah, I don’t know how to word that to be honest because the thing is all around the world I mean  [Jaz] Am I carrying out supervised neglect basically because a lot of times I say what you say i say does it hurt and they say no i say ‘you know is it getting worse no but it’s significant and it’s you know it’s obvious and i’m just thinking sometimes gosh should i be referring more of these people to a periodontist now offer the referral but a lot of people like yeah can we just watch it and i say yeah i guess we could but is there a point would you say there’s a clinical point at which you know is there a number like a x millimeters of recession or whatever at which point we should be a little bit more proactive is there anything like that?  [Amit] No, I’ve got to be perfectly honest with you so there isn’t because as long as you use the classification so i mean i have had patients where we’ve got eight millimeters recession in the lower anterior okay and you know i can still fix that and i can get 100% recovery so there’s no limitation on when you do it so for example if i have a patient who wants orthodontics right? And you know Invisalign or whatever it is you know, it’s usually Invisalign and and it is usually with Invisalign where the teeth are moved out and then you get all this recession okay? So I want them to have the orthodontics first then i can come back and fix the recession defects does that make sense it’s I can do you know you can do stuff.  [Jaz] That’s good to know actually  [Amit] Yeah, you can do stuff like you know you can reshape the enamel and the root surfaces in such a way that they bring them back a little bit so then you can put a big chunk of tissue graft there and it works really really well you know. What i have had recently  [Jaz] You touched on the classification just give us a guide about these just tell us about the classification just educate us about the classification of those listening. We’re talking about miller’s here right? I guess.  [Amit] There’s lots of classifications now that’s the best that’s you know we as dentists love multiple classifications you know you look at a classification and you know you and i will use you know the tile classification which has been around for like so many years and that’s simple you know you go in through you know less less than a third or you know less than two you know all the way through and through is three and then anything in between is two but there’s multiple versions of it with different people with their classifications. So Miller is the first one and i like using that right? There are newer versions and i’m quite content with PD miller’s classification and essentially what he says is if you’ve got proximal bone in between the teeth in between the roots and if that’s higher than the recession then you’re gonna get coverage at that point does that make sense? Because you’re getting blood supply from the peaks of the bone so if you’ve got a tooth and you’ve got mid-recession, recession in the mid of the tooth but the bone peaks are higher than that you’ll be able to achieve 100% root coverage i think does that make sense okay and that’s the Miller class I. [Jaz] No, it makes perfect sense think that’s sort of described quite well.  [Amit] And then the Miller class II essentially is the recession defect that has gone beyond the mucogingival junction which is where the band, the keratinized tissue is and then you’ve got the loose mucosal tissue and then as long as you’ve got no bone loss then you can get 100% coverage. Miller class 3 where you’ve got some bone loss between and i’ll tell you why actually in a Miller class III, you got bone loss and essentially you’ll only be able to if you’ve got two millimeters bone loss you’re only going to be able to achieve root coverage two millimeters below the cementoenamel junction so where the bone is does that make sense? So you’re only gonna you still get exposed dentine but you’ll get attached tissue in that area and a Miller class IV is technically periodontal disease because you’ve got recession that is the bone is below the level of the recession so essentially you’ve got a pocket  [Jaz] Tell us about why we can get 100% and then i’m going to tell you about a scenario with a patient i had actually  [Amit] Okay, so let me explain this to you actually because going back to you know [Julia rasporini] and some of these Italians, the techniques have you know they’ve pushed the boundaries they understand the anatomy of you know the tissues and the tissue planes and they understand what they’re trying to achieve right? So i’m a, you know, technically I’m gonna, I’m a refer, you know, a referral oral surgeon that’s why my friends call me i’m a reformed oral surgeon. So when we were ever trying to close a flap and we couldn’t get closure we just make a cut in the periosteum right okay and then you just keep slashing the hell out of it until you get closure, would you agree? that’s what you’re taught at university right? Now the problem with that is you’re making a cut that’s into muscle and when you’re cutting muscle, you’re cutting nerves, you’re cutting blood vessels and that’s why patients get tons of bruising and swelling right? So that’s what i would do on a regular basis because that’s what i was taught and even when i was doing my perio training that’s what i was taught right? And so when i was doing like say if i had an eight millimeter recession defect in the lower central and i try to currently reposition that i would never get 100% root coverage because you’ve traumatized the muscle to the point where it’s gonna shrink back significantly.  So in the last ten years there’s a guy called Massimo de Sanctis and there’s another chap called Giovanni Zucchelli. The two of them sort of looked at coronally repositioned flaps and mucogingival surgery and they proposed the technique of split, full and a split incision in the flap. Now you know it’s easy to say you know you’re splitting the tissue first and then you’re doing a full fitness flap and then you’re doing a split further on. Now this may be a bit complicated but essentially what you’re doing is you’re making an incision in the periosteum and you use a sharp blade just making a small incision in the periosteum and when you do that and unless i mean you know if you know people are listening if you’re doing any surgery on the next day or whatever it is maybe try and just have a look you make incision in the periosteum and you’ll sort of see it gape okay then you’ll see the little fibers of the muscle there so all you have to now do is you get a periosteal elevator and use the back end of it and you gently start stretching it and as you stretch it you’ll see the fibers spread so now you haven’t cut the muscles you haven’t, you’re not going to get the bruising and the swelling that you would have done if you cut the muscles and by doing that you then going to get a significant movement in the muscles sorry in the mucus or in the mucosal flap then what Giovanni Zucchelli does is then gets it then takes a scalpel and he then makes an incision a superficial incision so that the muscle separates from the mucosal tissue, right? So essentially what you then do is you know we know that the mucosal tissue is elastic so that’s going to advance all the way to the palate if you want halfway down the palate it’s amazing when you use that technique. So now utilizing these techniques i’m now able to get 100% root coverage before especially the lower anterior because of the mentalis muscle my predictability wasn’t that high and now i can guarantee my patience i get they’ll get 100% root coverage  [Jaz] Why are Italians so amazing?  [Amit] Right? I think it’s their food and their wine it.  [Jaz] Must be because honestly in every field of dentistry at the moment where it comes from when you talk about verti preps to perio to any field nowadays there’s always some italian you know thought leader or someone really progressing there you know.You’ve got your Marios and Menzers and [Macerarones] of the world and whatnot and prosthodontics as well so it’s just crazy  [Amit] I’ve got to be honest and I’m going to be very critical of you know the training we have here in the UK you know as a dental student or as a specialist trainee. You’re still being trained within the national health service right? It doesn’t mean you’re going to be good right and i think when you look at you know so for example you know i talk i do accelerated orthodontics and you make Piezo incisions into the bone you know we have patients whose teeth will move if you have an in you know orthodontics which could take two years you can do it in six months you know so you and I know majority people around the world have this done right but here in the UK you know your people will turn and say well the evidence is very weak but you know you’re choosing to find evidence to say that and it’s like you know the truth is if you look at the evidence as well for it it’s very very good you know and I’m definitely not in the camp where i want to limit myself to not give my patients all the best options.  So i think when you look at the Italians I think their litigation rate is significantly low you know the patients trust their dentists massively and so they just push the boundaries and you know and if it wasn’t for people like you know the Italians or some of the, there’s another guy called Istvan Urban, he’s a hungarian you know all these people pushing the boundaries you know we won’t be using these new techniques but yet you know people are bringing them here going look what i can do and actually it was done about 10, 15 years ago you know. So it’s for me very few  [Jaz] Two great points there, Amit. One being the training and I think that’ll be a bitter pill to swallow for many people but i think you’re being very real and i respect that and i can see where you’re coming from with the training that is present undermined within this national health system and i completely respect that but the other thing is that dentists in other countries where they’re less regulated they can be and i don’t want to use this term by will a bit more gung-ho but I mean that in the sincerest way right they can do something wanting to do the best for that patient but not worrying about oh but if it goes wrong then this is the end of my career. They can do something to advance, science advanced dentistry and to for the benefit of that patient without worrying about the potential repercussions so for example when i moved to Singapore I actually, I did feel as though this massive weight had been lifted over my shoulders and i can just push my own boundaries a little bit. So wisdom teeth for me, surgicals I gained so much more confidence because i wasn’t it’s like i broke away from the shackles of the GDC for that time which is i think it’s wow i didn’t you know you really raised a great point there  [Amit] Yeah, so let’s see that’s it see this is the problem you know you know so there’s a is it Frank Herbert, he wrote the book ‘Dune’. I’ve read that and the most important thing that i that was good in that book was you know fear is the mind killer right and it is this is the problem you know you meet all these young qualif- young dentists just qualified and they’re all you know you speak to these VTs and or they call VTs or foundation dentists or whatever it is but i like to them on a regular basis but and then you sort of ask maybe 15 of them and seven of them say they want to get out of the profession it’s because they’re worried about being sued and they’re worried about being struck off by the GDC and it’s like you know when did that happen and you know it’s really bad you know and you’re right about gung-ho you know we know there are some rubbish clinicians out there who will you know try to find a technique and sell it to you but you know fortunately you know people like yourself and myself we know who are the right ones. We want to affiliate ourselves with and you can see they’re showing consistent results you know so but i think here in the UK. Are we pushing the boundaries here? The answer is no, right? And you’re right about the bitter pill to swallow you know if i was a trainee and you know people will say oh i met you know he’s talking again and but you know what i don’t care because I was i did the same thing and i saw the limitations now the problem is they need to justify that you know what they’re doing. I don’t have never had to do it you know I’ve just been plotting along i mean if i had a real plan i would have taken over the whole world you know but I’m just like yeah I’ll just give this a go, I’ll do this whatever you know but i think the sooner.. [Jaz] One thing that leads to.. [Amit] The better really then you can you know like you said get away from the shackles and just become you know better than you want you know better than you are now do you know what I mean?  [Jaz] That’s fantastic and what i want to know now is it leads very nicely to GDPs now doing soft tissue surgery perhaps to do some recession coverage. So i know that in other countries gdps have been upskilled to do soft tissue surgery whereas in the UK because of all the things that we said about litigation and stuff in fact i’m not gonna name him but this fantastic truly brilliant dentist in Yorkshire, I believe he unfortunately had a GDC hearing about a perio surgical case that he was doing actually and it was so sad to see that he was going through it because he was truly remarkable GDP but then you may know who i’m thinking of we’ll again we’ll chat at the end about who this person is really great dentist and then unfortunately he fell short because he wasn’t a specialist you know it was almost felt as though he overstepped the line. So where do you see the role of GDPs and doing perio surgery is that, do we have a place in that?  [Amit] See the thing is i don’t ever read any of the GDC newsletters to send me. So i’m not in no so i don’t know what goes on only because you know but you know it’s just not you know but so when i’m teaching so i teach you know GDPs on how to do root coverage and does do many of them go and do it, no, right? But i do tell them you know you should try to do this you know and the way i look at it and i have and i’ve got to be honest right so again when i came out of Guys i did 12 root coverage procedures after four years that’s not good enough right? Okay so and there were others in my year that had done, okay?  So going back to that so what i the way i worked my way around that was to say to a patient listen we’re gonna do this procedure and we’re gonna try to improve the quality of the tissue here okay and so that you know it’ll be easier to brush and that’s what that’s essentially what we’re trying to do right now I’m not going to say to my patient I’m going to get 100 coverage because you know especially when i haven’t done that many does that make sense and you know even now when i talk to my own patients i say you know i say the same thing so we’re gonna try to improve the quality tissue and we’re gonna try to cover as much as we can and see what happens you know and it just i want to play down my patient’s expectations but if i can then do better then it’s sorted but that’s a real shame about this individual because i do think dentists should do it right because if you think about this dentists are replacing implants right? They’re doing a surgical procedure and they’re doing something that’s even more complicated well not really but it’s still complicated and you know so why not try to use these techniques as well do you know what i mean but don’t over you know and the way i also when i’m explaining to my the delegates who on the courses i say to them you know ‘do on a case where it’s not an aesthetic issue so it’s only going to get better. ‘So when you’re doing these sort of root coverage procedures one of the most important thing is you can’t technically mess it up, okay? Because you’re putting soft tissue on the gum next to the tooth and if you cover it up nicely it should work and if it doesn’t if get some shrinkage of the flap you’re still going to get more root coverage than you had before does that make sense?  So that sort of gave me confidence thinking okay i can do more of this and when i was doing these at the beginning you know you know even up to even five years ago I’d be charging a couple hundred pounds to do a two hour procedure two or three hour procedure you know and even now you know when i see patients that i want to do on i’m gonna charge them like the same price because i really want to do it you know. It’s not a massive issue i just like keeping my skill set up really. Yeah so going back to the case. Sorry i do think dentists should be doing these sort of procedures really i mean you know within their remit you know this if they don’t you know if they’re doing recession from six to six then maybe you should get a little bit more experience in it but you know if you’re doing the odd one you know it’s not an issue especially if it’s part of a cosmetic case you know if you’ve got, you know, I mean how many dentists are doing crown lengthening right? So if you’re doing crown lengthening you know then you could do some root coverage procedures and actually the way i look at it is you know when i call when i went to university in 1992 you know dentists came out when they qualified back then before i did they were doing perio surgery, they were doing free gingival graphs, they were doing you know really difficult wisdom tooth. They’re doing such complex restorative work and now it’s sort of almost limiting what a dentist can do and that’s a real shame really i think you know why spend five years at university when you could just do [Jaz] Massive shame  [Amit] Yeah it is a real shame and i think you know young dentists  [Jaz] And i think the fact that you’re encouraging GDPs to do soft tissue is like it adds a you know variety is the spice of life it’s the same in our careers as GDPs if you can do if you can dabble in a few other things safely and i like what you said there you know choose the easier cases and build up so i think that’s definitely food for thought for any dentist out there who thinks that is beyond their scope i think you know a bit of root coverage once you have the training should be within any one scope and certainly I’ve seen loads of GDPs you know university or Facebook nowadays sharing their cases which is the beauty of social media. We get to see humble GDPs and specialists and whatnot share their cases and you we get inspired from what other GDPs are doing especially in other countries so i think we can definitely take a leave from their book but i mean because in the interest of time two main questions left now two main questions. One is when you have that patient who’s been referred to you and you’ve had that sort of conversation and the patient really doesn’t want to have anything done because quite often they don’t want to have anything done right like you said and you’re happy to monitor it. What advice are you giving them to prevent their recession from getting worse? What’s the blanket advice that you would give it would be really nice to know? [Amit] Yeah so that’s just the same as everything in perio for me so you know we get the patient to, so in my practice i get my patient only to use an oral b electric toothbrush okay the circular headed one and you know if and i show them how to use it in a particular way so that they can’t cause any more recession okay and i think the problem is with dent with with patients is they usually try to hold a toothbrush in their fist right so they scrub away and we know that you know you know there’s multiple risk fact, you know multiple causes of recession and one of them is over self brushing and i do think i mean let me ask you, how do you hold a toothbrush?  [Jaz] I do hold it with the fist grip but I, you know, i’ve got the sensor, I use oral B i’ve got a sensor so i’m not you know going beyond the red center right?  [Amit] It means nothing you see the problem is you’re still holding in your fist. Now can you write with your fist, you can’t, can you?  [Jaz] No.  [Amit] So would you drill a tooth with your fist? you drill that you drill a tube like this don’t you? and this is why i tell my patients when they brush the teeth you do each tooth individually painting each tooth where the gum line meets and think about exactly where each tooth meets does that make sense and it’s always a vertical action and then you can use your left hand to get in the lingual aspects whatever you need to because then there’s more dexterity does that make sense and that’s the most important thing information. Use the oralB toothbrush correctly like a pencil and paint each tooth individually and that’ll maintain everything but all my patients will use interdental brushes because when we look at all the evidence which is now about six years and i looked up all the systematic reviews and they showed that essentially we should be using interdental brushes because we’re not very good at flossing and that’s it really. So if they do that i can monitor it, take a nice photograph, see the patient six months a year and if nothing has changed then you know then we’re good but if they’re complaining of sensitivity or whatever then we can you know get them to use a desensitizing toothpaste on it or you might then perform mucogingival surgery to achieve root coverage  [Jaz] Brilliant! The next one is as a patient-specific one. I want you to throw this scenario at you and the listeners there’s a patient i had who had periodontal disease and this would be something like a 3c right with the under the new classification for those listening there were pockets of around about let’s say five six millimeters anteriorly there was inflammation and i consented the patient i said look if we start improving your oral hygiene obviously first and then we will start doing some non-surgical periodontal treatment you will get recession because all this gum that I show in the photo is is almost like a diseased fake gum this has got to go you know you’ve lost it this is this is bad, this is going to go you’re going to get recession and then for that reason the patient funnily enough denied treatment she was no longer wanting to have non-surgical periodontal treatment and i said to her well this is in the old saying right it’s better to be long in a tooth and have a tooth no longer but yeah but how can you, the question I’m trying to get to, is how can you set realistic expectations to patients about what kind of aesthetic complications they will or compromise they will get after periodontal therapy?  [Amit] Okay so that’s, it’s a really good question and i also like the way you just said that you know better to be long in the tooth then tooth no more so that’s good but so one of the things. So if you think about this right so when i when i become a periodontist you know all i was teaching people was how to brush your teeth right and that’s not easy is it because you know the patient when i used to try to do that the patient says you know would make a complaint that i wanted the filling and I’ve not had a filling. Well they didn’t need a filling they’ve got periodontal problems all right so I’ve sort of learned to work things differently without being offensive do you know what i mean because the guy would you know the patient would say well this young up starts trying to teach me to brush my teeth you know so and one thing that i so for example i ended up having to do the Ashley Latter course okay not because i wanted to do it right? I had really good friends implant dentists that do it on a regular basis you know friends like Bill Schaeffer and Stephen Jacobs and bill Paul Stone. They did it on a regular basis and they said i meant you need to do this and my girlfriend was saying you need to do this course because you don’t you haven’t got a clue how to make any money right? So i did the course and i learned from that in the way you need to communicate with the patient but someone like you, Jaz right you know how to communicate with the patient and get the best out of the patient do you know what I mean? Whereas i don’t think many dentists understand that so i obviously Debatable, i mean it’s very kind of you’d say i’m still always improving Yeah, i think you do i mean when i talk to you on the phone and just sensed and you know i can sense the way you are but so for example when i have a patient they’ve been referred to me and they have the same sort of problems as your patients have and I’ve had patients like your patients who never come back and see me all, right? The most important thing here is that you’ve written your notes down and you’ve told them they’ve got a problem that’s it you’ve done your job right? So that’s the most important thing the the take-home message for all anybody listen to this you’ve written your notes down, you’ve told them the score and that’s the end of it you’re telling losing you know if you’re not going to have periodontal treatment you’re going to have increased recession, increased sensitivity to your teeth and that’s it.  Now going back to after Ashley Latter’s course what i learned was i had to find something positive to say about a patient. You see the problem is as dentists when the patient comes and sees you the first thing they’ll say oh you’re going to tell me i’ve got bad teeth you’ll tell me i ate too much chocolate and then all you know the same old rubbish that we’re supposed to talk about right and so when a patient comes and says to me oh you’ll say that i drink too much i say listen it doesn’t have an impact on your periodontal problems i’m not fussed right it’s your decision right? so that’s fine right a patient says to me they smoke 20 a day i said well let me let me just tell you once i want to say once only smoking increase your risk of periodontal problems and if you even there’s evidence shown that if you cut down that improves things and even if you decided to vape you’d be able to give up and i give them the spiel and i said but it is your choice i will still help you know what i mean i think the more you inform the patient and treat them like a human being so when it comes to these cases where they’ve got a huge amount of periodontal problems and you’re going to cause massive aesthetic issues and i do that to all my patients right? so what I’ll be saying to them is listen all right I’m not i let me apologize first I’m not here to patronize you so i do apologize so what’s the first thing that patience says to me? [Jaz] I don’t know i mean i like where this is going because you’re starting off with the setting they’re setting a really nice comfortable environment right you know you’re saying a comfortable environment here for the patient  [Amit] Yeah but Jaz if I turn around and said to you so listen you know you know let me apologize to you know everything i want to say to you is going to come across patronizing so i must you know so please forgive me i apologize what are you going to say to me?  [Jaz] I’m saying oh no that’s fine carry on.  [Amit] There you go you’ve given me permission you’re giving me permission haven’t you now to almost go for the kill right and then i will say to my patients in a way  [Jaz] Oh this is brilliant i’m so glad you mentioned this because here’s something that I do, Amit and I think you’ll like this a lot actually is when i see patients with with suboptimal oral hygiene right and and this this is definitely something that we’re both doing now i realize is you have to you know if you keep banging on like a broken record like oh you need to do this you need to do that it’s too negative so just like what you do I you know you say that’s your way of getting permission I’m very direct I actually say hey can i have your permission to just show you a couple of areas where if we can improve then I’ll be so much happier and your gums will look amazing that’s why i say i said can i get you i literally say can i with your with your permission with your kind permission whatever and i show in the mirror and i find i get such better results when i instead of saying look you need to brush back here is that hey can i get can would you like to for me to show you can i get your permission and just like what you said it’s so much more powerful  [Amit] It is and this is and this is one thing that works really well you know something I’m not here to blow my own horn or trumpet or whatever but essentially you know something i have a referral practice and my perio uptake is like 98 okay now obviously the dentist done the hard job saying listen you need to see Amit he’s going to help you and then I’ve had to you know convert that so it’s obviously easier right so going back to this this this the way i speak to my patients I’ll say you know but you know we have many patients like you right that have the same problem and I’ve been able to help them so you’ve been positive about it right then I’ll be saying well the only negative is you know we have you know because we have we essentially have this much pocket right and the gum is going to shrink back so i say you know you have a tent. If you have a tent standing on the on grass the tent poles are much further down we need to push the temp down and they’re like they understand the concept of the disease that way and then I’ll say to them you know so the negatives are that you’ll get recession and you’ll also have sensitive teeth but the most important thing is you’ll be able to keep your teeth for many years to come so then you’ve been positive at it you’re ending it with a positive right and majority of my patients I’m happy to have that done and then if i and i think one thing that really works for me is to give them a story you know just like you would you know you I’ll say well listen but my mom has really long looking teeth she’s a smoker smoking from the age of 14 you know and you know even she’s got a recession of a tea around you know the gums and she’s got sensitivity of her teeth and i say well you know it took her six to nine months before she could eat you know an ice cream but she did all these things. So she’s sort of sort of saying well i did that same thing to my mom so they understand that you know this is part of the process so i think that’s the way that’s the way I give with the aesthetic concerns explain it to them and i always explain look our aim is to keep your teeth for many years to come. That’s the main aim, you know, and that’s what they want to hear and i think that works quite well i mean so if for example if aesthetics is a massive issue they’ll find out at a later date you know because you know i can show them photos of what it can look like but i don’t do that anymore at all just say look we can do this for you and and they’ll go for it but if aesthetics is an issue you know you can make gingival with veneers you know to close up some of the gaps and they work really well. The good ones are ones that are made by it’s a german material called mol plus but val plus is not a good material or acrylic is not good but here in the UK then i don’t think there are anybody making them at this point in time anymore but go back to recession what we can do now it’s so difficult to make and quite costly for the labs to make and it wasn’t profitable so but going back to recession you know so these kind of cases you know they’ll have loads of recession around all their teeth what we now can do because there’s a lot of clinicians out there.  So there’s individuals like [Pat Allen] and who else [Sofia Rocker] as well as [Tony Schoolian] these are all periodontists. So Sophia’s from Paris. Tony’s from Burn university and Pat Allen’s from Dallas Texas and essentially what you can do is you can utilize this thing called [telling] technique all right? So where we are making an incision just in the gingival crevice around each of these teeth and then you’re sliding a connected tissue graft through all of them or maybe a you know another kind of material that you can you can buy off the shelf and essentially what you’re doing is you’re bulking the whole area up and you suture it back up and in time you get some creep back right yes you don’t get pocket formation but you get some creep back and then the aesthetics improve a little bit you know so we’ve i’ve done quite a few of those kind of cases and the patients are really happy with those results they still look like they’ve got periodontal problems but they’ve got a lot more bulk of tissue. So there’s less black triangles.  So perio has changed quite significantly and it’s going to change you know when you because what’s interesting is you know again talking about the Italians they’re utilizing these enamel matrix proteins it’s called (Endogame) and they’re regenerating bone in areas where you think you could never do you’d be taking a tooth upon an implant but the techniques there’s a guy called (Sandra Cortellini) he’s exceptional you know and again he’s going to be lecturing at the congress showing some cases where the teeth are like there’s nothing holding them in the mouth but he’s just splinted them whacked in some materials and it’s just amazing, I’ll send you that video so I’ll try I’ll send it to you right we transfer so you can watch it it’s amazing clinician he’s a good man as well again through what  [Jaz] If there’s any resources you have to share but you know for their ADI or these future congresses and whatnot second one I’ll put them on the protrusive dental community and the website but amit thanks so much for for sharing the in the first half your journey because i think that’s gonna inspire a lot of young dentists who are thinking should I specialize, should i not and i think they’ll take a lot of encouragement to know that hey if they didn’t finish at the top of their class at dental school or they’re just not sure or they’re not enjoying a certain part of that course but the the value of finding someone who can inspire you and then of course we talked about the the recession and the clinical bits but then i think particularly what i think the listeners find valuable a lot of time is the communication gems and i think the whole thing about asking for permission and remaining positive especially in perio. When it comes to perio where you’re always you know almost just blaming the patient trying to be non-judgmental it’s going to be massive so i think we’ve gained a lot from our chat today. So it’s always a pleasure to speak to you any last words, my friend?  [Amit] One thing you just brought up is you know should you become a specialist and I’ve thought about this so when i qualified in 2005 and i met all these implant dentists and and what i realize is you don’t need to be a specialist yeah you need so you look at you right for example you know you’re not you know you i don’t know if you’re going to be a specialist or whatever you know it’s fine but you know you have such an interest within a certain aspect of dentistry so people around you will refer you cases because they’ll think hang on Jaz can fix this right and i think that’s what i learned when i qualified is that if you are good at one aspect and if you’re in a nice area you know dentists in locality will think hang on this is the individual who know who can do it don’t you can have a special interest so being a specialist i don’t think is the be-all and end-all right? I think if you had a special interest in endo perio or restorative, you build up a portfolio cases you can send newsletters out to local dentists, give them lectures or whatever it is and then slowly you’ll get a referral base and i think that that is i think is the future really i mean i’m talking myself out of business right but end of the day i think general dentist i think is a good think.  [Jaz] I think that’s really inspirational what he said then I expected no less i expected a real talk from you and i think that’s definitely what we got today Amit so thank you so much for being so real, for being so giving and being so blunt that’s the best way to be and honestly we really appreciate that all the best for 2021 and well you know obviously stay in touch my friend thank you.  [Amit] Yeah definitely thank you, Jaz it’s been pleasure and it’s been fun. Jaz’s Outro: So there we have it guys I hope you enjoyed that and now you can approach recession with a little bit more confidence and assurance that you’re doing the right thing. Next month August is all about back to basics. I’m not going to spoil exactly what we’re doing and all the guests are having one but essentially a lot of you requested this you wanted something just you know you wanted something just foundational you wanted something really really basic so I’ve covered a lot of basic themes like for example when is an amalgam truly failed like long-standing amalgams when should you actually cut into them or what is involved in a comprehensive examination and how do you do one. So all these themes we’re gonna cover in August which is back to basics month. Catch me then guys and I’ll see you soon you.

Online reviews for Dentists are a big thing in 2021 and it’s only really just lifting off now. A few years ago I had an appointment with an ENT consultant and the first thing I did was google his name. Most of our patients are googling us and our online reputation is critical. In this episode I am joined by the founder of Doctify, Dr Suman Saha to help you get more high quality reviews for your practice. https://youtu.be/LiHSvoWBuPA Check out this  full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How to increase the success rate of capturing review: Consider text messaging and/or having a tablet in your practice so they can leave it immediately after treatment. In this Group Function we discussed: What is the role of patient Reviews dentistry? (07:02) Doctify vs different online review sites/apps such as Google Reviews (08:39) How can we make sure the reviews are accurate? How to overcome fake reviews (12:18) How to create a win-win scenario between Principals (the practice) and associates (that want their reviews to stick with them) (17:48) How to get dentists (who might be introverts) to have awkward conversation with patients and ask for reviews (24:20) If you enjoyed this episode, you might also like this episode Think Comprehensive – Communication Gems with Zak Kara Click here for Full Episode Transcription: Opening Snippet: You know even if you're not paying for it yourself just knowing that actually this person's an expert or can deal with the condition that i know i'm going to see him for or her is like it's so powerful and i think that's what we want to try and solve... Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome to this group function where we answer a really big and important question i get quite a lot from our colleagues. Now you guys know that I’ve been using something called Doctify to collect reviews but the number one objection or query I get from dentists is that hey Jaz, you use Doctify but my principal is being really funny about me collecting my own reviews. How did you overcome this or something related to the fact that there’s some sort of friction between principals and associates? Like even if you collect google reviews as an associate when you are doing all the hard work to gain the google reviews to uplift the goodwill and the reputation of the practice but what if you leave that practice those reviews don’t go with you. So we asked Dr. Suman, who is actually an orthopedic surgeon, who actually created Doctify to answer this very important question as well as how to harness the power of dental review so even if you don’t use Doctify you will gain something about how to use reviews in a clever way. How to collect more reviews and how to actually improve the social proof of your practice. Hope you enjoy this group function.  Main Interview: [Jaz] Part of this podcast is journeys. Learning what motivates people learning about the different routes people take. So Suman, do you practice clinical density at the moment?  [Suman] No, so my background is so I’m not a dentist. So I’m gonna put it out there now, I’m not a dentist.  [Jaz] You know, what I totally thought you were. I totally thought you were.  [Suman] So this has been super interesting learning because I’ve been in and around dentistry for three, four years now and I’ve got a lot of dental friends. So I’m an orthopedic surgeon by background so i trained in London, myself is an orthopedic registrar when we found the Doctify and then I guess we’ve been in dentistry because we started the healthcare and medicine and surgery because that’s what I knew but we suddenly went on to our site and I think the third most searched thing was dentistry even though we had no dentist, we weren’t working with dentists about four years ago and so we basically just knew one of the things people not even patients just people care about is finding a good dentist. How do they find a good dentist and then that’s why we kind of started the journey on the dentistry on.  [Jaz] Okay, well let’s roll back the years a little bit your position as an orthopedic surgeon. Now are you still practicing medicine now and surgery now?  [Suman] I’ve had. I’ve been a very long sabbatical so it’s been a few years now. So i guess if to so i was i trained in London myself and Stephanie, my co-founder both orthopedic surgeons. We started the company around five, five and a half years ago and then we’ve been full time for at least three years now I think. I think this there’s something which is pretty quite interesting to your listeners there’s something called the NHS clinical entrepreneur scheme, which is really looking for basically forward-thinking health professionals dentists, physios, doctors, surgeons whoever it may be and it allows you to basically work in innovation whilst maintaining some clinical practice or taking time out actually protecting your training taking time out so you can use you can work in innovation.  [Jaz] And that’s what you took the advantage of right?  [Suman] Yes, I did. So I was doing both things it was a full-time job in orthopedics, we were both in the evenings. We were working on setting up doctor 5 many years ago and then it just didn’t become sustainable like you just have so much going on and then so we applied for this NHS scheme and I guess that was the first stepping stone of giving us a bit of bandwidth to actually work primarily on Doctify and really make this happen and then the rest is history I guess and then it’s kind of grown rapidly since then.  [Jaz] Amazing and tell us about this move to the UAE like just give us a little flavor of that.  [Suman] So I guess so I said the UK was obviously our base and we had really strong growth in the UK so it was going well and then I guess we realize healthcare is healthcare, you know, wherever you are in the world, there’s an issue like you know whether you’re in UAE, Germany, US. Everyone kind of wants to find good health professionals it’s one of the most anxious moments we go through, unfortunately ourselves even as professionals would go through it, family members would go through it. So we kind of realized that this is not a UK-centric problem. Often when you train and live and we’re born and brought up in the UK, it’s the whole world and then you suddenly realize actually you can really apply this elsewhere so and there’s traditional healthcare links between UAE and the UK. There always have been and so it was really like a natural testing ground for UAE. We’re actually now since we’re launched in Germany, Austria as well and soon probably two more markets by the end of the year so and then really it’s the same problem we’re trying to solve like it’s the same thing regardless of where you are in the world.  [Jaz] Amazing now and that is really cool. I really like your story about going for the NHS clinical sort of I think it’s called entrepreneurship scheme. That’s really clever and I think that’s probably still available today for some people who may be looking for that kind of stuff?  [Suman] 100%. I know there was a big push in dentistry two, three years ago so I really would encourage anyone with an idea. It’s like a nice soft like no commitment stepping stone like if you’re you know a practicing dentist and you’ve always had ideas and you’re into innovation it’s a really great scheme to just join up to you know, basically become part of the community  [Jaz] Funnily enough i actually went to this. I actually went to like an open day for this like a little meeting with some doctors, I was there regarding this scheme actually and I just decided that I just love. At that time I was still developing as a dentist and I had so much to learn and was just so much learners I can’t step away from my clinical commitments just yet so that’s why I didn’t go you know full bolt into that but I appreciate what you’ve done is that you’ve actually saw that okay there’s a big problem beyond just you know the small number of patients you can help. You can actually help the bigger picture here so I really respect the fact that you made that very bold decision to do what you’re doing now which is amazing. Do you miss the practice of medicine?  [Suman] I miss it a lot. I often, I mean I joke it’s that it would always be less stressful to do a clinic now to sit down and see pain. I really miss that interaction but I guess it’s like you said the idea is that we, I do think that we can help people on a lot a wider scale instead of viewing tens of thousands, you can help millions potentially  [Jaz] Well, the one thing I want to talk about is the power of reviews. I guess I appreciated this around about four years ago myself, obviously, reviews are a huge thing now even four years ago they’re big but reviews some years ago it’s more something that you associate with like you know tripadvisor go into restaurants and finding out where to eat right? And then when I had a coming up with an ENT surgeon about my nose and there were some so a few issues going on previous cricket injuries and stuff. I always seemed to get injured playing cricket and the first thing I did is I Googled the name of this ENT surgeon before I was going to see him privately and I was really encouraged to see all these positive reviews and stuff and I almost felt as though I knew him the guy before I got there for my consultation and that’s when I appreciated, hey you know if I’m Googling this orthopedic surgeon then dentistry being the second most intimate you know part of the body surely patients who are very anxious are Googling us as dentists and I think that’s happening more and more and more now is that do you think the what the trend is now and was that the sort of rationale behind creating Doctify and going into dentistry?  [Suman] Yeah no absolutely so I think it’s I mean it was a personal experience so like I guess I’ve told this backstory many times but it was Stephanie. I was looking for a dermatologist, we were friends, we trained together and she was looking, she had a problem she was looking for a dermatologist and she couldn’t find one she went on to Google and basically ending up seeing someone paying a lot of money. She saw them privately and didn’t have a great experience and actually that person was not as I guess had the expertise to deal with the problems she had but she had no idea and I and it kind of just when clinicians can’t find other good clinicians even though they’re in the sector you just suddenly think how lost the patient is or what sort of decisions they’re making for themselves and I think you know it’s weird to think about it but Google didn’t exist I know 10 years ago, 15 years ago like it’s like it wasn’t a thing now it’s just so natural to pick up your phone and even if you’re going to see an NHS dentist or doctor or surgeon. You kind of still goggle their name just to see and I think if you can get good information back and trusted information that even that changes that interaction you have with that clinician. You know even if you’re not paying for it yourself just knowing that actually this person’s an expert or can deal with the condition that I know I’m going to see him for or her is like it’s so powerful and I think that’s what we want to try and solve.  [Jaz] So I think we appreciate now in dentistry the value of reviews. I think it’s growing more and more the trends on Instagram is that as soon as people will put a google review people then share it on Instagram and whatnot so I can totally see why Doctify has his role. So a couple of questions I have I’m gonna challenge you, Suman, I’m gonna really put you on the spot here is why bother with Doctify when you have google reviews? Okay, that’s the first probably objection, you might get and then I’ll tell you my second one shortly. So this answer I think I know why you have it but I want to hear it from you.  [Suman] So yeah so I’ll go back a bit I think so just to clarify like what you mentioned in every sector you read reviews now, every sector and whether you’re buying a bed or whether you know going on holiday or going to a restaurant. So and I think well the most important thing about reviews now is the quality and the trust so reviews have now become a thing but I think you’ll see a lot of stuff around now is are they verified? Are they trusted? Did that person actually go see that use that service, let’s call it that for example?  [Jaz] Like fake amazon reviews big thing now.  [Suman] Yes, it’s everywhere and they’re all doing things to like combat that and I think that’s because there were lots of open review services like that which is I think still a good thing because it’s been proven there’s still lots of them are that are true and verified but there’s two things that happen. So google reviews you mentioned is it captures the extreme. So I know we did a survey of like hundreds of providers in the clinics and hospitals around the world and these are hospitals that have seen 10,000 patients 100,000 patients how many Google reviews do you think they had?  [Jaz] Hardly any and they’re probably like the odd five star and loads of one star because that’s what people want. People, obviously they want to tell more people right?  [Suman] Absolutely 50, it’s like 50 to 100 and I almost found that sad so basically you get the really ecstatic people which they really want to tell their story and then you have the really unhappy people who then go well i really want to event and I guess what I find quite sad is like you know your practicing clinician now you have most your patients are very happy you can see. Loads of happy patients every single day but you’re just not capturing it. You know people and that’s whether your huge hospital a big thriving practice, you know dental practice or just an associate within a practice, you’re seeing patients every day and I guess we know that there’s amazing healthcare being delivered but it’s not being captured so I get I guess how do we capture it regularly so it represents you and then I guess the one elephant in the room is things go wrong.  This is healthcare things are going to go wrong in dentistry, medicine whatever and you just have to accept that and I think what I’m trying to do is say well if you have a bad review that’s not a bad thing in fact how you reply to that is so so powerful because it tells you more about me as you as a clinician to me like if you apply and go you know what I’m really sorry this happened this time I’m gonna fix it. I’m gonna go see you now like I’m gonna be like that, when things go wrong you look after me but that only works if you’re capturing reviews across the board. It doesn’t work if you’re capturing outliers because then you’ve got like three bad reviews, three good reviews, and is that really representing your care? I would you know you and I would both argue it’s not.  [Jaz] Well said and I think it’s great you mentioned the fact that you know to draw a parallel to like the restaurant industry. I actually like those restaurants where you go and then you have the odd bad review but then how the restaurant or the manager responded to that, just shows how much they care. It’s the same in healthcare like you know how you respond really just show about your values but your point really leads nicely to my next question which is you don’t want just all the outliers. You want to capture as much as possible but here is my, I’m a happy Doctify user and I think patients do come in quoting the fact that hey I read your reviews.  Now I don’t have a google review page. So it must have been my Doctify reviews or the fact when I’ve embedded my Doctify reviews on my personal website and I speak to Alex and he says that my Doctify page gets over 600 views a month. Which was like wow I didn’t know it had that sort of exposure and I do, I’m quite an open book I mean I’m out there on YouTube, Tik Tok, etcetera but I’m quite impressed that when you Google my name you know Doctify’s up there like right number one, number two something like that which is pretty awesome but here’s my beef with Doctify and I’m gonna just keeps it very open honest with you but I’m gonna give an opportunity just reply to me. My beef is this, is that I think it’s better than just Google reviews because of everyone who’s been bit by a fake review or a negative review that you know or a competitor down the street writing, giving you a zero star. That’s a terrible thing so I think what Doctify gives you is verified, right? You could only someone who’s actually definitely been a patient of yours can leave a Doctify review that’s correct, right?  [Suman] Yeah [Jaz] But my worry is that when I read Doctify reviews online of other dentists I feel like they’re too skewed towards positive there’s like you know I’ve got 4-5 star reviews. When I get someone who’s not the happiest I’m less likely to give them my link to lead them to the review. So do we have a problem here in being able to compare dentists because if everyone’s got like a 100% five stars there is a problem in that? How can we combat that?  [Suman] Yeah so it’s a good really good question and okay I’m gonna take it in two parts. So one now you’re more confident as we’ve just discussed it that actually replying to negative reviews is a good thing. So Jaz, you’re going to be way more confident and you know that unhappy patient you get feedback from me, you’re going to reply and that’s what I want to get people I guess that’s my well that’s our goal and our vision of where we want to get people to and I guess it’s all automated reviews. So we build software really so yes so we see Doctify’s a publishing platform you know it’s not about generating patients. It’s about where we publish the feedback and we basically give you software whether that’s tablets verified review links. We work with like the big providers like so we can automate it from SOE or r4 whatever it may be and we can literally automate a link to every patient that goes into a dental practice for any family dentist and we do that with our big chains we work with and stuff so that that kind of combats that.  Now you’re absolutely right there is still a reluctance to be like ‘oh that patient’s not happy let’s try not to get them to leave a review. It’s you know and I’ll be honest five years ago no one would even let me leave them a positive review. I couldn’t even get a clinician to say please review me. So I think it’s like this path we’re on to get getting there and I can now go on and show you like 10, 20, 100 of native reviews with dentists and doctors replying and they would never I could say they would never have done that five years ago. They’d have been scared, they’ve been on but the reason they’re more confident is those clinicians are asking every patient to leave feedback. They’re getting good representative feedback and it becomes less scary, it becomes way less scary I mean and I think I want to try and I guess fill them with confidence that they’re going to get good reviews and I do lots of talks on this then you say in uber there’s a big difference between a 2.8 uber driver and a 4.0 uber driver you always give me like something’s going on there with a 2.8 uber driver.  In healthcare actually, we’re all highly trained professionals. We actually I like to think that most people have you know even if they’re having a bad day they’re providing a very good service on a daily basis and there’s actually a big difference between 4.4 and 4.8 and we’ve got all this data we’ve seen it and I guess that’s the thing we’re trying to show people is that it’s amazing healthcare and they’re almost if you’re creeping into 4.4, 4.3 well let’s look into it. Let’s look into the reviews. Let’s look into the feedback. Let’s analyze it and that’s where I guess where we sit now is A) let’s make it representative and represent the industry as it should be. There’s amazing care like particularly through COVID I know like super stressful, there’s amazing care being delivered It pains me that I go online and that’s not represented in dentistry still not represented. and then let’s learn from it so we build like an analytics tool you can basically learn like what are your patients saying about you.  So I know for example we work with one chain and we can analyze their reviews for COVID like how do they perform during COVID and you don’t think patients would be like ‘oh it wasn’t COVID safe, it wasn’t this. They mentioned COVID a lot but actually, most patients mentioned it in a positive way. They made the point of saying I felt safe and COVID safe. So despite COVID I went into this clinic and I felt really safe and that was such a good learning point for the chain to be like you know what we’ve ticked a box we’re actually doing something well and just things like that and you know we’ve had hospitals chains, their reception team because they go we love the clinicians but the receptionist was a bit moody and it was literally like the same thing happening over and over again and but because they weren’t collecting feedback on a daily basis they never knew. They kind of maybe suspected things.  So our aim is actually to take this review data and this is where I guess we’re different from google views and I want to feed it back to you as a clinician and be like this is what I’m doing really well, this may be what I need to work on well actually just keep it up. You know that’s kind of what we’re trying to do now  [Jaz] Well one of the arms of clinical governance is to actually get that data from patients patient satisfaction and if you’re able to give them a link to Doctify to leave a review for example that’s a verified patient then you can collect so much data and that can form as part of a portfolio for ‘hey what are we doing good, what can we do better?’ So I definitely appreciate that. I’m going to pitch you another scenario now, I’m going to make it very tangible for you and related to medicine maybe. Imagine you have an orthopedic surgeon who works in a couple of different chains or let’s say three different chains, in the private sector. Three different private hospitals and so he has three different contracts. That orthopedic surgeon, when I searched for that ENT surgeon I told you about. I wanted to know about him. I didn’t care about the hospital as much as I cared about him and the care he was going to give me, right?  The big problem that I’m because obviously, I’ve mentioned, I’ve talked about Doctify a lot on the podcast for something I’ve been you know very open and honest about I like it, I have it on my website and people ask me a lot about Doctify and the biggest barrier I’m getting or the biggest issue I’m having the friction I’m having is principals and associates. So in the same way you know, the associate may move clinic one day and they want their reviews to go with them because it represents them as a clinician equally the clinician is working on the premise of the practice and the practice wants to generate reviews. So there is real friction there. Any thoughts as to how best to have a win-win and create a diplomatic scenario?  [Suman] Yeah, so maybe I’m an idealist but so like it’s a very happy you scratch my back, I scratch your relationship. You know it’s a harmonious relationship and that you know yes they may wake up at some point but the truth is the practice is benefiting from the associate working there seeing patients doing a good job and generating you know revenues let’s be honest like from there and the prac.. and that’s great and then the associate as well is bringing work in if they do a good job they bring work in and it’s like, it like the two don’t work without each other. So it’s like I find it difficult when this and maybe as a clinician there’s this power play and it happens in medicine as well.  So the same scenario, a consultant works in three different hospitals and I guess they’re a bit further down where they’re basically like we’re going to use this consultant to generate you know as someone who works here with a good reputation and generate pay, if he moves on he moves on that’s fine but whilst he’s with us we’re going to use that and I guess I’m trying to get principles to that point because I see it as you’ve got to have a good working environment, a good team. You’ve got to like make them feel empowered, you go you know, you’ve got a new associate joins the practice no one wants to see the associate. Why?  Because they want to see the principal. Like very I’m sure it’s a very common thing because they’re the experienced person. She’s been doing it for 20 years, you’re new so I actually say to them, ‘look why didn’t you validate them? Give them a colleague so you know we have colleague recommendations. So I’ve trained this associate they’re really good and I recommend them for these procedures like I get feedback for that associate. Now the argument then is well, I’ve built up this associate, great. Now they leave, my argument then is well you’ve used that associate to work for you as an employer who’s worked for you like you know given their time worked hard. They kind of you know it’s almost a bit maybe vindictive to be like well, now I’ve built you up, I don’t want you to be successful elsewhere. I would hope that there’s this kind of happy roundabout where we’re all in it together, we’re all looking after patients ultimately. I know this is a bit idealistic but that’s where that’s how I say it. That’s you know I don’t think there’s ever going to be a perfect scenario but I, well the way we say it is ultimately the reviews for the person are the persons of use we use the practice of the person for the practice because you’ve got to like you know ultimately that’s the person’s identity in that and their, you know, their expertise.  [Jaz] I agree with you totally and it’s just there is an element of toxicity around the atmosphere in the UK Dentistry at the moment for sure whereby there is this friction I do feel way more associates would have something like Doctify if there wasn’t this friction or this difficult conversation with the practice and I think what you’re saying is very idealist and should be the way forward but I can understand from the principal side as well that they want to collect reviews for practice because it’s their babies, their investment and they want to grow the practice rather than this associate. [Suman] So can I answer to counter that. You know on you know what if you know if an associate chose to collect reviews themselves, a principal can’t really stop them or can they is that were you saying actually?  [Jaz] I’ll put it this way. You’re self-employed so really you can’t.  [Suman] Okay, so no, so my argument is that they are they’re trying to improve their practice they want to understand what their patients. They’re new to the bit you know to dentistry like in terms of practice you know I don’t want to encourage associates to do it and then I would say to the principal look you’ve got a really good associate on your hands who patients are loving. Use them to build your practice, your thing and it’s like you know if you’re really smart and, to be honest, you know we work like with a few chains where all the associates are and all the dentists are on and it is working really well for them. Yes well, one day they may move on but to be honest, during that period you’ve really really built your practice, you know you’ve got a patient who’s walked through the door now are they some may follow an associate you, right potentially but some will also be like actually I, you know, I’ve been in practice for five years and I, you know, like that and that’s the way, that’s life I guess. [Jaz] I think it’s the difference between having a growth mindset and appreciating that you know you’re doing everything to build everyone up and grow and then there’s a fixed mindset. So I think there’s you know the principal who’s very much against their associates collecting reviews has that very narrow fixed mindset, whereas, the principal are like yeah let’s go for it you know you’re gonna bring more business in has a growth mindset so I think there’s a definitely a mindset issue there and I think you’re right you know a principal can’t stop there, legally I don’t think their associate collecting reviews it just creates potentially some friction. So I’ll tell you how I do, Suman, because I want to keep my principal sweet and I do notice that you know I’ve got more reviews in my Doctify than one of our practices has on the entire google reviews, right? I don’t have that many still, I could be doing better and that’s the next question I’m gonna ask you is just lack of time and stuff but yeah I know you guys make it easy so we’ll discuss that but what one thing I’ve started to do now is for everyone review that I collect from my Doctify, I’ll make sure that the next patient I’ll get one for the practice who uses google reviews or who may use Doctify or whatever right? So that is for now a happy ground it’s not a conversation I’ve had on principal, it’s just me out of respect doing that because I think there’s plenty of reviews to go around so you keep everyone sweet. [Suman] Yeah and then just on that I guess we’ve built it because it’s a good point you’ve made is that we can actually with your review link you can actually collect reviews for the practice, you know we can actually set up your practice so that every time you collect feedback same as your practice and vice-versa and that’s what I’m trying to do like create this harmonious balance is you know depending on the scenario a patient does go ‘oh this is the dentist and this is the practice’ and I want both to be almost tick the box on both you know this is like you know it’s the same with medicine you know some may go oh it’s practice first because I like the big shiny practice then I’m going to choose who I see or somebody go well actually I just want a really good dentist and I’m less concerned about practice but generally they will almost sanity check both so I, you know, to even to your point I would be like let’s get your practice set up. Let’s keep them happy because I want to collect more and more you know for us. It’s we don’t make money off patients we, I literally just want to capture all these stories like as many as we can you know as high volume and ultimately then validate good care which I’m sure is happening.  [Jaz] Amazing, perfect. So my final question is what is your recommended advice to dentists to help them have those conversations about collecting reviews. A lot of dentists are shy. A lot of dentists are introverts and they don’t want to get these video testimonials. They don’t want to like push this upon them. So there’s actually a communication issue there.  What advice can you give to dentists when it comes to collecting reviews and collecting feedback and testimonials?  [Suman] Yeah, so I guess the simplest one let’s say they’re completely independent. They don’t have access to the practice software or they can’t send, they can’t collect them by the practice let’s say volume sake. So one thing is you just you know after you’ve treated the patient you know typically even at the end of a treatment plan so you’ve discharged them you’ve done everything it’s just be like I love I’d love some feedback on your care and you send them a little link and it’s neat. It’s a template email and our team are very good at kind of making them feel engaged and hey you’re doing two things you’re showing them that you actually care about your practice and improving and becoming a better dentist and you’re also checking in on them and saying are you doing okay post-care, how are things email me back if there’s anything you want to discuss.  So that whole thing about negative reviews again comes now is that you will have less negative google views as a practice or as a dentist if you start taking these steps. If at the end of a treatment plan you take the time to just say how are you, anything go wrong, are things great. They’re going to directly come to you, they’re going to directly email you back and go you know what things are great or actually, things are good but there’s this one concern I have. So you’re instantly you know reducing your complaints, you’re reducing everything, your negative reviews and that’s really low touch. You can be an introvert and send an email. Super easy and that’s what I would suggest.  [Jaz] Very good and it’s something I do as well as asking verbally and sometimes even video testimonials. Are there is any data that we have to inform us as to what improves the success rate of collecting a review for example sometimes I’ll ask a patient hey will you leave me a review they’ll say yes I email the link and they don’t leave a review because they just don’t take that final step but now I imagine if Imagine the lowest rate of review collecting is you don’t even ask a patient and you send them an email right and that’s probably going to get a low percentage return because they weren’t even expecting it? I think by asking or telling the patient, Hey, I’m going to send you an email that probably increases it. Now is there anything else I could be doing to increase the acceptance rate  [Suman] Yeah, good question. So I actually don’t think you need to ask them so actually, I think the industry has changed enough that they’re always expecting a little bit I think it’s great to ask them but to your point, some people don’t feel comfortable as clinicians then I would almost be like it’s not essential. Now email like we all have like email overload now I mean we all have like junk emails or main email another email it’s like crazy so emails has the lowest like conversion of like sending an email, giving a link and getting it back. Text message now this is where you need your practice management system a text link will have a much higher, you text their phone they let you fill it out and it’s done we’ll have the highest and then we’ve got tablets to set within the practice that obviously has you know where the receptionist can just say we’d love to get feedback we have these nice branded stands to sit in the practice. It’s you know you know it’s a bit it’s almost like those smiley faces that you see. So we have those like sitting in dental practice as well and that obviously has if done right has a really high you know their practice is capturing 60-70 percent but we’ve done a, I think we have probably one of the most reviewed dental chains in the country now because they automated from their software, a text message that just goes out after a treatment plan so we literally have the well you know one of the most reviewed like chains in the country if not like even regionally in Europe I can tell you now because again back to Google you’re capturing like 50 100 reviews when you see thousands of patients so that there’s you know the technology’s moved on enough. That there’s a lot you can do  [Jaz] That is a Protrusive pearl right there I think that’s amazing so I think the take-home message there is yeah email is good but we are getting email overload to consider text messaging to get increase your success rate of capturing review and even having a tablet in the practice which I know you guys have been good at setting up the QR codes and stuff which is very forward-thinking and that’s awesome. Suman, you answered all my questions I really appreciate all that. Is there anything else that you want to say?  [Suman] Well, I guess, there’s two things I think because I’m super interested in your listeners and also like we’re really open on like feedback particularly from the dental community so I’d really encourage anyone who’s got ideas who want to push us you know good and bad I do I really love hearing it. That’s number one.  The second thing is I think there’s one thing we’re trying to do and that’s not we talked about reviews and they’re quite specific like quite generic like my pet peeve is generic reviews ‘oh this is a five-star dentist’ it’s a five-star clinic great. I want to actually look meaningful views and i think that’s what we’re trying to do so and this comes back to like being recommended for specific condition or procedure that you perform so and this comes back to general dentistry to cosmetic to specialist stuff to you know endodontics whatever it may be so I was talking to a friend the other day and he was like there’s same day implants now you know there’s that you know you can do and you know you do 3d printing and yeah I’m not a dental expert, so I’m not going to say the right thing but you do same thing and it’s a new thing it’s cool tech and imagine collecting 100 reviews for that specific procedure and that’s what we want to get to and that’s whether you’re an associate or principal or for invisalign or for whatever it may be and you know or you know you treat gum disease and you’re one of the best perio people in the country, I want you to be recommended for that specific thing so where as a patient I could be anywhere in the world and I can go I have had this real big problem with let’s say gum disease I’ve seen five specials that hasn’t worked i now want to find the world’s expert and our plan is to go on you go on Doctify, you can find someone who’s got recommendations from colleagues, a thousand reviews for gum disease and that’s the person you can go see now and that’s i guess what i want to encourage the dentistry to go so I’m always open to ideas, it’s about yeah people are smart now like they’ve reviews everywhere and i mean what all that means is they go ‘oh five stars great but five stars five stars they go I’m gonna read them I’m gonna understand them are they deep they’re going deep into who what i want as a patient. I just encourage people to start thinking a bit more like that, particularly because we all train for a long time you then do specialist training and then you know all this stuff and like you generally people are experts in four or five things like you tend to get really good at certain things and also I guess you as a dentist correct me if I’m wrong there’s certain types of patients you want to see. Like the patients, you don’t want to see places you want to see and it really helps if you can then start positioning yourself as an expert in something you will start to see the patients you actually want to see and that’s going to provide better care because you’re seeing patients you enjoy seeing you want to see you know you know you can help them because you’re an expert in that field so I think there’s so much so reviews is one thing but I think there’s a lot more you can do with it and I guess that’s what I want to open people’s minds to is it’s yes it starts with just making sure I look good online but there’s a lot more you can do with it. [Jaz] Well said it’s about the quality of the review it’s about establishing yourself in that niche whichever niche you’re in and really giving that social proof for that niche yeah the power of a good review just I had a good treatment, everything was clean that’s it. you actually want to come in and say oh I had one recently oh I came in to see Jaz because I’ve been suffering with TMD for years. He spent his time, he listened to me, he adjusted the splint and now my headaches are gone that’s the kind of review you want and I totally get your point and I think I’m so glad you raised that  [Suman] Yeah and exactly and so you almost want another patient who has that same problem now let’s say like who can then find that review really easily go like finally I found a dentist who has actually got experience in treating this has got results showing that good results are great I’m gonna go see them, Yeah so I think it’s yeah it’s there’s a lot you can do with it and for your associates, get in touch with us I will bring transparency to the dental market. I’m super passionate about it we’ve done it in medicine so like we really we want to work with people so if there are people who are a bit skeptical, a bit unsure on how they do it, or their associate.  So they’re not sure how to kind of navigate the I guess the politics of the industry where there’s always things we can do and help you know and I’m really open like in terms of we can help the practice like even in your studio I’m more than happy to set up your principal in the practice make them feel good like you know you’re collecting reviews, let’s help them do it the same process like there’s lots we can do so I would I think Alex is our head of dental has got a special treat for anyone who I think quotes this podcast and gets in touch with him and he’s going to look after him he’s going to help him through the journey  [Jaz] Yeah, he’s been very good in the past. He helped sponsor one of my conferences occlusion 2020 with Michael Melkers and I believe that I need to get an update for this I believe is 50 off for the first four months but I, you know, don’t quote me on that just yet, I’ll do it in the intro and outro. [Suman] I’ll cover it yeah, well it’s fine but they if, they get in touch we could like for us honestly we’re a subscription business so it’s our goal is to work with as many dentists across the country. We’re not like exclusive you know healthcare’s healthcare so I, you know, we will you know we can we’ll help like work with whoever so I’m really really keen to engage people whatever level of experience whatever stage they are in their training.  [Jaz] Amazing. Suman, thank you so much for coming on today and giving time up in your very busy schedule to come and join us today thank you so much.  [Suman] Thanks, Jaz nice talking to you. Take care.  [Jaz] Hope you enjoyed that group function with Dr. Suman, everyone and I’ll catch you in the next episode. Let me know what kind of topics you want I’m always happy to answer and make these group functions you know where it says @protrusivedental on the Instagram page Thank you so much for watching or listening all the way to the end.

Surely injection moulding composite resin is too ambitious to restore Toothwear? Well, let Dr Kostas convince you otherwise! Restorative Dentist Dr Kostas Karagiannopoulos will reveal all the the nitty gritty secrets from patient evaluation to the entire bonding protocol. https://youtu.be/hL5aAdzk-hk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below!  Protrusive Dental Pearl: How to improve the resistance form of ceramic onlays: Use a big fat round bur, sink it into your composite core (be sure you’re drilling into core material and not sacrificing healthy tooth structure) and allow your ceramic to extend into that to help your onlays stay on when you’re trying them in. Whether this extension improves retention form is debatable Step by Step PDF Infographic. Click here In this episode we discussed: Role of injectable composites as a transition (and as a long term solution) (12:59) Follow-ups and maintenance of injection molded composites (16:52) Contraindication for injection molding (20:28) Indication for injection molding  (20:54) Minimizing voids when restoring with injection moulded composites (21:48) Filling the stent with composite (a thing of beauty!) (28:17) Other techniques vs Injection molding (31:29) Injection molding composite case sequence (35:04) Isolation during injection molding? (46:36) If you enjoyed this episode, check out eMax Onlays and Vertipreps Want to learn more? Do check out this one-day course by Dr Kostas with GC UK Click here for Full Episode Transcription: Opening Snippet: Wait hang on a minute you’re going to use flowable composite and you’re going to squirt it inside a clear stent and then you’re going to expect that to hold up when it’s restoring anterior tooth wear? Have I got that right? Jaz’s Introduction: This is exactly what I thought when I first came across this technique but you have to understand something. That is not regular old flowable composite and there are some micro details to gaining predictability which is exactly why I’ve got Dr. Kostas Karagiannopoulos Kostas, I’m so sorry if I perverse your surname there. He is a phenomenal dentist based in the UK. He’s a fantastic restorative dentist and he teaches on this technique so who better to talk about this technique than Kostas. He’s going to go through the entire workflow from case assessment to see who is suitable for injection molding composites to how to execute it and some key gems to take away. So, if you were to do it Monday morning, you’re going to gain a lot from this episode. Protrusive Dental Pearl:The Protrusive Dental Pearl before we go straight into this really cool episode is the following right? So many of you are placing let’s say Lithium Disilicate onlays, right? The problem is when you get them back from the lab on the model, they fall off really easily or when you put them on the tooth to try it in like there’s no resistance form. There’s a real lack of resistance form on these on layers therefore they just fall over the place. So, if you have a composite core in place. I’m a big fan of getting the biggest, fattest diamond bur you have which is around or spherical in shape and just sinking in until you get this kind and if those of you watching right now will describe. If you’re listening, it’s like you see like a semi-circle or a half sphere drilled into the composite and what this does is that the ceramic will now have this extension of this half sphere into it so that now it’s less likely to fall off the model and weigh less likely to fall off when you’re trying it in. Now it’s debatable whether this actually improves the resistance form of the restoration technically anything that opposes your finger removing a crown improves the resistance form so technically it does, but you do it for just convenience really and as long as you’re drilling into core material and you’re not sacrificing healthy tooth structure then i think this is a great little technique tip. So I hope you followed along there. So, use a big fat round bur, sink it into your core and allow your ceramic to extend into that to help your onlays stay on when you’re trying them in. So, let’s join Dr. Kostas and I’ll catch you in the outro guys. Main Episode:Kostas Karagiannopoulos, welcome to the Protrusive Dental Podcast. How are you, my friend? I knew and raised I said it correctly, I think? [Kostas]You did it very well naturally with an accent as well. Perfect. [Jaz]I used to work with a few Greek dentists, so I always made an effort you see. That you are of course Greek right I haven’t complete or I haven’t completely messed that one up, have I? [Kostas]As Greek as it gets. [Jaz]Okay amazing well listen you’re someone who has been on my radar for a few years now our mutual friend, Ricky told me about you some time ago and what Ricky said, and he’s been on the podcast as well. He did a whole episode on Productivity with a Prosthodontist. Lovely guy and he said some things about you like ‘Jaz you need to speak to Kostas. You have a lot of sorts of similar philosophies.’ And what he admired about you, Kostas and I don’t know if he told this or not. What he admired about you was you’re working in a hospital setting. You’re teaching, you’re performing, you’re also in wet-fingered practice and in Richmond until as well and then as well as that you haven’t fallen into a trap of falling into like a very narrow mindset. Because he felt as though he saw something in you and the fact that you actually have training from the USA and you do things a little bit more open-mindedly is the best way that he described it. What do you have to say to that and then also for the good listeners can you please introduce yourself? [Kostas]Thanks for having me. It’s a kind of a mutual feeling. I’m going to talk about you first before I talk about myself because I kind of bumped into one of your little videos and there’s this expression that we all know it sounds Greek to me and I said, ‘Hang on a second that guy speaks the same language like me. There’s one more person in this planet that kind of speaks Greek.’ So, it’s kind of okay you’ve got an occlusion background, I’m a prosthodontist. I did a lot of training in the US with an anthologist and an educator called Frank Spear. I followed the British society of occlusal studies about 10 years ago doing equilibration on kind of patients. So I was looking for this kind of terminology, this kind of workflow so I really liked what I heard and only last week I kind of gave a lecture to my students. Here are guys my post grads about selection of splints. And I said you know what, you just need to go online and do that course. I know you’re paying a lot of money for your employment then but go and do that he’s better than me. [Jaz]You’re very sweet thank you so much. [Kostas]Coming on to me. My name is Kostas, I’m a prosthodontist. I work here at Guys where I’m speaking from at the moment. I’m a consultant in the postgraduate center I look after the training specialist so it’s purely in an educational role. That’s one day a week but otherwise I’m in specialist practice kind of four days a week in Essex and St. Albans. I do have indeed quite a mixture of things. If somebody told me hey, you’re going to be in practice five six days a week that’s kind of too much this is like teeth are rattling in your head or you’re going to be in hospital full time that is a kind of a different kind of mindset. And I’ve never really had that. So, I like having a bit of a mixture of the two but then again I do all my training and all my CPD  kind of approach. Now it’s a little bit tricky with Covid but I’ve been all around the world to kind of gather some information. As far as today’s topic, it kind of the inspiration came from teaching people like Ricky about four or five years ago. We have a toothwear clinic here at Guy’s and we treat a lot of it. Erosion, attrition, a lot. We’re doing the full workup of photographs, wax ups, face bows, and when we actually go to treatment which usually is resin composites as a first line of management, we were not using any of this. So, we were spending quite a few weeks on the diagnosis, on the smile design and then we were going freehand, and I said hang on a second there’s got to be something different than that. Now freehand is difficult to teach, there’s people in this country and other countries which are excellent with this. But it is difficult to teach and it is difficult to execute let alone teach in order of consistency because if you’re doing a big case by the time you hit the canines or the premolars kind of your eyes are fried up. So, I had to think of ways to cheat, replicate, copy paste and I’ve been doing this for five years now and then I’ve kind of used every single way possible. And I’ve kind of narrowed it down to the technique that I use these days and I teach which is the injection molding technique in collaboration with GC. [Jaz]Amazing. Well, that’s exactly what the episode is about today, injection molding for composite restorations and the why, the when, the how, the longevity, all these nitty-gritty details which I think as we were discussing before like you always get the classic questions, the same questions over and over again. It’s time to let it all out and no longer shall people ask you these questions because they will listen to this podcast and they’ll know all the answers. So, I’m going to hit you with the number one like your origin story of why you needed this kind of a way to treat patients, makes sense. Because to go free hand is very technique sensitive, it’s very time consuming. I love the fact that you also mentioned that yes, we get tired it’s true. Our eyes get tired, and the canines are not easy teeth to actually get anatomically correct by the way. So, by time you get to the canines and then things are looking out of place, spot on. When it came to injectable composites, a lot of dentists who haven’t used this technique before or maybe have never been considered using this technique before will have some natural reservations. They’re thinking wait flowable that’s not strong enough that’s the first thing they could come up with. So, did you have similar reservations or did you have some evidence to go by initially to think that okay this thing we think that this has a future, this has some legs so was it a bit of a punt or was it based on some pre-existing data? [Kostas]Good point. Let me start by saying that clinical kind of evidence in terms of peer-reviewed and meta-analysis and systematic reviews are not there, okay? I’ve been kind of looking for them they’re not there. I’m going to be making a clinical study here at Guy’s but that will take a few years to make so there’s quite a bit of in vitro the data which is very promising. How did my, let’s say flowable journey start? It was about six years ago when I went to Geneva one of my mentors and composers is Didier Dietschi and he has his own composite called Inspiro, a big proportion of which is unflowable so there was six flowable dentins and four enamels and they kind of transformed the way I do things because they have this thixotropic property that you shape it on a marginal ridge and it kind of stays there. So, I said hang on a second, let’s research this. Now the filler content of his product is 69%, the filler content of G-aenial universal injectable which is the material of choice for me now is 69%. This is actually higher than some of the composite pastes out there. So, I’m not going to say that it is stronger but the myth of flowables are weak is a myth. So, they are hugely kind of reinforced these days but they do have the stereotype that oh I’m going to do my resin coating with this, it’s just going to be as a base of a cavity and it’s going to be a stress breaker and I’m putting this on the incisal edge. So, I didn’t have the evidence but if I hear to Didier Dietschi telling me that hey I put flowable on my incisal edges that’s pretty good enough evidence for me because he’s been doing it for 35 years. So, I have my own evidence, I’ve been using them for six years and the failures that I have seen are not in my opinion related to the material itself. It’s more down to the technique and ability to bond, an ability to etch the way that you would like. So, the properties of the materials are definitely there. The clinical studies will definitely come very soon they have all already come out for class fives and class twos but nothing in the kind of load-bearing areas. So, it’s a matter of time before they do. The benefit that you have by using an injectable or a flowable composite is first of all the ability to replicate anatomy are not to be determined by a lab technician they are better than us. And of course the ability to kind of conform to a specific shape determined by a clear stent. So that’s the benefit that you get. You kind of copy paste an already verified design rather than rely on being on a good mood and being consistent between Wednesday afternoon and Monday morning which I cannot be consistent. [Jaz]Very well said and those of you watching on the video, Kostas was waving one of the stent examples which I’d love to see. The origin story, going back to your origin story of trying to plan these perhaps a wear cases or full mouth cases and trying to do like an interim period and that’s why you thought okay there’s got to be something quicker than spending hours and hours doing you know paste composite freehand. Do you see the role of injectable composites as a transition? I mean in honesty all restorations are transitional we know that already I mean you can appreciate that that nothing lasts forever so you know in a way even all these composite veneers we see on Instagram they’re transitional they’re going to need, who knows what’s going to happen three, four years’ time when it’s been you know 10 years since these composites. Are they all going to go to ceramic? Are they going to be recycled composite we don’t know but essentially the question to you is when you do it is your intention that hey if I can get the occlusal scheme set up here this is going to be my definitives for some length of time or are these just long-term provisionals to test the occluding scheme? What is your mindset when you’re placing these reservations? [Kostas]I’m a little bit biased. I have two kind of main principles in my head which determine how I approach a case. First of all, the tooth wear cases they’re going to be presenting with 30%, 40%, 50% damage the last thing that I want to do on this teeth is take them down more. So, I want to avoid crowns. So, I’m already leaving this as a last resort. So, my default approach is going to be additive adhesive dentistry. Now the second thing that influences my opinion is that all the studies that have looked at tooth wear, the very cumulative. So, they put all the diseases in one bag, erosion and attrition and it’s like different all right? Okay sometimes you’re going to have a bit of a grinder, who’s got a bit of reflux and a little bit of both but on many occasions, you’re going to have pure attrition flat as a pancake and pure erosion crate as big as bigger than the moon. So, I’m going to approach the erosive cases purely in additive composite resin. There’s not a single facet in that patient’s mouth even for the pure bruxist, the neurological bruxist let’s say. Yes, I’m going to do a little bit of a build up to crowns because I want to refine my occlusal scheme and the force distribution and my localized kind of group functions in resin rather than in temporary crown material without double charging the patient. Because I don’t see the point of going for composites and then going for crowns because you kind of double charge somebody. So yes, I do believe a lot in adhesive dentistry. I do consent appropriately for this that hey and this is a long-term kind of measure but like with all composites I mean injectable composites are no different to any composites. They are going to chip, they’re going to stain, they’re going to break, they’re going to look matte and longevity is somewhere in the region of about four to five years. So, nothing different to the normal composites that we do. Now they are high maintenance and if somebody is not happy with this, they’re going to have to take the hit and have the teeth cut down for onlays or crowns but I want to avoid this as a first line of management. [Jaz]I mean I love what you said that because it touches on the whole thing about functional risk right? Like I think Kois talks about and Spear, they talk about you know functional risk. I don’t like that term that much personally because I think it’s parafunctional risk, I don’t think it’s functional risk because the functional teeth shouldn’t be touching at all anyway. That’s the way I see the world but anyway let’s go with the functional risk thing and you’re right I’d much rather confidently treat that erosive case than that purely attritive case it’s just more going on and like you said you have to almost over engineer that attritive case. So, I see what you say that in terms of when someone’s main etiology of destruction has been purely attritive you know in your mind already that okay this is more of a transition but when it’s purely erosive without as you said any wear facets you might get a longer time there, but it’s still composite at the end of the day. So what I want to know from you now, Kostas is you’ve been doing this five six years are you yet to recycle one of your ones that you’ve placed five years ago how they’re looking now because I see them you know what I admire about you is you’re posting your cases on your social media to instill confidence in dentists and patients using this technique and I’ve seen a few of these follow-ups over some years and including in private practice. So give us an update how is it looking and how much maintenance did it take? [Kostas]Yeah, It’s a question that actually patients ask that hey you’re doing a six unit case or an eight unit case and the kind of the minute you tell them that hey this is going to be about five years they think on the anniversary they’re going to find eight bits of composite by the pillow like they’re all going to come out together. So, what I tell them is that no I mean I’m going to come to the annual maintenance but at some point that maintenance becomes so frequent that it’s just better and easier and makes more sense to just go all in instead of getting a handyman just getting the builders. So on a consent process I let them know that hey we’re doing this additive approach we’re not cutting your teeth but you’re going to have to come once a year and I will need to polish this and when I do your checkup and I’ll take your x-rays, I’m going to take a little bit of a disc so I will find kind of proximal staining and this is twofold. Firstly, because our polishing and our finishing is not as meticulous on the embrasures proximally as it is on the facial and secondly the patient’s oral hygiene, cleaning, flossing or lack of will lead to some staining in there so you’re going to see a little bit of a halo. Thankfully a little bit of disking and some kind of spiral silicons are good enough to maintain this So, if people know about things they are kind of okay otherwise they can kind of complain so at the beginning maybe my consent process wasn’t great but now I let them know that hey once a year we’re going to do kind of a maintenance kind of thingy it’s going to cost a few hundred pounds and you have to put that into the kind of budget of things. I haven’t had any catastrophic failures and as I said I don’t really blame the material I always blame myself so I’m going to if I get some kind of distal of laterals breaking off. I’m going to blame my occlusal control because we don’t kind of eat and grind from the inside outwards but it’s the opposite. So, I spend a lot of time at least on the attrition patients to check kind of all the eccentric movements. So, if anything I will blame my etching, I will blame my hybridization and I will blame my occlusal control not the material. So, coming on to the negatives of this injection molding technique it does have some. Now let me start with the contraindications, if you’re making tiny additions, it doesn’t work. Mind you, if you’re making tiny additions freehand it doesn’t work but that’s a different subject you need to have a certain volume and about a millimeter incisally is kind of the cut-off point. Another contraindication is kind of having black triangles and not adding facially or incisally of it. Like a clear stents like this is not going to help you get in there so you need something like a bioclear or other kind of freehand techniques. So, the main contraindication for injection molding is the single tooth so I’m doing a layered polychromatic buildup with incisal effects and a little bit of opalescence and all of that. Forget it, you got to get your whatever system you use like dentin enamel and go lay it. So, this technique is not here to substitute layers, it’s here to complement it. So, the main indications for injection molding are kind of tooth wear cases, the aesthetically driven patient who has kind of a small teeth and they need a little bit of a smile lift and just aesthetic changes, and these are the kind of main indications. Now in terms of problems, it is a technique where you kind of placing a composite tape through this stent and you’re injecting the material. The material has the consistency kind of flowable. It’s not running but it’s compressible. It’s like you can squirt it out you don’t need to heat it up let’s say. So, there is a possibility that you’re going to get voids so a good analogy is like you know when you’re making your Protemp or your looks at your crowns, you always have voids you just don’t know that you do. So, there’s always avoid in there. So, I’ve come up with all sorts of ways to minimize or avoid this. So, one in ten cases I will get some a bit of air trapping and then unfortunately that air trapping is going to happen from the vent where you’re injecting from which is incisally so it can lead to a bit of staining or a fracture. So, there are kind of ways to compress this, so the clear stent is made pressurized. It’s not just a bench made kind of stents. It’s made in a hydro flask, in a pressure pod so that it fully polymerizes so the adaptation of this material called Exaclear which is a clear silicon from GC is outstanding. It will even replicate printing lines on the composite made from a digital model. So, there’s no problems with this. The concept is to have this thick enough it needs to be about a centimeter facially, a centimeter palatally and a centimeter incisally to be rigid enough. So, it basically acts as a stop for the injectable composite. The silicone is compressing the composite so and I’m using this now to compare it to some other techniques which are using restorative paste, heat it up. I believe that if you’re using a restorative composite heat it up to 60-70 degrees or whatever. The paste wants to displace the stent, whereas here the stent is determining the show. It’s the other way around so there is no way that a flowable composite is going to displace because this is rock solid. I’m trying to kind of bend it back lingually and I can’t. [Jaz]Have you thought about, Kostas that with that stent made of exaclear in a pressurized format to supplement it with an Essex retainer on top to or is that just not necessary? Is that something that you’ve tried? [Kostas]It is something that I’ve tried. Let me tell you about the alternatives to this technique because I wasn’t the only idiot who had this problem so other people had this kind of issue of like how can we copy paste not going freehand. So back in 2015, the index technique came out from Ricardo Amanato and Federico Ferraris. It’s basically a kind of the same concept like this but individual teeth. So, you slice up the stent like a sushi roll and you kind of do it on an individual tooth so that you don’t have to mess with the cleanup. So, you clean up each tooth and you go along that works well for mild to moderate tooth wear because you have quite a bit of referencing from the tooth underneath but not for severe wear. So, the Didier Dietschi technique describes exactly what you said. It’s an essix retainer realigned with clear silicon to pick up the detail but the essix gives it the rigidity. So, the problem with this is that you’re kind of having to make holes through two things and you need to kind of drill the holes and that creates a little bit of dust in there. [Jaz]Very annoying I usually delegate that to my nurse with a micro brush be like just half an hour just get it clean. [Kostas]It’s very annoying so the people that I’ve learned this technique from I mean the person that came up with this technique is Terry Douglas out of the states. [Jaz]Hilarious guy and really great with ceramics and material tools. [Kostas]So he describes kind of cutting holes with a tungsten bur I just didn’t like the dust because I was leaving it. It was kind of within the matrix and it was looking messy. So what I’m using is the actual tips of the composite you might be able to see the either the vents over here to make an equal kind of diameter hole. [Jaz]Hey guys I hope you’re enjoying the podcast so far if you want to download an infographic on step by step like visual aid on how to carry out this technique then go to www.protrusive.co.uk/injection. If you just type in injection it’ll take you straight to the page you need where you can download this infographic and pdf it’s like a visual aid like an aid memoir of all the steps involved. Hope you enjoy and back to Kostas. [Kostas]It’s a technique that kind of works but it can have its kind of limitations. It’s designed for mono shades let’s put it this way. It’s not designed for layering so it can allow for layering but it’s a hundred percent mono shade technique which makes it popular for tooth wear cases. [Jaz]Makes popular for Essex where you are.[Kostas]Yes, so there are different ways to kind of go about it like the essex retainer and stuff but in my personal opinion this is the most rigid. I mean the thickness of this makes it super rigid. So, I have to hold this firmly in place and I need my nurse’s assistant to kind of inject. One problem that it doesn’t solve but it minimizes the cleanup so I’m getting some excess but less I believe than other techniques. So, the equipment that I need to finish a case are a 12 number blade a very sharp curved blade and some ipr proximal strips. I don’t need to use burs or discs. The anatomy is already there for me if I use burs and disc. I’m going to destroy what the lab did. [Jaz]Perfect. In my mind, I’m trying to position myself as I’m trying to remember when I used to do this technique and we could talk about some other techniques as well similar to this. And I want to eventually come on to your workflow your one minute workflow like step by step by step because that’s what dentists are hungry for but I’m just remembering some of these times I’ve done it and I used to get sometimes this air void not just where the channel was but in the mesial incisal corner and in the distal incisal the corner. So, then what I started to do was pre-load the stent in the mesial incisal corner and the distal incisal corner and the few times I haven’t got enough cases to be able to say hey this is this works. Is that an issue that you’ve had and basically my question is do you pre-load the stent a little bit as well as injecting from the hole or is it purely injection from the hole only? [Kostas]Let me put it this way. If there is any other exit other than the one where the material is coming from, the material will be under compression. It will be within like a lot of hydrostatic pressure. So, I do make sure that there is no kind of escape channels and I will be getting some voids occasionally when I’m retracting the syringe vertically. So, I’ll get some incisal kind of voids but not what you mentioned because I ensure that laterally and gingivally I have stops. I have a frame within, I’m compressing the material. So, I can actually visually see through that stent because it’s completely clear, some of its competitors are not clear so any voids will actually be visible. So I’ve never had it within the material just upon pulling out. [Jaz]And you’re purely just injecting? You’re not pre-loading the stent with any- [Kostas]No, I don’t. I’ve never seen the need for this. I do like seeing the material being injected and then gradually filling it up as if it’s about to overflow on a glass or whatever so I like it. It’s ever so satisfying saying that but then if you overdo it, you expect some flush. So, the flush management out of all the techniques that I’ve tried is by far the best so you’re going to have a very crisp junction between the composite that you need and the composite which is kind of excess on the cervical and then you put a knife between them and that breaks off. So, the reason I’m cleaning up this technique is not designed to do multiple teeth together. So, it relies on little blankets, on ptfe tapes and the alternate tooth technique. So, you can either do one tooth at a time but that is quite slow so the fastest you can go is doing 3 teeth together canine central and- [Jaz]Other lateral. [Kostas]Yeah, the other lateral and then coming back for the other three. So, if these giving you kind of some speed but then again, I’m coming on to the workflow it has more appointments and a higher cost than freehand. So, when I’m pricing things up for my patients it is more costly than freehand because you have multiple appointments, you have a lab fee you have to make stents. So let me now go through how I approach this case somebody comes to me in this case- [Jaz]Before we go, I’m so excited for just to you know geek out and tell me your workflow because it reminds me of when I used to do this as well and I probably just haven’t had the cases through to discuss this but also I have recently been moved to a paste system you know let’s just be honest it’s elephant room smile fast. I have been using smile fast let’s get it out there, okay? I’m Jaz and I use smile fast, okay? Don’t shoot me. So, now that I’ve moved to that kind of system. It has its own challenges, it has its own challenges so I’m sort of experimenting with that at the moment but no doubt I think, I do miss when I did the injectable technique and when I’ve got one or two more cases of smile fast my bet I’ll be able to really then pick and choose between the two different techniques and tell you maybe a few years later which one I prefer but definitely the flush that I found with the smile fast system was a bit but it’s quite quick to manage. I mean the best thing that you said there were about all the lovely things that I remember using is that every other tooth technique that is a real gem right there and by doing that the downside is that you need two stents right? You need one every other tooth model and stent and one full smile stent and that’s where the higher lab fee comes, have I got that right? [Kostas]Well, correct. I mean one way to do it is on the digital workflow you have a six unit wax up, you ask the technician to click the mouse three times and delete the alternate teeth. [Jaz]Yeah. [Kostas]Then you have like it’s like up and down because one tooth is going to be longer than the other. So, three wax ups have been removed and the other three remain and they make a stent based on that. So, I don’t routinely use this technique I actually just get one made but I create some stoppers for the ones which are not to be bonded. And I do this with my kind of mock-up technique to prevent the injectable from flowing laterally. So, if you’re doing an analog wax up it’s very difficult to remove conventional wax and make a stent for three and then for six. So there are different ways to go about it and after, as I was telling my delegates in the course that I did on Saturday you got to do five cases and in these five cases you’ve done all your mistakes. It is like I’m 100% sure about this. So, there are a few mistakes to be made and the alternate tooth technique works. You can’t do all the teeth together. Other techniques like smile fast are aiming at doing multiple teeth, I am not interested in doing multiple teeth. It might be an excellent technique, but I don’t want to do multiple things. I don’t want to do fast dentistry. So one big benefit in the technique that I do is that I am in control and that comes to the workflow. I am not working with a central lab. The lab that makes my stent is my own lab. It’s no fancy central lab which only works on scans and not alternates and they kind of do one case after the other. So, I don’t rely on any kind of specific brand it’s down to me and my usual lab communication. I mean I WhatsApp my lab technicians all the time regardless now if that’s one more reason. [Jaz]He must hate you man. It’s a love-hate relationship. I’m sure. [Kostas]My wife might do because I text him more than I text her. But anyway, so, let me let me walk you through my typical case. [Jaz]A sequence please do. [Kostas]So, William came yesterday, lovely guy. He’s got a little bit of rotation, he’s got a little bit of microdontia. He is not going to benefit from invisalign because he will still need some restorative work. So, he says okay everyone’s talking about composite bonding you’re the man go ahead and do it. So, I will take a full set of photographs, I will take scans of his teeth on my intraoral scanner and I will send all this to the lab prescribing a wax up as if I am going for ceramics. So, this whole concept is basically using the whole build up as if you’re going for crowns or veneers but then in the nick of time you just whoop you kind of turn and you go for composite, so you don’t have to. So, my lab prescription to for the wax up is going to be the following. The first thing that I tell them is that is this an additive wax up or subtracting. If it’s an additive, you can mock it up you’re just adding volume typically 90% of wax ups are going to be purely additive. If you have teeth which are massively rotated and there’s the distal kind of corner is coming out, the lab will need to remove some before they wax. In that case you cannot do an additive mock-up. The second thing that I tell the lab is do they conform to the occlusion or not? So, if it’s an aesthetically driven case it’s going to be an MIP case, ICP whatever you want to call it. If it’s a tooth wear case, they’re going to be opening up the vertical. I will tell them that hey, open up the incisal pin or the virtual incisor pin by two millimeters and separate the posteriors like a DAHL concept, so occlusion, conforming or changing. Then under the aesthetic principles, is the incisal plane correct? Because if you give a dental model to a lab they haven’t got a clue, they need the photographs and especially the portrait pictures. So some information on incisal plane, some information on the midline, typically you’re going to be increasing length and if I don’t want to increase length I will find one tooth which has the correct length and I will tell them hey, use that upper right one to design the smile just like complete dentures nothing. [Jaz]Reference tooth. [Kostas]Absolutely, then as far as the facial addition which is pretty common thing that people want they want bro the biggest smiles I will kind of give them an indication of where I want them to add and I will take my little kind of pencil on my iPad and I will make some lines and I will send these across. So, basically, I’m giving a lot of information to the lab. The last thing I’m going to ask the lab to do is what stents I want them to make. So, I do not use this clear stent to do a mock-up with. I make a separate one just putty and wash. Why? Because this is going to get dirty. I don’t want it to get dirty. So, I want it to be super clean for the day of the injectables. So, I’m giving them a long text, a long email which you might think well if I do this in a one of the competitor techniques all I have to do is kind of send them off and they do it for me. Well, I’m a little bit of a control freak. I designed a smile I want to let people know yes the experienced labs will know how to do this for you and if somebody comes out of dental school they might not know how to prescribe kind of these lines and where the midline is counted and all of these things so I want to be in control. So, the lab will then send me a wax up, I prefer a hybrid wax up so it’s a printed model with a handmade wax up on top rather than a fully digital one because the detail that you get on a manual wax than an analog wax in my opinion is better than the one, you’re going to get on digital. [Jaz]Purely for the purpose of the of the mock-up right that you’re getting this hand wax up? [Kostas]Yeah it is purely for the purpose of the markup but then again nine out of ten mock-ups that I do are fully approved and they become the kind of blueprint for the clear silicon stent so I will rarely modify the wax ups because- [Jaz]The Indian in me it can’t resist but say that the lab bill’s increasing here man like if nine out of ten are approving it bite the bullet, go the digital that’s the Indian in me like yeah come on save that lab. [Kostas]What do you mean? What’s the benefit of going digital? [Jaz]The benefit, because that so the final one where you go to every other tooth model and the full set model. The full set model, the design, the model is all there like he can pretty much send you he doesn’t have to print every other tooth model yet because it’s not been approved yet, but he can just send you that model and make you a putty wash on that for you to transfer into the patient’s mouth. That’s the way I’ve done it because I want to do two wax ups. [Kostas]The only limitation of the full digital workflow is that the primary, the secondary anatomy, the tertiary anatomy within the central incisor, the lobes, and the grooves and the perikymata is not as well defined as a well-crafted manually. That’s the only limitation. [Jaz]You guys can sense the control freak in Kostas, the attention to detail which is very admirable and you definitely see that shine through social media. So, do check it out. [Kostas]But in terms of the workflow you’re absolutely right the digital is kind of the future when the tooth libraries are that good like hyeto’s kind of tooth library from the anteriors. If you use that kind of stuff you can get excellent anatomy but I still prefer like a handmade wax. [Jaz]I respect that. I can see why, and I think you’re going for the cutting of the fineness of the fine and that’s awesome. [Kostas]So I will then fabricate myself a putty and wash stent as if I’m making temporary crowns. I’ve got a little pressure pot in my clinic so I will make that mock-up stent it looks like this but it’s out of putty and wash and I will use my bis-acryl to make an additive mock-up. [Jaz]Your favorite brand bis-acryl is? [Kostas]Luxatemp. And I will then scrutinize this, I will take pictures, I will take a video, I will show the patient, I will let them know what they like and what they don’t and as I said nine times out of ten it’s going to be a stunner because the lab is pretty damn good at making this. So, it comes down to the detail on the wax up but the waw-ups are going to be full contour I mean just because it’s a wax up it doesn’t always have to be full contour you’re just filling in corners here and there but basically it’s the art of working out where the teeth need to be just like the Prosthodontic dentures. [Jaz]Kostas, can I ask? Is this case mounted on an articulator i.e are you also dahling the function this stage or is it purely esthetic at this stage? [Kostas]Well all the MIP cases, the ICP cases they’re going to be kind of relying on the buccal bite of my trios or my scans or whatever. Now if I’m doing any kind of Dahl cases three to three four to four. I will deprogram someone on a leaf gauge and I will take some centric bites with some stone bite or whatever I might have and I’ll keep one kind of centric bite on one side and I will scan the buccal bite on the other side. So that when the virtual models are kind of mounted, they are mounted in CR. So I will not do a face bow I mean the only thing that my lab sometimes do is that they use kind of an interpreter line to kind of do an aesthetic aspect of the face bow. So, I will nevertheless take physical centric bites when I’m changing the occlusion, but I will still kind of scan the mouth the back teeth are apart the OVD is maintained by one century bite on the other side and then swap so I mean. [Jaz]That’s a real gem. I just want to highlight that because at times I’ve done that and I’m such a big fan of scanning the occlusion at your desired OVD which is determined aesthetically like I’m just amazed that when I’ve done the injection molding or paste molding or whatever and then I’ve just get them patient to bite together how little adjustments I have found I need to do. Has that been your finding as well? [Kostas]100%. [Jaz]It’s cheating.[Kostas]It’s cheating. I mean you kind of do a big case in ceramics or composites you focus aesthetics, aesthetics, aesthetics, and you’ve got a couple of patients waiting and then you ask the patient to occlude and it’s like a disaster. So, I mean I know that this is going to be very there about so the notion that regardless of how much you open them up it because it’s a kind of a parabolic, you’re going to be at the hinge axis well that’s nonsense because we’re never going to find the hinge axis. So, you’ve got to be pretty much at the right vertical, two millimeters open which is like the thickness of a occlusal appliance, a b-splint or whatever. So, I will try and do this at the right vertical it’s what percentage of cases are kind of reorganized the small percentage is about 10 percent of the cases that I do. [Jaz]In private practice. Because imagine in hospital it’s the other way around. [Kostas]Absolutely the other way around. Because in private practice people come requesting this on aesthetic grounds. Now, they may have a little bit of tooth wear but it’s mainly the facial, it’s mainly the looks. So I’m going to get referrals in practice for genuine tooth wear cases, it’s functional cases which needs dahling or a full arch or proper offer because dahl is kind of awful for the poor. But in hospital, is it’s the other way around so here we have functional tooth wear cases, where the teeth need crown lengthening and more extractions. Just last week, I managed to get the injection molding materials approved through procurement and they’re available at Guy’s. So, we’re going to stop just doing a free hand right, left and center but in practice it’s a small kind of percent of cases which are requiring centric bites, opening up the vertical and things that might be outside of the comfort zone of average GDP. [Jaz]Amazing. Is there anything else left in the workflow there so you’ve told us about the design, how to transfer that with the luxatemp to the mouth, you gain your approval. We’ve talked about the different models you make every other tooth; we’ve discussed a little bit about the actual injection molding procedure itself. The common mistakes which obviously you do in your course, and I think there’s too much because I’m going to wrap up here now. And then anything different, I mean it’s just composite bonding right? So, I don’t imagine there’s too much differences in terms of bonding. [Kostas]I mean in terms of longevity studies the technique, there’s nothing special about it. It’s basically about the material so if you do a class to cavity and you put your composite horizontally or in increments it doesn’t really matter. It’s about the material that you use. So, when we have clinical evidence about this technique we’re going to be looking at the injectable composite so on the day of doing the composite, let me make this kind of clear is rubber dam. Rubber dam and injection molding and fighting against each other like they don’t really like each other because this wants referencing points if I’m doing three to three the premolars are acting as reference the palatal tissue and the buccal tissue are acting as reference. So, the few cases that I’ve done with proper rubber dam not split dam or whatever is the thickness of the dam, and the stretchiness of the dam is fighting me. I don’t want anything to fight me so how do I isolate? I will use my OptraGate I will put retraction cord and I will put my teflon tapes which are going to be tucked into the papilla so that I cannot see the papilla. So, I’m creating a frame gingivally retraction cords and the teflon tapes on the proximal so that I will not have any gingival crevicular fluid, tongues, cheeks. So, the purists might say this is nonsense anything without rubber dam that might be a little bit right. I don’t know yet, but I do know that if I go for the full dam, it’s going to compete with the stents. Now split dam– [Jaz]It’s the same for me by the way Kostas with class fives like sometimes it gets in your way rubber dam. So Richard Porter taught me you know eight years ago use rubber dam, always use rubber dam except when it makes your life more difficult and in this case, it’s going to be too fiddly, you’re more likely to make mistakes have the rubber dam stuck in between the stent and the tooth these kind of issues. So, I think it’s actually more predictable without rubber dam in this technique. [Kostas]Correct, so for anterior restorative dentistry, it’s of no benefit. Now if you’re doing the wound and tissue and you’re adding on sixes and sevens, that’s a different story. So, you got to have good isolation over there so I’m going to aim for rubber dam and I’m going to trim that stent so that it actually sits accordingly. So, posteriorly you can’t really control. So, on the day of the injectables, I will do my isolation in whatever way. If I’m in doubt about the shading because luxatemp and resin composite, they don’t always kind of talk to each other. So, I might actually do a quick mock-up which is the most expensive mock-up in the world with the actual injectable material. And I will replace my teflon tapes, my nurse will have everything ready she will cut double the number of the teflon tapes that I probably need because they shred, they break and whatever. Lots of number 12 blades, ipr strips the asap kind of polishers which are like idiot proof and I will not really need discs and burs maybe if I get a little bit of a lip on the cingulum palately with the probe I might feel that something I might put a bird to that. But typically not, so it’s a technique mainly designed for monoshade but the success comes from the communication with the lab. So, the spotlight goes on the GC materials exaclear and the injectable material they are amazing materials and the unsung hero the lab technician who is filling in the bench shaping a wax up having a bit of coffee looking outside doing exactly what I would do if I were to do freehand. Now, there’s lots of people as I said at the beginning who are excellent at freehand and they teach it very well but I wanted an easy technique and I also want an easy technique to teach which this technique I think is easy to teach. Freehand is not so easy to teach. I like the fact that it improves the relationship with the lab technician, it’s like short-term orthodontics. It’s like it massively improves your relationship with the orthodontist rather than undermining it. And I think there’s a big future for this technique in terms of copying anatomy and okay you might not have incisal effects but most people don’t really look for this anyway. [Jaz]Very true Kostas, thanks so much for that absolutely. I’m going to call this a injectable composite masterclass. I’ve never used that word for masterclass. Can’t use master class, as a masterclass. Just give us a real decent juicy flavor of this technique. It’s something that a technique that I actually enjoyed using. When I used it I’ve got a few cases that I’ve put online in the past and I’d look forward to you know using this technique again. Because I’m a big fan of the GC universal flow, the injectable one the gold one is that the one used right? [Kostas]Correct. It’s the universal injectable is kind of the that this the sequel to the universal black world. It’s pretty much the same material better salinization and a better tip. [Jaz]I just love using that because you know as you said you can actually place it and it will not slump or move and it’s got all the properties you want from flowable but also it’s a highly filled resin, so that’s amazing. Please, please, please, tell us where can we catch your courses? Are they only in England, London, GC where are they? Is there anything that you do abroad because you have quite an international audience here, tell us. [Kostas]Yes, I mean I’ve started this collaboration with GC. I love their materials, I love the ethos of the company and I’m going to be doing these hands-on courses in Milton Keynes in their kind of a HQ. And I’ve planned quite a few from now till Christmas. They’re going to be on Saturdays, if you email GC UK they will kind of give you the details. [Jaz]Send me that as well any brochure. I’ll stick it on the website. We’ll call this episode protrusive.co.uk/injectioncomposites not injectable because you might spell that wrong. Injection composites and then on their I’m going to have all these details so I want the GC email to get on there any posters that kind of stuff. I mean I saw the feedback on social media recently, it was phenomenal everyone loved it and I can see why. You’re such a great educator. [Kostas]If you pay somebody 50 pounds, they’ll say very good things for you. [Jaz]Please tell us some more sorry. I stopped you in your tracks. [Kostas]But I’m going to be doing some in Ireland, so I’ve planned kind of Cop Dublin and in Belfast for the autumn and it’s kind of going to start, going up north towards kind of Newcastle and Glasgow. So, I would like to do a little bit of a road show because it is a fantastic technique. I don’t want to kind of steal the spotlight as I said is about the technician it’s about the material. So, I do this in collab with GC kind of one Saturday a month and it’s a full kind of a seven-day, seven-hour course like a full day course and I’ve got four hands-on exercises kind of a single central, the peg lateral, six anterior teeth from the alternate technique and then the war indentation four five six and seven.[Jaz]So I’m going to I think I’m going to I couldn’t come see your recent cohort because I was teaching in Edinburgh myself actually doing TMD splints for like one hour. So, I couldn’t come to that date but I want to come and see you in Dublin because I really want to go Dublin. I’ve never been in Dublin. So, I’m going to look out for that date. Can you tell us your Instagram handle so we can actually see these cases because they’re brilliant. [Kostas]So my Instagram kind of page is @kostas_karagiannopoulos, my surname by the time you get to the first few letters of the surname it should come up because it’s such a ridiculous. [Jaz]Good work. [Kostas]Name and surname. So, you can drop me a private message on Instagram to ask anything about the courses. I’m always on the other side and I will answer questions rather than tell you no you’ve got to do my course first. So, I’m not that type- [Jaz]Kostas have been really approachable I find it easy to speak to him so if you’re any sort of cases, ask opinion, send it to him. It’s been really lovely to connect with you over the last year, Kostas and thank you so much for making time. I know you’re probably looking at the clock thinking oh my god I’ve got to go back to my clinic and my students and stuff. Thank you so much for giving us so much value in this episode, my friend. [Kostas]Thank you It’s been a pleasure thank you thanks for having me. Jaz’s Outro: Guys, I hope you enjoyed that episode you should totally check out Dr Kostas’ work on Instagram. He is such a giving clinician he’s one of those people who’s always sharing knowledge and honestly, his occlusion knowledge is up there he’s a clinician I really, really aspire to be like. So I hope you enjoyed that do check out the pdf download once again on /injection and I’ll catch you in the next episode.

It’s my sister’s wedding but the Protrusive team managed to get this out for you – and boy it is a good one! Dr Omid Azami AKA The Noobie Dentist will inspire to you adopt a growth Mindset. https://youtu.be/NSEbShIeD04 Check out this  full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “Have that mindset like ‘it’s a journey’, you’re never ‘there’ necessarily. You can always get better, and do more.” – Dr. Omid Azami Here with me, Dr. Omid Azami, host of Noobie Dentist Podcast, who inspires and gives voices to clinicians all over the world and inspiring Dentists. In this Interference Cast, we discuss all about: Tips on making life more efficient, better and more productive. (09:26) Key attributes that help a young dentist to become great. (16:33) Tips and tricks to make a habit of taking photos. (20:54) Journey of self-discovery. Finding your pathways and niche. (24:20) Importance of mentorship, even remote mentorship. (32:58) Most inspirational guest from Noobie dentist and their takeaways (39:03) If you want to learn more, please do subscribe at  Dr. Omid Azami’s Noobie Dentist Podcast If you liked this episode, you will definitely love and will learn a lot from the episode 10 Habits of Highly Successful (and Most Valued) Dentists  Click here for Full Episode Transcription: Opening Snippet: As an example early on i was all about the money right? I was, you know, in toronto I was a new grad I was like I want to make you know x amount of dollars per year and day to day like my happiness was like up and down on how much production I had and how much I was making and it was pretty early on I was like man this is not a good way to like think about dentistry of just like how much money am I making. Let's instead focus on my clinical outcomes like is my restoration is looking better today? Is my marginal contours better? Is my contacts better? Is my extractions faster and cleaner? Is my post-op comforts? So that's I had that mind you know mindset change and it really made me happier because I was challenging myself to you know learn the craft better day to day instead of just focusing on the money and the outcome side of it... Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati. Welcome to this interference cast with Omid Azami better known as the host of the Noobie Dentist podcast. This episode was actually shot many months ago. Right now when i’m recording this introduction I’m quite nasal. I’m so sorry. I have got a bit of a non-covid bug. It’s a bad timing but at least it’s non-covid. I’ve got that confirmed. It’s my sister’s wedding at the moment and for those of you who are familiar with Indian weddings It’s not like a one-day affair, I wish it was a one-day affair. This is like a three-week bonanza I am so grateful I have just one sibling but anyway let’s make the most of it. I’ve got my son. I’ve got good food to look forward to. Dancing. Indian colors and festivities and traditions. So I’ve got a lot of that going on. I’ve got a lot of the episodes on autopilot that have been pre-recorded So they’ll be getting released by the team over the next few weeks. So you won’t go a week without having a Protrusive dental podcast episode, don’t worry. This themes, the themes that we cover in this episode are very much related and intertwines some of the previous themes that we’d cover The theme of journey. The theme of career decisions. The theme of mindset and the theme of just being the best version of you. The two biggest takeaways that you might get from this episode is funnily enough something I like to call toilet university and yes I have no shame and number two is something that only describes later in the episode as the social multiplier effect and something that’s so relevant in dentistry. So i hope you enjoyed me and Omid just you know have vibing out chatting about dentistry in Australia. Dentistry in UK and how to power up your mindset in dentistry. I hope you enjoyed this one. Main Interview: Omid Azami, welcome to the Protrusive Dental Podcast, you are better known as the Noobie, well you i don’t know if you are the Noobie dentist but your podcast called The Noobie dentist but maybe that was inspired by the situation that you felt in so let’s go straight in what inspired you to make the Noobie dentist which by the way has been awesome i’ve been listening to it. It’s such a great resource so please jump on and subscribe to Noobie dentist as well but you are the original noobie dentist Tell us how did that get to be? I appreciate it man thank you for having me on. I’m a big fan of your work as well and your podcast and you’re doing great things like i was telling you earlier when i first started the podcast it was sort of a small space. I mean there was you know Mark Costas an the howard friends of the world and you kind of knew every podcast that was out there is a millennial dentist and you know shared practices So when I first started there was a lot of business of dentistry podcast so i was i enjoyed the topic a lot you know, how to start a practice, how to control your overhead, how to communicate with patients and case acceptance but i didn’t find a lot of sort of practical day-to-day clinical topics being discussed and so i thought that was a cool niche that i personally as a consumer podcast wanted to kind of find and learn and so at the time it was 2016 i graduated from Melbourne dental school and I had moved back to toronto where i’m originally from so. I moved back and i was working in different practices and i just didn’t have a network because i you know in Melbourne you know i’m pretty outgoing and a good networker and so all my university demonstrators and things were people who i you know could rely on as mentors and things but when i moved back it was tough i didn’t have them those people around me to help me with cases and how to deal with difficult situations. So early on instagram was pretty good as well so i started the noobie dentist instagram account first and i said once i get this audience big enough i’ll try and convert that to the podcast and obviously it’s tough, it’s hard to put yourself out there.You’re nervous like what if i make it, no one listens to it, no one you know subscribes to it So it took me a while. – Did you have the same moment Did you have the same objection that I had? The one that i had the biggest one i had was i hate the sound of my own voice. Did you have that one? It’s cringy man. I still cringe i mean i’m getting a bit better with it now and i’m trying to become a better speaker and try and control that but for me now it’s video because i’ve started to you’re good with video because you record your podcast and release them but didn’t you know dabble in video until recently and that was a very big thing because i was quite trying to do that and things but yeah just you know getting back to the podcast point it was about mentorship I just wanted to connect with local dentists in toronto first through the instagram community started that and start to grow and you know eventually some dentists in the US and then abroad and yeah it was just a small hobby and it’s amazing how a couple years of sticking with something things can grow and expand and to see where things are and you know being here having the opportunity to speak with you and while you’re in the UK and I’m here in Australia, it’s quite amazing It’s so cool and I know you’ve got this because you just mentioned it but it is just the most flattering, humbling, sensational feeling when someone from like Kingston, Jamaica messages you or i had a student the other day from Germany messaging me saying, I love listening to the Protrusive Dental podcast or whatever and you must get loads of messages from various countries of the world and it’s just one of the best feelings and that really keeps us going in terms of you know making stuff because people is helping people and your podcast has definitely done that i mean generation of young dentists and I always say it’s never been a better time to be a dentist than today because there’s so much i don’t know how it is in australia oh me tommy Do you feel as the morale is low in dentistry or do you feel like there’s lots of like problems because in the UK, I don’t know how much you know, I feel like you probably know a lot because you’ve had guests from all over the world but the morale can be really low in the UK and with the fear of litigation and the public sector and how that’s funded. So the morale can be low but you know, my mission is to convince everyone that it’s never been a better time than today to be a dentist. What do you think? – I love that. I think that’s great and i really think that’s a positive message to be spreading It is true like it’s people get burnt out i have friends, even myself i’ve been through like the waves of the work is stressful, your patients aren’t always grateful necessarily but i think the way you’re approaching it in terms of you know education, learning, doing better work, providing better care for your patients i think that’s one way to kind of get out of it. I think and the message i’ve been telling people in in the podcast and things is how you portray? How you see dentistry is how you measure yourself in dentistry so as an example early on i was all about the money right i was you know in toronto i was a new grad i was like i want to make you know x amount of dollars per year and day to day like my happiness was like up and down on how much production i had and how much i was making and it was pretty early on i was like man this is not a good way to like think about dentistry of just like how much money am I making. Let’s instead focus on my clinical outcomes like is my restoration is looking better today? Is my marginal contours better? Is my contacts better? Is my extractions faster and cleaner? Is my post-op comfort. So that’s you know mindset change and it really made me happier because i was challenging myself to you know learn the craft better day to day instead of just focusing on the money and the outcome side of it. So I do agree there’s tough times especially in the UK and other countries in Europe you hear with the NHS and the reimbursements and things being so tricky. We have a lot of UK dentists here in Australia because they flee the public system there to come here. – The refugees of the dental system. It’s so true Yeah, it’s definitely tough. I think we have it quite good in Australia in terms of insurance, reimbursements and things still. So the litigation side is a big one that personally weighs quite heavily on me as well because we you know all most of us come from a good place and we don’t do things to harm patients or don’t do treatment with the eye of it failing but if it does and then patients come at you with that threat. It’s just like a bad place to be How much do you know let me ask this. How much is like a maybe a dentist five years out of dental school general dentistry like you are. How much would you expect to pay for your you know dental protection or insurance or whatever in Australia? – So there’s different companies with different rates. I would say probably the lower end would be about eight hundred dollars and then the higher end would be about three thousand dollars. So that’s like the sort of the range i would say Oh my goodness these are Australian dollars, right? – Yeah, what is it like in the UK Okay are you sat comfortably? Are you, you’re not going to like face, right? The lowest of the lowest end and this is what general dentists is not like a public sector community The general dentist the lowest of the lowest of the lowest is probably around about and it’s like after five years qualification. Non-implant. Nothing complicated, the lowest lowest is two and a half thousand three thousand pounds is the lowest of lowest right? You’re looking at 6k 8k gbp, okay? And i know plenty of people are on that and for a lot of people it’s the second biggest monthly expense after their mortgage after their house right? So the house, number one. Number two is there So it’s just paints a picture of what it’s like you know in the UK with litigation stuff So that’s why when i was in singapore, I felt as though this massive weight had been lifted off my shoulders and you know it’s good of you to sort of say that you feel yourself that maybe perhaps you don’t feel as strangled by that because the biggest thing you said was burnout was as a real issue whereas here that yeah there’s burnout but there’s so many other complicated factors but I don’t. I want to keep this episode positive because there’s so much positivity about you Omid as a person and i love the fact that we’re into the same things like we’re into this self-help, productivity. All these sorts of cool things and you’re always putting out these like weekly mentorship things which people should totally check out about how to be the best version of you. So my question to you, my friend is we have a lot of similar interests in that productivity habits that sort of stuff. Can you share your one or two biggest tips dental or non-dental for making our life more efficient, better, more productive? – Yeah so like i said i was thinking about this as i was running today and i i don’t think i’m great and i think that’s one the first thing i would say is like have that mindset of like it’s a journey like you’re never there necessarily so you can always get better and and do more. I’m very productive at consuming information i think so like i said i like to multitask like it’s not often where i’m sitting at home or on commuting or even at work where i’m not trying to like learn something while i’m doing something else. So i always have a podcast in the background or like a youtube video in the background which is good because you’re always you know learning and consuming it but i think the next step of that that i’m working on this year has been implementation. So you can always have the knowledge, you can you know go to all these cpd events and learn a procedure in dentistry or you can watch these tutorials or podcasts about investing or whatever it may be but like that step of okay i’ve understood the factors, i know the knowledge but now i need to like apply it to my real life. Take that step you know buy my first stock or you know do my first implant or take out my first tooth or wake up at five tomorrow and actually do my morning routine whatever it makes you. Do you do that by the way? – You know it comes and goes i’m pretty good. Normally i try and wake up around 5:30 and i have like a thing that i do and i think one of the videos that i did recently was the cool thing about it is you don’t need to be so regimented I think. You can have different phases where you try different things or whatever fits in your life at the moment. So for me right now for the past maybe six months eight months running has been probably the biggest thing outside of work that i focus on and spend time on. So my morning routine is like wake up do my like morning mobility and things like that and then have breakfast and watch like a youtube investing tutorial because i’m trying to learn about investing all that at the same time. So that’s sort of it but in terms of to answer your question. I’m going the long way around here but one of the main things i use is like apps. So i use trello, I’m not sure if you’re familiar with that? Yeah, I’m familiar with trello. Explain to everyone what trello is Yeah, so trello is essentially it’s like a it’s like a big to-do list so you can have columns of things. So it took me a while to like really master my sort of the workflow there so essentially how i have it right now and maybe i’ll share a screenshot or something of it is. I have you know on the left side i have like open loops i call them so there’s like long-term ideas and plans and things that i want to get to one day. So for example before i did the noobie dentist rebrand that was there like i was there for months because i was like i want to do it one day whenever i get the time. So those are my open loops and then i have like my monthly, weekly, daily to-do list so then i kind of drag it across like when the week comes i’ll be like okay i do these ten things this week. Put it there and I’m gonna go of those ten i’m doing these three today. So that way you when your time pour you sit down, you just open up your trello board that you’re organized. I usually do that like on the weekend on the sunday or something for the week ahead. So when i wake up i only have 30 minutes i can just look through my list like these three things i can just bang out right now it’ll take me 10 minutes to do it and i’ll do it. So that’s been a big you know time efficiency for me because i don’t waste time thinking okay what do i have to do, what’s next, what do i have to plan, who’d have to contact and then you get a nice dopamine rush because when you like take it to the completed list then you see your completed task list grow that’s pretty rewarding as well So that’s, i guess my tips are one is productivity and consumption so multitask. Try and listen to a podcast when you’re out for a run or at the gym or – Toilet university Yeah so that’s always fun but and then try to do this like some people just like pen and paper that works for most people like having to do list. I think i mentioned one that i learned from Kevin O’Leary on a youtube video i was watching actually is he has like a sticky note that he sticks onto his computer three things that he’s gotta do first thing in the morning. So he does that before he goes to bed and then when he wakes up those three things are there just gets it done and then he can start the rest of his day. – I like that a lot and i like your trello system. So trello is a really cool app The way i’ve done it recently which i found helpful as well and maybe you try it this way or maybe you will try in the future and let me know what you think about this is sometimes a to-do list and i’ve got a massive to-do list here man and i found that sometimes just like you had those open loops and you get around to it whatnot i had too many of those and now i’ve started to integrate it more with google calendar so now you have to you put it into a physical space and you’ve allocated got like protected time for that and i find that i’m getting more done because i’ve got that protected time but you know there’s always issues doing it that way as well but I do like your trello system because it breaks up into you know weekly, open loops, daily sort of thing so you know i’m always looking for gems like that so i might look at it again. I think it’s good for teams if you work as part of a team, trello is good because it allows everyone to sort of access and and tick things off right? – Yeah but that’s what we do with the podcast and this is you know like i said this is just stuff i’m learning this year and a lot of it goes down to my friend David who has his own dental podcast as well. We, he’s very systemized whereas i’m not as systemized of a person but i’m learning a lot from him so David. -What’s David’s podcast? Tell us. It’s an Australian podcast called Dental Head start. So he’s doing great as well Growing quite rapidly much like you are. So i like that systemization with the podcast we have you know episodes that i’ve about to record, episodes I’ve recorded, episodes that have gone off to the editors and then the guys that i have helping me with the social media side of things. Know where things are at and can track it as well. – Do you think people dentists can use this in practice? Do you think, is it something that you can use as a practice manager? Have you heard of dental practices using a system like this because it sounds pretty good actually if if you got the manager, the treatment coordinator, some dentist using a version of trello to get more stuff done efficiently as a team? It would be an interesting thing to do. For sure and i think there’s a lot of space to improve that in a lot of dental practices right? Like not many of the practices would be that systemized but i think it’s such a nice visual tool, you can like color code different tasks and things in there. So you know even like as an associate dentist for example you have like cases that are ongoing you can have them on there, you have cases that you got to do a case presentation on or chase up lab work. I think it’s a really useful tool for dentists to use for sure. – And i like that dopamine hit you said because sometimes i don’t know if you’ve ever done this, Omid, tell me I sometimes I make a to do action and i take it away straight then and there because i’ve just done it but i need to register that i’ve done it and then that’s a level obsession that sometimes you get when you have these dopamine hits so i i love those little gems so guys check out trello also check out the dental head start podcast because i love promoting our own you know our fellow podcasters and stuff because because we It takes a lot of hard work and effort and when you look at your own your website and stuff and the amount of visuals you have, the amount of great content you have. It takes a lot of effort you know I stan more than anyone. So we have to support each other and and send each other to these the awesome podcasts. The next thing i ask is something that you’ve covered so many times i love it in your podcast but i want you to introduce to my audience as well is what makes a great dentist like this is such a big question, right? Like you know we all want to be this awesome dentist but what do you think because you’ve spoken to such a huge variety of guests and i feel like you’ve pinched a few things. You’re like as my colleague Zak calls it you’re like a patchwork quilt of all the other dentists or whatever, right? Or the average of the five dentists you spend the most time in, one of your recent episodes as well but what do you think is the key attributes that’s going to help a young dentist become great? I think the main thing is communication. I think at the end of the day regardless of your skill level, if you can communicate well with the patient, if you can get what you know or see in your head to the patient and make them understand, why they need certain treatment or even you know the consent we talked about litigation and things like that i think a lot of that comes to like poor communication, right? So you know if you’re good at warning the patient of what can potentially happen before it happens it’s a whole different conversation once if it happens, right? Whereas if you’ve never warned them about it and oh now oh sorry the instrument’s separated in your two thousand endo If you’ve never warned them that this could happen or it does happen then they look at you like you’re making excuses at that point, right? So I always think communication is the number one tool for success because you don’t have, you don’t need to have the best hands, you may not be the best clinician but if you can communicate really well. Those are the really successful dentists so that’s one. The second thing is that internal accountability because you know once you graduate, Once you’re working there’s no one looking over your shoulder, no one’s telling you, you could do that a bit better, maybe just do that again or maybe re-prep that or just refine that margin or you know what, just take that impression again it’s not good there’s a bit of a bubble on the margin. You might just be in a rush, your next patient’s waiting in the waiting room and you’re just like i’ll just send it off. So i think that sets precedence because if you are relaxed with yourself and you let your own standards slip. Nobody else is going to reach you on that so that adds up over time and then you just build bad habits and that has a big impact on you. So good communication, good internal accountability for, like set your standard because like you know the quote is like “How you do some things is how you do everything” So i’m a big believer in that now and i wasn’t like that always like i said early on i was all about you know production and fast and speed and it wasn’t great because i let my internal standards slip and eventually i was like you know what this is not the level of work i want to do. So i started posting on instagram i started posting my cases and i started getting feedback and that became the game then was okay how can i get better like clinically. So I think that’s the main two things i would say and then the third thing is obviously it’s an interesting one it’s like being selfish like you have a good level of self assuredness. You need to be confident in yourself and your own abilities and the difference between that and being like egotistical is you’re open to feedback and you’re open to ongoing learning, so if you’re assured you say i want to get better you’ll go to a mentor, you’ll go to events or cpd events and courses and things and you’ll not be cocky about it. You’re like yes i can improve, i can get better, i can learn, i can do that better. So I think that’s the main three things communication, internal accountability and being self-assured I think i was going to say that one and three but even two to some degree of those three things. They definitely have the theme of emotional intelligence you know having the self-awareness and communication theme it’s not just verbal, it’s the non-verbal, it’s the empathy , it’s a sympathy. So that screams emotional intelligence which is great and you know we’ve covered that on the podcast before and number two point i’m gonna go to it again because i wanna emphasize that your own standards can drop so quickly it’s amazing right? As a dentist because you’re right. No one’s looking over your shoulder and you just the more shortcuts you take and we’ve all done it, we’ve all done it, right? The more shortcuts you take the more drags you accept in your impressions or the technician will just guess where the margin is or whatever but you’re right. I completely agree with you that is to taking the photos when you start taking photos of your damn impressions and when you start showing other people’s there is no faster way to improve than that. So i’m so glad you mentioned it there as well I mean. Do you tend to post cases daily, weekly because that’s something I struggle with time especially with covid demand. I have so much respect for the clinicians on instagram that are like prolific with that stuff I started to i mean i like with the noobie dentist instagram page, early on was more about i would just like share what i was doing and with my cases and things and you know it’s hard to maintain it. So i’ve just made it now just like a pure podcast sort of page. I don’t really post like my own work or anything like that at this point. Because it’s tough man. It’s like you have to rotate your photos crop them like people do amazing things that they get the crowns and they overlay it beautifully onto the preps. I know how to do it but i haven’t got the time to go on photoshop and do that and it’s amazing and i’m not saying these people have surplus of time or anything it’s just they value that and they love that. It’s a habit. It’s amazing. It’s so good. Any tips to post more cases be able to any tips you can give us a you know What can someone do to because yes we’ve identified that you should post your cases or just take more photos you don’t have to post them but take more photos but how can you get into the habit you mentioned habit and something you spoke about in your podcast for as well but What tips can you give someone to make a habit of taking photo. It’s early friction, right? Like with any new thing that you’re going to take on. Any new habit you’re going to build. It’s going to feel annoying. It’s going to feel like it’s taking too long and you want to, it’s going to be easy to give up right away because it’s just like a new thing that you’re trying out So especially if it’s not something you don’t enjoy. Like if you enjoy it sometimes it’s easier to form that habit but if it’s something that doesn’t come naturally you’re not familiar with the camera. It’s clunky, it’s you gotta take your glove off you gotta just slow things down So i think it’s just making a commitment to yourself okay i’m gonna take a photo every third case this week and like not an ambitious goal like i’m gonna photograph every step of every case because that’s then you’re easier it’s more likely to fail so i think pick a one or two cases ahead of time like oh i’m doing you know three back-to-back fillings on this quadrant and I’ve booked an hour and a half. Book an extra 10-15 minutes just take your time. Take your photos and then look at it and then analyze it. How can i get the photos better first of all, how can i make the work better clinically and then i think that’s the best way because i think a lot of us we want to start working on it like i’m going to go to gym seven days a week. I’m gonna wake up at five and you’ll do that for like two days and then you just stop doing it, right? So I think, yup i think that’s the best way just pick one or two cases in a week. Book an extra bit of time. ‘I’m doing a nice crown prep wednesday morning let me just give it an extra 10 minutes i’m gonna take good photographs’ Look up before time how to use the camera. Look up some photos on instagram and kind of see what can i can i mimic that? Can i imitate that? And then try and aim for that level and then i think gradually you’ll enjoy it and kind of start building it up from there. – And you have to make these i love the term early friction used and you have to reduce the friction You have to lubricate it and the way i think you can lubricate the friction is by making sure that you A) you tell your nurse ‘hey i’m thinking of taking photos of this case’ because if suddenly you say Let’s take photos and i was like wait we don’t even have retractors in this room right or where the mirrors and what you know to even warm your mirrors to prevent steaming or whatever so you gotta tell your nurse you gotta have that stuff out and the biggest thing for me starting out taking photos a year at dental school was i just have the camera out it’s like within arm’s reach, right? It’s like out. You should never be in a situation where you think oh i’m gonna take photos but now i need to go into a cupboard assemble the body to the lens assemble the ring flash. That’s the worst frame of mind, right? -That’s just adding friction right it’s definitely the opposite of what we’re trying to accomplish there. – 100%. So that’s how we’re going to lubricate our photography fiction. Friction even. Tell people that’s just accountability as well, right? If you tell your nurse you’re gonna like i’m a huge accountability person because i think if i tell my nurse look ‘we had this crown prep at nine o’clock today i’m gonna take photos of every step’ then you’re more likely to do it as well because they know they’re planned. Your plan, the plan is in place and then you’ll execute it. Accountability from the nurse also sounds cool man, right? The next question i have because i’m going through this because these are questions i get all the time and i want to ask your perspective because again you’ve had these amazing guests on is pathways like you know what kind of dentist do i want to be do you want to be and before i hit the record button you know you were telling me about you. What you’re up to. So maybe you can hear a little bit about what you are up to and what you where you want to be but the most common thing and even i found it like you know three years at dental school i’m thinking what I want. How do i want to mold the rest of my career, right? Like it’s such a big such a huge topic. Do I want to specialize? Do I want to do any advanced MSC programs? Do I want to Do i want to be placing implants or do i not want placing implants and sometimes you have to make these decisions early on about which direction and people say all the time find your niche, right? Find your niche so the question i have for you is Omid, have you found your niche and also what what is your pathway likely to be and then how can you self-discover that where you’re going? So I guess i’ll start with answering the second one first, the journey of self-discovery I think that’s a really great question you know it’s such a broad specialty, right? There’s so many different levels and you know what i’m about to say is not to like demean people who just you know you know stick to their scaling cleans and just do like their fluoride and fissure seals and then they just want that stress-free life and that’s it and they just come to work and that’s it that’s fine and there’s a place for that and a lot of people are happy doing that you know one thing one quote that i love is just like you know you got to be the driver of your own ship essentially. You got to be the captain of your own ship. So when you graduate there’s a lot of options you may not necessarily pick the right option right away but i think after a few weeks or after a few months of work. You start to realize okay do i want to work you know in like a treadmill type practice where i’m just pumping out work. I’m not necessarily happy. I’m not necessarily enjoying the type of work I’m doing. I’m just trying to fill quotas and make money and the clinical side of things is kind of slipping. The standard is slipping. Some people love that. Some people just like the flow and just want to pump it out and their job satisfaction comes from the income and that’s fine as well Other people are like craftsmen, right? They want to master the craft, they want to sit there, they want to take their time like slow dentistry and the whole movement with like rubber dam rubber damn fam and like all that kind of stuff on instagram but and they love that because they’ll sit there. They’ll spend an hour and a half doing a composite even though they may not charge enough money to like make it worthwhile. It’s not about the money for them, it’s about the arts and the craft and just getting better at that. So i think that’s something that you got to decide for yourself is do you enjoy the craft or do you enjoy the business side of it or do you want to just have a stress-free work environment? Just come to work and clock in clock out and your passion comes outside of work and whatever maybe hobbies and things that you have. So that’s i mean there’s no judgment either way you can you can as everyone does there’s a whole plethora of that. There’s public dentistry where it’s like no stress you can just you know put in GICs all day and then just go home or you can do all four implants or orthodontics or advanced you know high stress high failure rate type of things or like you’re going home and you’re stressed before you go to bed because you’re worried – High risk high reward. – Yes, so for me you know that was that was. I worked in a lot of practices. I worked in toronto and i came back to australia and i was working and i got to experience a lot of this So i worked in a you know a pump practice, treadmill practice in canada just really busy i was a new grad and I just. I didn’t have the skill level to like keep up with the principal dentist. So my work quality was really bad and i still look back and i’m still like oh man i feel bad for these patients i should like call them and be like are you okay like can i still do your work again – We all feel like that don’t worry. We all feel like that. – And then i moved to Australia and i got a job in a really good practice with one of my old university demonstrators and he’s like a craftsman at heart like you know we rubber dam every even like a simple occlusal, we’ll put a rubber dam on. We take photos and the practice is set up for it like the nurses know that we’re rubbing daming every tooth. So i had a good year of just like high-end good dentistry. High standard of dentistry and that changed my mindset from the you know production side to the let me get better as a clinician side So i think that’s the journey that a lot of people need to go on and decide what’s for them and then within that then there’s okay what do i enjoy like? I tried the whole restorative route and it’s just not for me. Like it’s too finicky for me. I like more macro and so i really fell in love with surgery like I rather, much rather you know break a root tip and get stuck for an hour trying to dig out the root tip than to try and get a you know invert my rubber dam so it’s not like a little speck of but coming up from the margin so like that stuff i hate it like i just sat there like the sort of thing and surgery you know it can be clean and art and finesse as well but it’s like it’s more macro. So it’s just a bigger scale where you can just have a different level of control. So that’s why this year i chose to sort of take a step back almost you know a huge pay cut. Even to go back into the public system and do a one-year sort of hospital residency training just to get really really comfortable with like poor oral surgery. So you know wisdom teeth, surgical extractions, managing medically compromised patients. So from this then i hope to move on and i’m doing like a post-grad cert program in implants right now. So i think that’s my niche will be because I still will probably do some general dentistry like i’m not getting any sort of like specialist credentials out of this but it’s more so just to focus my practice on surgery. Taking out wisdom teeth, taking out teeth putting in some implants because i think that’s where i get my my job satisfaction and honestly we had this chat with the realtoothdoctor on instagram i’ve recently just podcast interviewed him. They’ll hopefully come out in a couple weeks but we were agreeing that we would take out wisdom teeth for free even like if they said come work on saturday just take out wisdom teeth like i just love doing it like the the satisfaction when the tooth like flicks out is just like nothing beats that for me. So that’s been sort of my adventure and my path to finding my niche. I would say structured learning is important, right? So you mentioned the master of science programs and like kings and things. There’s a lot of australian guys that do those via distance learning and they come over to the UK to do the hands-on components. So i think that’s if you really want to find a niche then you have to do something structured like that because it’s very hard to get that depth of knowledge by doing a weekend course here and there so i would say work for a few years, see what you enjoy and don’t enjoy, see what drives you crazy and what kind of keeps you motivated and then maybe just pick what you enjoy doing and go depth. I always look for a few gems and everything someone says and then, you were packed full of gems there but i’m gonna highlight one of them which is the fact that you you said you would do something for free, right? And so maybe for others they’d be like you know what i can do class four composites and i would do it for free because when that case comes through or sometimes people come in and they’ve got like a a dark central incisor and then they will heavily discount the whitening rate because they love that satisfaction of getting that black central incisor going white again and they get that lovely satisfaction from any certain type of case and i think maybe, maybe that is one way that a dentist can identify what their true calling is or what kind of work they need to niche down into. So that’s a great way of saying it so maybe dentists out there we should think is there any aspect of your clinical dentistry that you like so much that even if you didn’t charge for it all was not as profitable as the rest of dentistry that you think you know what i still do it? Maybe that’s the answer. So I love that you shared that and it’s really made me think hey you know what kind of stuff would i not mind doing and that’s a great way to put it. So thanks for sharing that. I think people will listen to that thing, ‘hey you know i i can now identify what it is’ because we all have that annoying friend at dental school who who from third BDS they knew they wanted to be an orthodontist or they knew they wanted and they went straight into that path but your path is very much, you’re still self-discovering but you’ve been through all the different sectors because you have done the public and and the high-end practice and then and then you came to terms with the fact that ‘hey i don’t like inverting dams but i like getting root tips’. So that’s an important part of everyone, you have to struggle you have to struggle a little bit right to find out what your niche is. Yeah and i like i always say you know there’s no race you know some of your friends may be more talented or more ambitious or whatever it may be and they might get there much faster than you. I think that’s everyone needs to just have everyone has their own kind of process and journey to get to where they want to get and some people are late bloomers and they you know different things in life. I think that’s one of the beauties of dentistry because I definitely found this myself before starting this job was you know if i was you know focused more on the podcast or i was more focused on you know training for a marathon or whatever it was. I could really easily just like turn down the dial at work like i would just like not take on big cases. I would just be cruising along at work and then when i was like no i’m ambitious at work i’m like you know presenting big cases and like getting all these like multi-unit like restorations and crowns and things and so i found that really interesting because you can really choose how involved you want to be at work as a dentist it’s not like you can be passive and refer things out or you can take on hard things. It’s really up to you and your appetite for how much you want to take on essentially. That’s a mindset thing isn’t it? It’s a mindset and how much you want to put yourself in a zone of discomfort or out of your comfort zone and like i said you can tone that down and you can tone it up and sometimes in life for your mental health or for burnout ,you have to sometimes turn it down and and that’s the way life is and sometimes your health you have to do that but i think when you’re a new grad turn it up as much as you can without entering the danger part and i think the more mentorship you can get, the easier it is then the less resistance that dial has and i think that the key to that is mentorship. So you said you worked with someone who used to be a demonstrator at uni. Would you say that was a mentor for you? 100% that job like redefined what dentistry was for me because i went from you know the single tooth to come in. ‘Oh you got a cavity there let me fix it too’. Understanding because he does a lot of ortho and things as well so understanding like full mouth, you know opening up VDO and it was crazy because i like i said communication is a big thing for me and i’m if you’re the same way you’re a podcaster you know words come naturally i’m sure you have great rapport with your patients so. I got really comfortable communicating and i just didn’t have the skills clinically to back up my cases like i would present the case like okay we need to like do a full mouth rehab and you’re like yeah i’m like are you sure like I can’t. – What do we do now? That was great because then i would just you know take photos, go next door, he would sit down with me for a few hours. We planned the whole case, this is what we need to do, this is we gotta add to this surface, gonna reduce this we gotta and then I’ll come back with confidence and a full plan and then just execute it and that was like amazing because it just changed how i was doing dentistry all together. I think you’ve raised a really good point there because sometimes you could be clinically excellent but you are unable to communicate well enough to just to really help your patient self-discover and find the value and how much you can improve their life and health with the dentistry that you can give them, right? But then if you’re on the other end where you’re just you know my nurse sometimes thinks that i’ve got the gift of the gab or with the patients what not but it’s dangerous if you don’t have the clinical understanding to back it up and just again you have that mentor. So i would say mentorship is a is a theme that can always happen exactly and these types of themes of episodes. I think the mentorship’s like the one thing that keeps coming again and again and again and i’ve always said that you can identify a mentor anywhere like Frank Spear is a mentor of mine I’d say. I’ve never met the guy okay? I just consume a lot of his content but to me he’s a mentor like i can really resonate with what he says and i learn a lot from him so it’s never been a better time to be a dentist you can have a remote mentor. That’s the best. That’s true with online learning and distance learning it’s incredible you can any time you have you can sit at home and watch lectures from around the world from experts and even social media is a great place to find mentors if you really enjoy someone’s work you can just reach out with questions and people are like amazingly free with information, right? You can reach out to like a periodontist in somewhere in the UK or in the United States and they’ll tell you exactly like this is what I use, this is how i use it, this is the material, this is the grafting technique blah blah like it’s just amazing how much information you can get if you’re hungry to get it. – And no other time in history could you just do that like you couldn’t. Even early 2000s you couldn’t just reach out to anyone, anywhere and you couldn’t just dm Pascal Magne, you know you couldn’t. Not that he ever replies to me. Same here, man. I tried. Pascal, listen help us out man. Omid from noobie dentists. Jaz for protrusive, just help us out buddy. Come on. It’s amazing I was listening to a book when i was writing a few months ago called grit and i’ve talked about one of the weekly mentorship things and this amazing idea that they introduced called the social multiplier effect. So and the example they used was basketball for example so in the United States you know until pretty much the mid 80s like NBA games or ABA games at the time they weren’t televised so people wouldn’t really get to see basketball at the professional level on tv every night and then in the 80s when they start showing basketball every night you know kids will be watching it they go to the playground they’re imitating MJ, they’re imitating you know Dr J and so the kids are getting better and then their friends on the playground see them doing it like what is that like where’d you see that and then they started practicing it. So when you look at the professional basketball player from like 1990 or even the early 2000s to the professionals now the level of skill in the game is just like unbelievably advanced and i think the same thing is happening in dentistry because you know think about it like in 1970 if i was in melbourne doing class 4 amalgams or class 2 amalgams. I have no idea what Pascal Magne is doing in Europe or Matt Najada is doing in LA I’m isolated, right? So now i’m every day i wake up on lunch or toilet university as you said before looking at instagram and it’s like man like this is like this guy’s doing this type of graft, this guy’s doing this type of implant, this guy’s doing this type of composite. So my understanding of what’s possible, your understanding of what’s possible is just like miles ahead of what a dentist 20 years ago would have been. I’m so glad you introduced me to that. What’s it called? The social? The social multiplier effect. – I love that and you’re so right, we see it in Dentistry and i mean i’m gonna go and buy lots of shares in rubber dam now after you said that because it’s true because everyone’s isolation game like you know i think the percentage of dentists caring about rubber dam isolation has probably gone from like two percent to 20 in the last few years because we’re all seeing on social media beautifully presented and then we’re starting to notice the benefits more and just like in basketball in the 80s and televised they used to see this and now they’re seeing all this awesome dentistry, everyone’s like ‘crap i need to elevate my game and i need to you know give a better service to my patients’ and you’re right we are improving because it is more televised in that sort of basketball sense. I never thought about it that way but you’re right so i’m going to buy shares in every rubber dam company there is because i think it’s only going to go up, right? That’s the best part and once i remember in dental school i was like man once i graduate i’m never using a rubber dam again I said the same thing Honestly now like if i have to do one without rubber dam, i’m just miserable because like the tongue is there, the cheek is there. You just put your dam on and even though i don’t love doing restorations and whatnot but it’s still like a peaceful situation to be and once you got the dam on. – It’s a stress-free situation i actually accepted a new job in march and part the terms and conditions was ‘hey i’ll work but you can never run out of the uno dent latex free rubber dam’ It’s you know, capiche and then and an agreement so that’s amazing. So i’m gonna wrap up now and ask you you’ve had such amazing guests on your podcast so you know you’re just way ahead in the game of dental podcasting with the caliber of guests you’ve had. I’m still catching up my friend, Nancy the guest you’ve had, amazing. So tell me who has been without undermining any other guests but this is a tough question, right? I hope never no one ever asked me this but who’s been the most inspirational guest you’ve ever had on the noobie dentist and what did they teach you. I know it’s really unfair. I’m sorry Yeah you know there’s so many that come to mind obviously like one of the main ones like just instrumental for the podcast was like Bruce Freeman, so he’s a orthodontist in toronto and he’s you know become a friend and a mentor. He you know he’s quite active in the dental community in in canada so when he came on my podcast early on maybe like episode like 12, 13 whatever it was. That was like a big turning point for the podcast in terms of downloads and exposure and things so that meant a lot to me and then we recently just did another like sort of two-part episode about and he’s quite experienced you know. He’s much ahead in his career towards the end of his like clinical practicing life and he’s on to like teaching yoga and mindfulness and all this kind of stuff. So i have a lot to learn from him in terms of you know staying like you know keeping the side hustles going, i love that because a lot of people at his stage of his career would be like winding down or maybe just you know comfortable with what they achieved but now he’s you know adding things. He’s lecturing on patient experience and mindfulness and working with big you know dental corporations in canada and things so as someone who’s won a great condition, good communicator, good side hustler, a lot to learn from him so he’s been one of the main ones the other one that really comes to mind is like the implant ninja like Ivan Chicchon. I’m not sure if you’ve seen him on instagram. – He came on the podcast for me as well we talked about basic implant occlusion we talked about because i wanted to just niche down into that area Ivan is such a cool guy, what a story he has. – Man like his drive, his hard work, his story of like how he got into like his man like specialty program. He just went over to like i think it was michigan from memory and he’s just like can i just come shadow you and then while he was there he’s like can i just interview him already here and he just like hustled his way into the program I have a lot of respect and admiration for his hard work and like the amount of content and the courses and the everything that he puts out is quite amazing. So there’s many others but i think those two are the main people that i’m just like i still i look up to like i wake up and I want to be like them one day. I really appreciate you answering those tough questions i know that they’re not easy but that is awesome. I really appreciate you coming on my friend i just wanted to get your word out there because the stuff you do with the weekly mentorship and and all the other you know i say go back and listen to all the you know big from the beginning of Noobie dentists and some great content there. So, Omid, thanks for giving up your time to come on my show. I really appreciate that buddy. – I appreciate the opportunity, man. It’s great to talk to you like i said that your passion is quite infectious. I got to raise my game up and with the execution but definitely hopefully we can return the favor and get you on the noobie dentist and talk. I know you’re big on you know occlusion and night guards and splints and things like that i think you can have offer a lot of value to the listeners so we’ll definitely arrange that. – Awesome my friend. Well thanks so much man. Jaz’s Outro: I hope you enjoyed that little session with Omid do dm us both on instagram. Let us know what you thought of this episode and i will catch you in the next one no doubt. Make sure you stay up to date with everything by signing up to the newsletter which is on protrusive.co.uk. Any sort of blog post or episode that you click into a pop-up will come up. You can put your email address there. There’s loads of infographics download and also of course our famous telegram group which is protrusive.co.uk/telegram and our facebook group which is the Proclusive Dental community. I will catch you very soon guys in the next episode.

Stop taking OPGs/Panoral radiographs for TMD…they have limited benefit! In this episode I discuss the Piper Classification of TMJ with Dr Jim McKee from the Spear faculty. We also cover exactly when and why imaging of the TMJ may be beneficial (MRIs and CBCTs). I have found the Piper classification easy to implement and I hope this episode helps you understand it. https://youtu.be/n4lRWAQeA5A Check out full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Observe the patient’s path of opening. If someone’s jaw opening makes a ‘V’ shape, that’s a DEVIATION. If someone’s jaw opens, and then it goes all the way to one side, and it doesn’t go back to the middle, that’s a DEFLECTION. If you want to Download the PDF version of the Piper Classification of TMJ Infographic we made, click here! Piper Classification PDF Dr Jim McKee is part of Spear Education – a platform that has taught me so much of my occlusion. In this episode I asked Dr. Jim McKee: What is the Piper Classification of TMJ? What are the risks of having to rehabilitate someone where you haven’t the health of the TMJ? (19:22) Are there any other useful TMD classifications? (21:01) Is there any benefit of taking a Panoral radiograph? (24:48) What is the difference between an MRI and CBCT for someone with a TMJ pathology? (26:51) What type of imaging is best for TMD? (28:58) What additional information can a CBCT provide above an MRI? (33:59) How do we decide the most appropriate imaging technique? (35:22) Dr McKee’s thoughts on idiopathic condylar resorption in adult patients? (32:58) Should we be taking routine MRI/CBCT for TMJ health diagnosis? Or only for patients who have a joint based history? (36:62) Is there a clinical way to determine which classifications patients are in (Piper III vs Piper IV)? (39:23) Is TMJ disorder always a progressive disorder? (40:51) How to manage asymptomatic clicks? (42:17) Deviation or Deflection as part of full workup and imaging of the way to get the exact diagnosis? (44:07) How does the Piper classification influence Restorative management? (47:12) If you enjoyed this episode, check out TMJ Physiotherapy – When to Refer and How They can Help  Check out SPEAR EDUCATION, a two-day seminar, where Dr. Jim McKee teaches 25% of the course! Click here for Full Episode Transcription: Opening Snippet: I used to work in the emergency department of a very large dental hospital. This is like a year and a half out of Dental school and I’ll never forget this one patient I had, right? She came in and it’s an emergency that had never seen before. Jaz’s Introduction:Like 99% was like acute pulpitis or an abscess. And you know we were doing extirpations and stuff. Now, this lady came in and she was literally like her mandible was all to one side. She was literally all deranged, she was in agony, she’s pointing to a jaw joint, I forget which side she was pointing on now, but she was in absolute agony and just everything about her bite looked way OFF, right? and I had no idea or the diagnosis was. I didn’t know. I had no idea what to do. So naturally what I did. The first thing I thought was okay. Looks like it could be something to do with the TMJ. I’m thinking TMD. Therefore, what do we do? Why don’t we get a radiograph? Okay? Because that’s we do with teeth, right? We take a radiograph. So, I suggested again O.P.G. okay? So I sent this lady for an OPG. Okay? Anyway, the OPG/OPT comes back and you can’t really notice anything unusual in it. And I show it to my consultant and my consultant absolutely flips to me. I mean it’s like ‘Jaz, what the hell you take an OPG for?” Right? Because an OPG is not going to show you much when it comes to TMD. Alright? So that was the lesson number one I had several years ago, and I want to share that with you. And on that topic, I’ve had brought on, someone absolutely amazing today is from the spear faculty. I’ve got huge respect for spear education online and what they achieve and their training facility, which I’d love to go to one day in Scottsdale, Arizona. I’ve got Dr. Jim McKee whose real authority when it comes to imaging for TMD and generally about occlusion, you know, and raising the OVD and treatment planning and all these kind of things. So, it’s great to have him on the podcast today on behalf of spear. Hello Protruserati, I’m Jaz Gulati. Welcome to new listeners. Really great to have you on. And as usual, all my usual listeners, thanks so much for continued to come back for more nuggets and more gems. Today’s gems are all around the piper classification for TMJ. There’s something I teach on my splint course, but I want to hear from Jim who’s been teaching it for way longer and applying it. I want to find out the clinical applications of the piper classification and I’m sure he will do a great job of explaining it way better than I ever could. So, I’ve got Jim speaking about that also about the clinical relevance of little things like clicks. Well, what about patients with asymptomatic clicks? What’s the best way to manage those patients? So, there’s a lot of real world TMJ and that could be related dilemmas that I’m going to give you answers for today. Protrusive Dental Pearl:The Protrusive Dental Pearl Have you today is regarding TMJ diagnosis and examination whenever you’re examining your patients range of motion. When you get the patient to open up, you will observe that they make a nice straight-line path of opening. And what happens if their path of opening isn’t normal and straight, it goes to one side. How do you write that in the notes? Simple thing is you draw it. But now these are all digital. So how can you describe it without having to somehow digitally draw it? Well, if the mandible, okay, does a shimmy. So, what I mean is let’s say someone’s opening up, moving their mandible to the right and then back to the left and down to the middle again, okay, Because the path or the trajectory that if you draw a line from the chin going down as they open their mouth and it makes a little V Shape, think of deviation. So, if someone’s jaw shimmies to one side, it comes back, that’s a deviation. Okay, now if someone’s jaw opens and then it goes all the way to one side and it doesn’t go back to the middle. Again, that’s a deflection, so that’s how you differentiate between a deviation. The deviation has a V, and therefore there’s a V shape in its path, and deflection doesn’t have V in it, it’s a sort of down straight and then off to one side, and it stays there deflects to one side. That’s a cool little tip to remember in terms of deviation, deflection. and that’s something you should write in your notes in terms of management and stuff. I hope you enjoy this one, guys and I’ll see you in the outro.  Main Episode:Dr. Jim Mckee, welcome to Protrusive Dental podcast, how are you? [Jim]I’m awesome. it’s great to be here. [Jaz]It’s so great to have you on because I’ve been having a look at your presence on spear and the kinds of group as a collective, spear EDUCATION has meant so much to me in my journey. I’m afraid, I’ve never been able to come over to Scottsdale, Arizona yet. But the amount of sort of articles I read on the website, the online membership, all the videos I watched from Frank Spear, Gary Dewood and now being able to speak to YOU. I mean you guys have had a huge influence to me, so thank you so much for making time to come on the podcast today. [Jim]Well, it is truly my pleasure to be here. Thank you for having me. It’s truly an honor. [Jaz]Please tell us for those who don’t know who you are. Dr McKee a little bit about yourself and who you work with. I mean, we were just speaking earlier, obviously there are some huge names, including yourself in the spare faculty. Obviously, I think Jason Smithson from the UK has recently joined your team as well. So, you know you guys got some superstars but tell us about you, tell us about you Dr. McKee. [Jim]Well, it’s kind of an interesting story, you know, I graduated from dental school in 1984. And really didn’t know what I was going to do. And there was a woman who was in practice in Downers Grove, which is about 45 minutes Southwest of Chicago, typical Chicago suburb. And she wanted transition or practice because she wanted to spend more time with her children, and I needed to practice. So that’s how it started. But it was a really, really small practice. First day in practice, I did a root canal or did amalgam build up on number, it would be 37 in the international numbering system. And that was at 8:00 AM, at 4:00. I did a root canal on number 27, and I said, I’m proud to say the amalgam build up patient still the patient in the practice and the Endo patient is why don’t you do endo. [Jaz]Sounds like me. [Jim]But a very small practice and gradually for the first four or five years, I just kind of felt my way through it. Kind of getting my feet underneath me. But I was starting to see cases that were making me uncomfortable. Wear cases SPECIFICALLY. clicking and popping joints specifically. I didn’t know how to treat those because my experience I think is similar to many done this that I’ve talked to are training in occlusion and TMD and Dental School doesn’t lead to a lot of confidence when we get out of school. So, I ended up, Pete Dawson is a name. Pete was a huge name in occlusion, and I got a seminar, a flyer for seminar that Pete was doing in Chicago, and I took the train downtown to hear him. And I had been out 4.5 years and it was the first time that it made sense to me. From there, I started going down and hearing what Pete had to say and I would take his courses. A year later I met an oral surgeon that Pete worked with. His name was Mark Piper. And Mark and I became very good friends. So, it was kind of interesting if you go back and look at a lot of dentist, how they got trained in Occlusion. They learned the Occlusion side first and then later they learned the giant part. I was really fortunate because I kind of was able to learn both of those together from working with Pete and with working with Mark. So, in terms of my thought process, I’ve always thought about the joints and the teeth is almost one unit just on different parts of the system. So, from there I just started basically doing as much CE/CPD as I could in terms of occlusion in TMD. I learned how to image again from Mark early in the 1990s. So, I took my first MRI in 1991 and I started seeing a lot of patients who had these types of problems. I also started a local study club in our community because there were a lot of dentists at that time either going to hear Pete Dawson or going to the Pankey Institute and we were trying to implement those concepts into our practice. So, I started the study club and then eventually the Dawson Academy asked me if I would come down and teach with them. So that’s how I started teaching. So, I taught at the Pankey Institute, I taught with Pete Dawson for 13 or 14 years, I taught with Mark Piper for 10 years, we ran a study club program and I’ve been in spear for about five years now, I think. So, it’s really been, I never thought I’d be doing teaching or lecturing. It’s been so much fun. I met so many wonderful people and I’ve had a great time doing it. So, I feel really, really fortunate. So recently I have another dentist in the practice, now a wonderful woman who joined us Dr. Courtney. So right now what I do is I practice 8 days a month and then I’m part of the occlusion seminar. It’s spear education with Frank Spear and Greg Kinzer. And then I teach the advanced occlusion workshop with Gary Dewood. that’s the workshop that’s kind of focused on patients who do have joint problems. And how do you manage those in the regular world? Because we see those patients everyday. So that’s a little bit about me. [Jaz]As you were talking and you’re mentioning all these giants, in occlusion, in dentistry. Honestly, every time you mention one these guys, I get like a little bit excited. So, one thing to learn about me as I get very excited when it comes to these exact topic. So it’s so, so amazing to have you on Dr McKee because I know we’re going to learn so much from you regarding exactly what you’re talking about. The confusions that we have in general practice about the TMJ anatomy and the diagnosis we can make and how to manage these cases. Now, we could have gone in any direction in terms of what to speak about, what something I haven’t spoken about yet in this podcast is imaging and how that can relate to classifications and how that can relate to the person in front of you in the chair. So I’m hoping to give us a little bit of tour, a little bit of flavor on that. So my first question to start that off and it’s so great to hear about your history with Mark Piper is obviously some of us who may or may not have heard of the piper classification. It’s something that I’m quite familiar with. I use it, but I want to know if you just don’t mind just summarizing for the dentist listening all over the world what is the piper classification? And then maybe give us a flavor of if there are any other classifications that use and if they are superior, inferior, just your general viewpoint on that? [Jim]For sure. Well, let’s start out with the piper classification. You know, it’s funny Mark Piper is known as an oral surgeon. But honestly, I have to say, I think Mark’s greatest contribution to dentistry has been his piper classification because there’s a restorative dentist what it allows me to do almost instantly is to assess the level of risk that I have in the restorative patients sitting in my chair.And I’ll get an idea whether I have to worry about potential pain issues in the future or whether I’ll have to worry about potential occlusion issues in the future. So the piper classification is really easy to work with. Here is the easiest way to think about it. If we think about the condyle, there’s a medial pole and there is a lateral pole and there is a disc that attaches to the medial and the lateral pole basically like a bucket handle. There was a ligament attachment at the lateral aspect and there’s a ligament attachment at the medial aspect. The reason why I like Mark’s classification system in the restorative world and I’ll talk about a couple other ones that are out there too, is because the medial pole for me really becomes an important discussion point because if you look at joint anatomy, the joint socket on the medial aspect offers dense thick bone that’s ideal for dissipating the bite forces that we generate when we function or para function. So, if we can have the loading forces passed through the medial pole, and if we can have soft tissue at the medial pole, most of the time, those cases are going to be very predictable. So, in terms of piper classification, Mark has different classifications. There’s a piper 1. A piper 2. A piper 3A, 3B. And then there’s 4A, 4B, 5A, and 5B. So, let’s go 1-3B first. 4 separate classifications or 4 separate stages, 1, 2, 3a. and 3b. All those share one common characteristic, the soft tissue is covering the medial pole. So if that’s the case, those cases tend to be very low risk cases for restorative patients and dentists doing restorative dentistry. Because if we have the disc at the medial pole generally, we can dissipate the load very efficiently. And the disc maintains the position of the condyle. We don’t think about the disc in that way but I really think as a restorative dentist what the disc is and this is a time that I heard Mark say, it’s the holding contact in the joint. Pete Dawson talked about holding contacts at the tooth level so you can maintain a stable occlusion. But that’s basically what the disc does at the joint level. It’s the holding contact with a condyle functions against. So as long as the disc is at the medial pole, those are really predictable cases. So, a piper stage 1 disc covered at the medial disc covered at the lateral, if you look from the top, the bones completely protected. Normal joint. Easy case. Piper stage 2, beginning laxity at the lateral pole, medial pole is still intact. This might be the patient was an intermittent click. They wake up in the morning, they click for 10 or 15 minutes, and it goes away. Typically, not a lot of pain, not a lot of bite changes. Okay, let’s move the piper 3s. [Jaz]This is where it gets very interesting because people, often my issue with the piper classification is just like you said, I think it’s really simple, but people, when they first look at, oh my God, there’s, you know, four or five different classifications and they look at the numbers and they look at the diagram and they don’t just pause for a second and just appreciate. Actually it’s really simple and what you’ve done already is really massively simplified it by saying that stages 1-3 and the definition with the medial pole and the medial surface. That really helps already. So, I think anyone who’s listening and watching the moment can really easily follow along so far, so don’t get confused or don’t let this worry or confuse you because actually it’s a really simple classification. It just gets a little bit exciting here. [Jim]Well, okay, so the 3s are related to the lateral pole. So again, everything up 1, 2, 3A and 3B. Medial pole is all intact. 3a, we’ve got a lateral pole CLICK a typical disc displacement with reduction at the lateral pole. 3B is a disc displacement without reduction. So, we don’t click anymore at the lateral pole. That’s it. So that’s 1-3B. [Jaz]Just before we go to 4 and 5, Dr. McKee because we have a lot of young audience, we have a lot of international audience as well. So can you just clarify for them. What do you mean by disc displacement with reduction? And disc displacement without reduction? Because a lot of people, a lot of young dentists may have not heard this term before. So, if you just briefly describe that as well? [Jim]So, a disc displacement with reduction is when the disc is forward and the condyle opens and moves back underneath it. Now in order for that to happen, the disc has to maintain its shape and as long as the disc maintains its shape, then that condyle can get back underneath that disc when a disc comes off the condyle, although it’s important to understand HOW a disc gets its nutrition. Typically, a disc will get its nutrition from lubrication fluid or synovial fluid being compressed into it. It wouldn’t make sense to have a blood vessel there because you compress the blood vessel when we compress the condyle pushing into the disc, so it gets its nutrition from lubrication fluid. If the disc is not in the correct position to have lubrication fluid would compressed into it, that disc can start to change shape. And if it starts to change shape, those are the cases where the condyle can’t get back underneath it. Reducing is kind of a confusing term. I agree with you. I don’t like the term, but it’s typically what’s used in the literature. So that’s why I try to tie that because some people will be you know, familiar with that. So here is the easiest way to think about it with reduction means it clicks. Without reduction means it doesn’t click. That’s I think that’s how I think about it. The easiest way. [Jaz]One thing that helped me as well to understand it is like the term reduces like when you reduce a fracture, you put it together so when the disc is reducing its going back where it belongs on the condyle. So that’s another great way. That’s helped me in the past. Thanks so much for covering that. You’re just about to come on to number 4, I think. [Jim]Well now that we understand 3s. Let’s talk about 4A and 4B. Because it’s the same principal, but instead of 3s being at the lateral pole, 4s are at the medial pole. So, a 4a would be a disc displacement with reduction or disc that clicks now at the medial pole, whereas 4B would be a disc displacement without reduction or the condyle cannot get back under the disc at the medial pole. Okay, so similar thought process 3a and 3B relates to lateral pole. 4A And 4B relates to medial pole. And the last are the 5s. There’s a 5A And 5B. And with 5s just think this. It’s perforated all the way through. So, it’s bone against bone. 5a is acute. 5b is chronic. So that’s really the piper classification in my mind, I think. Is it structurally intact? Which is a 1 or 2. Is it structurally altered at the lateral pole? Which is 3a or 3b. Or is it structurally altered at the lateral pole in medial pole? Which would be a 4a 4b or 5a 5b. And once I do that, that’s kind of how I think about it, structurally intact. Piper 1 and 2 have low risk factors. Piper 3A and 3B has low to moderate, typically low risk factors, and piper 4A. 4B, 5A. And 5B typically have a higher risk factor because that’s where the medial pole isn’t covered. So as a result, we tend to see an increase in pain or potential bite instability.[Jaz]Just to make it really tangible for the young Dentists listening is that, what you mean by risk is exactly how you mentioned there. Like if you rehabilitate someone and you haven’t identified which piper classification or the health of the joint itself, then you’re constantly chasing a moving target so there is a lack of stability and then you get constant supposed bite changes. Is that one of the worries about treating someone or rehabilitating someone who is at a higher number in terms of piper classification? [Jim]I think that’s always the concern now, having said that you can work on patients who have medial pole problems. I don’t want people to think that you can’t work on people and I’m going to say something real. Clearly not everyone needs surgery for as a 4 or 5 because that’s one of the common misconceptions as well. All this does is to be able to articulate the risk so you can communicate it to the patient. That’s really what I’m thinking about it for. And basically, risk generally develops in one of two ways. Either bite instability as you mentioned because the gasket or the disc isn’t there to position the condyle or we’ve got pain that occurs because we’ve got loading uninjured tissues. I mean, that’s the easiest way to think about it. [Jaz]I absolutely love it. That’s going to really help clarify that. [Jim]I think we’ve made occlusion in TMD too complicated because we didn’t understand it because we never saw the anatomy. Once you see the anatomy with imaging, it really takes all the concern away because you finally have a good idea. [Jaz]Before we touch on imaging, just tell us, are there any other useful classifications that we should consider reading up on? [Jim]You know, the two other ones you typically hear about? A research diagnostic criteria that was developed by the American Academy of Oro facial pain. And it’s an excellent classification system in my experience, many times the dentist to use that tend to have an oral facial pain practice. That’s not what I have. I’m a restorative dentist and I see patients who will have some pain issues, but primarily my referral bases general dentists with either joint cases that are more complex than they want to handle. Or restorative cases that are more complex than they want to handle. I never tried to develop a facial pain practice that was not my intention. So, I know a lot of the people that will use that classification system tend to focus more on facial pain. So, I don’t use that. I like the piper 1 because I think it relates more to the restorative world. The Wilke’s classification system is the other big classification system, Clyde Wilkes was a fabulous oral surgeon out of Minnesota, and he developed the surgical, he was an oral surgeon and his many times is very popular with oral surgeons because a lot of times it has a surgical approach to it. So, it all depends kind of on what type of practice you have for restorative dentists. And probably most of the people who will be listening to this podcast. I think the piper classification is a really easy way for the restorative dentist to organize their thoughts to be able to communicate not only with patients with other colleagues that they work with as well. [Jaz]I’m going to make an infographic for everyone to download based on everything. The beautiful way that Dr. Jim McKee explained things. will make infographic.So, I’m going to help you to remember and maybe stick it up on your practice wall courtesy of Spear and Protrusive Dental Podcast. You’ll always have that, and you know, one or two times you learn it, you’ll always get it. Hey guys, it’s just Jaz and I’m interfering with this little update because I know how much you guys love to download, how much you guys find these infographics very helpful, like following on from the massive success of the deep margin elevation infographic that we made after the episode with David Gerdolle, which by the way you can find on the Facebook, you can DM us on Instagram @protrusivedental and we will send that to you. But this one I’m going to make it really easy download. So, this is an infographic, a pdf download with a visual aid and a description basically summarizes this episode with Dr Mckee in a way that is presented quite nicely in the pdf with the piper classification and the clinical implications. So, it’s easy for you to follow along in practice. So, if you want to download this infographic, just head to protrusive.co.uk/tmj and you’ll be able to get your copy for free. Thanks so much for listening, guys. I will return back to Dr Mckee. [Jaz]And I think it’s wonderful how you can relate it to restorative dentistry. And the best gem there, just to really highlight it is how you can prompt you to communicate risk and you’re so right that, you know, just because someone has a piper 4 doesn’t mean that you can’t treat them. You know, there’s so many more factors. And I love that you said that. Let’s talk about imaging because it’s so much we can cover this podcast. I want to keep it going. So, let’s talk about imaging. In the intro I recorded just for speaking to you, I mentioned about the story of a lady or I saw when I was like a year out of dental school, she came in and she was completely like an acute pain. Her mandible was completely to one side. She couldn’t get her teeth together. She was in a terrific pain. And at the time I didn’t really know what I was doing. So, I requested an OPG and then my consultant was like what the hell? OPD shows nothing in this scenario and that’s how I learned at the time. So can you tell us. Is there any value at all or is it a waste of time? Because I know there are different camps in having an OPG or should we always skip that and then opt for other forms of imaging? [Jim]There’s something you can learn from any image. So, I want to make sure that we say that right up front. For an OPG, primarily what I would look for in terms of jaw joints is I would look at the ramus length. I think that’s the best thing I can tell at an OPG. And generally, I can tell us one ramus length is shorter or longer than the other. One almost universally, if we have one shorter one longer, it’s almost the one that’s shorter that didn’t develop as opposed to the one that’s longer that grew more. So, it’s almost always a lack of growth. So panorex’s themselves though in terms of being able to diagnose the condition of the joint. I don’t have a lot of faith in. Because basically it’s a two-dimensional x ray and any time we work with a two-dimensional X ray, we have to understand that if we take a panoRex and take a look at the condyle, right, let’s say at the lateral pole, all of a sudden this is the only view we’re seeing. The condyle may be very different at the medial pole. So that’s why I think today, I think two-dimensional imaging has some really significant limitations and diagnosis for jaw joints and problems. And today I think that really if we have a patient that we decide would benefit from imaging, then I think we want to look at 3-dimensional imaging, such as an MRI. [Jaz]Tell us the difference then between an MRI and what information it gives you for someone with a TMJ pathology, which we can discuss and so and why you may offer an MRI versus a CBCT and what additional information that might give you that MRI can’t? And then how do you decide or is it a matter of some patients will need both. [Jim]Let’s talk about MRI first, because that’s what I learned first. I learned that from Mark in 1991 like I said. So MRI is basically will show disc position. And if we have a normal disc, if you put it on a clock face, the posterior attachment, that’s going to be approximately 1 o’clock. Now, if you look at the literature, it’s going to say 12 o’clock. But if you really read the literature, what it says is 12 o’clock plus or minus 10 degrees in 1990. When the paper was originally written by [drase] If you look at 1997, it says 12 o’clock plus or minus 30 degrees written by Rammelsberg. And when you see that type of variation, what it really means is we don’t know what normal is. Well, 2011, Provenzano wrote a really nice article and I think you started to see more people build on that in the literature that when we look at disc position, we really should be looking at the load bearing part of the disc, which is the thin part of the bow tie. If that’s in a normal position, that’s going to be about 11 o’clock because that’s going to allow us to load against that. That’s going to put our attachment at about 1 o’clock. So 1 o’clock will be normal. 12 o’clock is mild displacement, 11 o’clock some moderate displacement. 10 o’clock is an advanced displacement. So we can tell disc position. We can also tell disc condition. Is it a normal sized disc as the disc started to change shape because it’s not getting proper nutrition? Is it swollen? So those are the main things. The other thing we can see is we can also look at the condition of the marrow space because many times what we’ll see is we’ll see swelling in the marrow space or we’ll see swelling outside the condyle around the disc as well. So, MRI is going to show. it’s going to emphasize soft tissue from looking a disc position, disc condition and marrow condition. For a CT scan, I’m going to get a better look at the bone. One of the main things I’m going to look at the bone is what’s the size of the bone. Did the bone grow properly? Normal Ramus length. We mentioned that before. It should grow approximately to 65 millimeters ballpark. And again, this is all the concepts that I learned from Mark Piper and also what you should have is a condyle full size that it’s approximately 8 millimeters, anterior to posterior and then 20 millimeters medial to lateral. So, we can start to gauge our condyle condition. We can also gauge our condyle position because interestingly enough, if a disc comes off and is displaced many times what the soft tissue does is displaced the condyle posteriorly. We many times calling an anteriorly displaced disc. It could also be called the posteriorly displaced condyle because basically what happens is the disc and the bone are fighting for the same space. If the disc comes off and moves forward and the condyle moves back, here’s my question for the restorative dentist, how does that influence the position of the lower incisal edge? [Jaz]It’s going to make you more class two or open your bite and you’re going to be having an anterior open bite of some degree. [Jim]EXACTLY. Any time we see a loss of dimension at the joint level. Either because the condyle moves up or moves back, it’s almost always going to relate to a class two bite shift. Unless one thing happens, unless the teeth adapt. The teeth wear, the teeth move. But most of the time if we see a change in joint dimension, we end up with a change in the occlusion. That’s why, you know, we’ve made TMD about pain. TMD is really about occlusion almost universally. You will see a bite change before a patient has pain. We’re just not used to calling those class two bites problems that started the joint level. So anyway, back to the CBCT. So, we look at condyle size, we’ll look at bone size and ramus line and then I’m also going to look at the cortical plate of the condyle because that’s a really important discussion point in the growing patient, we want that to be open so the bone can continue to grow. in the adult patient, we want that to be closed or corticated. So we know we have stable bone. If we think about it the other way, if we see a cortical plate in a 12-year-old that’s already corticated that means they’re done growing. That’s almost always in response to having an early disc displacement because the disc in the growing patient is there to protect the bone as it grows. And if the disc comes off in a growing patient many times growth will slow down or arrest itself. And as a result, now, those are when we see many of the facially asymmetries, the retrognathic mandible cases we talk about. So that’s where the discussion becomes important in the growing patient. And in the adult patient, as I said before, if you’ve got a condyle that isn’t corticated, those are the patients in my experience a tend to have an increase in pain. [Jaz]Is that something that would typically be termed as an idiopathic condylar resorption? And therefore, you have this, you know, middle aged lady coming in and she’s developing an anterior open bite which wasn’t there before and she’s getting pain because that’s the kind of stuff that I’ve seen a few emergency settings in secondary care. Is that the kind of thing that you would expect in that kind of a population? [Jim]You know, it’s interesting emerging idiopathic condylar resorption in my view is really early onset joint disease. And I think many of those resorption cases are cases that never grew. We just didn’t know because we’re not used to imaging young kids. I mean since I started imaging young kids, I can’t believe how many patients have joint based problems far earlier than we think. You know again Mark Piper talked about two types of joint problems developmental and degenerative. And I think as a profession, we think that the majority of the problems that occur are degenerative in nature where people grow completely and then break down. I’ve really changed my thinking. I think that many of the cases that we see our developmental and start far earlier in life than we think, and the patient just never grows completely. By the time we image it we just saw the problem. So, we thought it was resorption. But I don’t think they ever got there. I want to go back to CTs For one second because we talked about the things we could look at. So, I’m going to look at bones. I’m going to look at condyle condition and position. Same thing. I’m going to look at the airway because I want to see nasal airway again. I’m amazed at how many deviated septums we have. I’m amazed at how many compressed pharyngeal airway. How much compressed pharyngeal airway anatomy there is. And the last time I looked at the upper cervical spine that’s an area that is dentist we can do a great job screening for. And there’s a lot of people who have had neck pain that’s coming from upper cervical spine misalignments that we think maybe it’s coming from the occlusion of the joints. So, in terms of what you get from imaging. Those are the things. So, for MRI disc position, disc condition and marrow space. For CBCT Condyle position, Condyle condition, airway, upper cervical spine. And to follow up on that, most of the time when I am going to request imaging. I’m going to get both. And the reason is because if I don’t have the MRI then I’m guessing at the soft tissue. And If I don’t have the C.T. scan, then I’m guessing at the hard tissue. And I did that when I was younger. I don’t want to do that now. I mean patients I’ve learned over the years come to you for two things. They want answers and they want options. I can’t give them answers if I only have half the story and I really can’t give them good treatment options either. So that’s why when I see a new patient my first examination with them is going to be taking a history and doing a clinical exam. And once I’ve done that then we’ll figure out what diagnostic records we need. So, the second appointment will be diagnostic records and then the third appointment will be consultation. My case acceptance increased dramatically after I went to that format because I found if I did everything in one appointment it was overwhelming the patient, I was giving them too much information. [Jaz]That’s a really great insight and I love how you broke down the MRI vs the CBCT and how you feel that you know they should get both because otherwise you’re missing half a picture. Now you just mentioned about the point about in your practice when you see a patient you have a history examination and then you have your diagnostics and the consultation. Are you routinely taking an MRI and CBCT scan for every new patient? Or is this the patient who specifically has a joint based history or joint based complaint and or has been referred to for a joint issue or a rehabilitation? Give us a flavor of that. [Jim]I do not image every patient. So, I want to say that straight up front. Let’s tie that back to the piper classification because that really relates to one image. So generally, if after my history and my exam, my tentative piper diagnosis is of 4A. 4B. 5A. Or 5B. That’s usually want to recommend imaging. So, if I think it’s a 1 to 3b. Then usually I’ll just get mounted study casts and digital photography and do any type of sleep screening. We may need to. But if I think if it’s a 4a to 5b that’s when I’ll go ahead and get the MRI and the CBCT. [Jaz]That’s very useful. [Jim]So that’s how I determine my image. And basically, really from the exam, I think the most two important aspects of the exam are the history in terms of what’s happened at the joint? What type of treatment have they had? What’s your pain history and what’s your trauma history? So those are the four histories that I’ll take. And then really, I’m going to look at the bite. You know again Mark Piper taught me this a long time ago to read the bite. And if we check the bite with the joints in the socket, the thickness of the disc is about two millimeters. If the anterior teeth are uncoupled greater than the thickness of the disc, I’m beginning to think that I’ve lost the disc and the bites uncoupled. [Jim]That’s really interesting. I think nowadays when now that we have intraoral scanners, I think it’s going to be great hopefully in the future to be able to not only just rely on photos but scan people’s arches and bites routinely, even if there’s nothing to do with the piper beyond three. But in the future when we know it’s a change and how much more will be able to finally realize that are something has changed. The teeth are the same. So, what’s happened at the joint level? [Jim]I completely agree with you. I completely agree. 100%. And you know, we have a trios scanner we’ve been using it for five years now. [Jaz]It’s likewise. Thank you for all that wonderful information. I think you really explain these terms really well. So, I’m going to really make it extremely clinical and tangible now and there’s only so much we can cover in this sort of podcast format. So, I’ll ask you at the end, where can dentists learn more about this from you. But in terms of actually making, it clinically relevant, here’s some tricky questions I’m going to ask you. And these are tricky not because I’m being awkward, but these are tricky real-world questions that we may or may not have answers to. So, for example, if you have someone with a 3A. So, everyone remember 3A. That’s when they have a lateral pole. Perhaps that’s with reduction. Okay? And you have someone with a 4a and that’s when your medial pole is involved. But it’s a disc displacement with reduction. Is it possible to clinically diagnosed because they both may present with a click to a varying degree and they’re both with displacement. So, is there a clinical way to determine whether they are 3A Or 4A? [Jim]No. That’s part of the confusion because, you know, occlusion at the tooth level is easy because we can see it. Occlusion at the joint level, we can’t see it. So, we have to do our best guess from what we find for the exam. So, if it’s a 3a. I would expect to hear not a lot of pain, not a lot of headaches, not a lot of Jaw locking. Someone who may do pretty well with this. If it’s a 4A and they say they’ve got more pain, they’ve got more jaw locking. Their bite feels more uneven. That tips me in thinking that it’s a 4a as opposed to a 3a but that’s an awesome question because, you know, for years that question comes up, is there a way to know definitively without seeing? And there really isn’t. So, you just kind of have to go by feel in which case is you think you need to get the additional information. [Jaz]Is there any evidence or do you know from your history of practicing in this area whereby if you see someone with a piper 2 or a piper 3a that when you follow these patients up, will they remain stuck on that? Or is it always a progressive disorder? [Jim]I’m glad you asked that question. It is not always a progressive disorder. You can have patients stay a 3a their entire life. So, I’m glad you asked that. Many times, the classification system is misunderstood as a progressive disorder, but If I have someone who’s a 3a and stable. most of the time, if they don’t have another joint injury, they’ll stay that way their whole life usually. So, I’ve changed my thinking over the years. I used to think that the bite caused the disc to displace because that’s what I was taught. I really think now that it tends to have more of an injury that impacts the ligament attachment of the disc to the bone. I don’t think the bite causes the disc to come off the way I was taught when I was younger, the old saying was a bad bite would cause a bad joint, [Jaz]Very good now. So that’s a very good way to think about it actually. So essentially you said there that someone may stay on the 3A their entire life and as long as they’re stable, that’s okay to make that clinically tangible. That’s our patients who many in a 20% or whatever have asymptomatic clicking right?So, some dentists get very phase and worried about these clicks and then and when they diagnose them and then patients start to worry about their clicks. So sometimes we have a huge role in just reassuring a patient and doing a wider history, wider examination, taking a note of their range of motion and then monitoring these things over time to then help you decide whether it is progressing or is it staying still? Is that a fair way to think about it? [Jim]I completely agree with that. You know I see a lot of patients with asymptomatic clicks and dentists get really concerned about it. When you ask the patient they’ve been clicking for 20 years and they don’t have any bite problems. In a case like that I’m going to monitor it. There is a asymptomatic click though that I would say that we should pay more attention to and that’s in the growing female. If there is a 12 year old, 13 year old, 14 year old girl with an asymptomatic click, that doesn’t hurt yet. To me that warrants further investigation. Only because many times pain won’t develop to the mid to late teen years and many times those patients are patients that have displaced discs and aren’t growing. And if we could re-establish that condyle disc interface with maybe some type of functional orthodontic appliance, we may be label a positively influenced growth. So, if since it is an asymptomatic click in. [Jaz]That’s very useful to know. That’s fantastic. Next question because I can’t believe how fast time has gone Jim. The next question I have is deviations and deflections. Some patients have deviations, and some patients have deflection. The way I was taught, was a deviation is when they make a V Shape and the deflection is when they just go off to one side. Imagine area of concern and if someone has a deviation or deflection, is that when you are now thinking of having your full work up and imaging as part of the way to get the exact diagnosis? [Jim]Well, any type of deviation or deflection is typically because the disc isn’t in the right place. I mean, if you really think about it, deviations are typically where you’re going to open, let’s say you open to the to the right, usually that’s because you’re right, condyle isn’t moving, it’s not translating forward. So, I probably would want to take a look at that if the patient understands there is a problem, because I think we really have to be careful here. We really have to do a good job with patient education because so many times dentists get more upset about the problem than it really is because the patients really doing quite well and the patient may need diagnosis, but they may not understand why they need diagnosis. So that’s why I would say just be careful and create the value for the diagnostic. So, the patients, they will understand what the problem is. In terms of some type of deflection. Usually they’re coming forward, the disc is in the way and they’re having to go around it. So again, many times imaging would help. But again, patients have to understand what the problem is. [Jaz]Brilliant. You’re so right in terms of the patient must be able to have enough value, have enough understanding and the importance in their own sort of anatomical terms as to why this could be an issue in the future if unaddressed and therefore that then builds value into the actual diagnostics which is an important thing to convey to the patient. So, I completely agree with you on that and this going to be the final question because there’s so much we can do. I have to invite you back for a part two because being probably useful. I think there’s been excellent. You have to appreciate that guys Dr Mckee right now is on vacation in a beautiful part of the world and he’s getting up some time to record today. So again, thank you so much. You’re very kind. So, the next question then let me get my list. Okay, so because every patient is unique. Every joint. MRI, CBCT will come back with a unique proposition, but just as a sweeping statement, if possible, for a generic average case, if they have someone who’s getting, let’s say with a piper 3B. So that’s when they have a disc displacement without reduction and it’s affecting the lateral pole and maybe they’re also presenting with deviations and or deflections. What is your typical regimen in terms of what kind of treatment and they may be looking at? i.e. are you actually looking to change the shape of the teeth? Change the occlusion a way to better accommodate the joint? Or are you generally going to be at that point involving an orthodontist or is it usually something in a removable appliance that you want to get things corrected in first before committing to anything a bit more invasive? [Jim]It depends on what they present with. If they have problems, my typical first approach would be some type of an appliance. I do a lot of flat plane appliances. With a piper 3b You could also do an anterior deprogram as well. So that’s the situation. So, it would be easy to do that as well. I tend to do more flat plane appliances for joints though because I tend to have better success having support all the way around. Generally, if they’re not having any problems and they’re just clicking a lot of times, I’m just going to monitor it to be honest with you. I mean I might do an equilibration if the teeth present with that because what I’m trying to do is to try and maintain and protect the teeth. So, if I could change the low distribution at the tooth level and that would benefit them, I would do that. But I may not do that necessarily simply to treat the joint. [Jaz]I know there was a really unfair question tricky question cause there’s so much to it and this is why I enjoy this area so much because it’s very fascinating and something that’s really skimmed over in dental school. So Dr Mckee, tell us more, where can we learn more about this? Do you have any seminars that you run specifically about this? Because a lot of people listen this podcast, they often really resonate with the speaker. They really like speaker and I’m always flooded with questions usually on my Instagram saying, hey, that guest you had on, how can I learn more about that? So please do tell us where we can learn more from you. [Jim]Well, I would say the best place now is spear education. the occlusion seminar is a two day seminar and I teach 25% of their course Frank Spear. If you’ve not heard Frank Spear, go hear Frank Spear. [Jaz]Everyone on this podcast is listening has definitely heard of Frank Spear, I guarantee that. [Jim]Yeah, he’s fantastic to listen to Frank explains things so well and Greg Kinzer is just such a talented Dentist. I really enjoy teaching that and then the advanced conclusion workshop as well. I also do study club programs for different study clubs, and I’ve lectured, like I say, I’ve been really fortunate, lectured all over the world, so I do a lot of study programs. I do national meetings, I have a little bit more time now, so I’m looking to put together something a little bit more structured so I’ll have more information for you that in upcoming podcast. Please do. [Jaz]And you know, you can always send it to me, and I’ll be happy to share it with the Protruserati. So, the name given to the listeners is PROTRUSERATI and they’re always like the geekiest bunch and they always want more and more knowledge and they love guests like you who break down a very complex topics. I’m hoping everyone, there’s no excuse if you listen to the end of this podcast and you cannot now recite the entire piper classification as clinical connotations, then you, it’s impossible. You’ve definitely got that nail. So, Dr Jim Mckee, thank you so much for giving your time on vacation to cover this really complex topic, but broken it down in such a simple and beautiful to understand the way. I appreciate it. It was such a treat, Jaz. [Jim]I can’t thank you enough for having me and I’d love to come back any time that works for you. Jaz’s Outro:We’re going to definitely have you back. Thank you so much. Well, there we are guys. I told you you’d be able to gain so much from this. So, by now you must know the piper classification, you know, a few other classifications out there, you know, now the value of an MRI and a CBCT and maybe not so much an OPG. But now, you know why that’s not going to give you as much information as you need. And hopefully now when you have your patient that has these clicks, you’re able to really close your eyes and think, okay, which piper classification is this? How might this affect what I will say to the patient in terms of their risk going forward. So, I hope you enjoy this. I’m definitely bring Jim back in the future because I just love talking about topics like these. Thank you so much for joining all the way to the end. I really appreciate it. Do check out the protrusive dental podcast Instagram @protrusivedental if you enjoy this episode, please, would you consider leaving a review on Apple podcasts. We listen on Apple and if you leave a few comments, I love reading them. Thank you so much and I’ll catch you in the next episode. Same time. Same place!

Does Biological Width, apparently now known as ‘Supra-crestal tissue attachment’ confuse you? Or would you like an introduction or a refresher on the clinical stages of Crown Lengthening? Fear not, I twisted specialist Periodontist Reena Wadia’s arm and finally got her on the show to teach us! https://youtu.be/No-8hjFsWNs Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How to find out what kind of biotype you’re dealing with: Use a ball ended Perio probe and use the ball-end/tip (sometimes it’s coloured) and probe in to the sulcus – if you can see the tip of the probe shining through the gingiva then that’s a THIN biotype. and if you can’t see the tip of the probe then that is a THICK biotype. “Don’t complicate things, if something works in your hands and you’re doing it well, keep things simple, don’t have too many variations because then it just starts getting unpredictable. So test everything out, go on courses, and then see what works in your hand and then stick with that.” – Dr. Reena Wadia In this episode, we discussed: Bone sounding (10:35) Aesthetic crown lengthening (13:06) and Functional crown lengthening (18:02) Altered passive eruption and active eruption (14:21) Fundamental difference between the two types of crown lengthening (20:06) Biology of keratinised tissue (24:13) Steps involved in crown lengthening surgery (26:32) Using dental stents as a guide (29:44) Post-op management for flaps (30:35) Pre- and Post-operative care (33:05) Ideal case for beginner Dentists (35:19) Placement of sutures (36:28) Check out Dr.Reeda Wadia’s Perio School Check out Reena’s Crown Lengthening Live course on a Sunday in London! If you liked this episode, you might also enjoy How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique  Click here for Full Episode Transcription: Opening Snippet: When you start taking on more complex restorative cases or you start doing smile design cases. These kind of cases you tend to appreciate that there are two other types of disciplines or too hard skills that really benefit a lot of these patients. Jaz’s Introduction: Number one is orthodontics like a lot of my restorative patients, they will really benefit from pre restorative orthodontics and that makes sense. Okay? With ortho you can actually intrude teeth get the gingival levels even you can actually make your dentistry less invasive, less prep by getting the teeth in the right position. But the second one is actually soft tissue related more and more and more to get the gum lines even or what we call aesthetic crown lengthening. There is a huge role in the Perio. So, this episode is focusing on that THIS with Reena Wadia. Reena Wadia is someone who has really inspired me so many years and when I was a dental student, she qualified, and she’s always been a mentor to me. In fact, I’ve mentioned Reena’s name in the previous episodes as you know what Reena taught me this or Reena taught me that. So, she’s such a great giving clinician, she’s a specialist periodontist. I know you will love her, and today’s episode is talking about just CROWN LENGTHENING SURGERY where it comes to aesthetic crown lengthening. i.e. doing some sort of surgery to make the gum lines or gingival zeniths more even and presentable or functional crown lengthening. This is when you’re actually doing crown lengthening to allow you to get more of a Ferrule so you can actually restore a tooth. We’re going to talk differences how to plan for each one. What’s a post op advice to give and many more gems. Protrusive Dental Pearl:The Protrusive Dental Pearl I have for you is how to find out what KIND of BIO TYPE you’re dealing with. And the classic way to do is use a ball ended perio probe and use the perio probe has like a black ball, right? So, it’s like a black painted ball, and then you put it inside the sulcus. Okay? And if you can see the black or the probe shining through the gingiva then you know, you’ve got someone with a thin bio type and you write your notes, okay, diagnosis, thin bio type. If you can’t see the probe or if you can’t see the ball end, then that is a thick bio type and that’s a good little technique that I learned, which is very relevant to this episode. We’ll also be talking a bit later this episode about HOW TO DO BONE SOUNDING. Okay, what is bone sounding and how to do it and how it’s relevant to your planning for crown lengthening surgery. So, if you don’t know what your altered passive eruption is to your alter active eruption, then this episode will sort you right OUT. Let’s join Reena now, the main podcast and I’ll catch you in the outro. Main Episode:Your ears must be burning because I know you’re super busy and stuff, you probably haven’t had time to listen to podcasts, like for commutes and stuff, but your ears must be burning because I talk about you now and again on the podcast, I say, you know what? Reena taught me this many years ago, you know Reena once taught me this. So it is so nice, Reena Wadia to have you on the podcast today. How are you? [Reena]Yes, really good. Thank you. Thanks for having me on the show. Congratulations on such a successful podcast and delighted to you. [Jaz]Thank you, so it’s down to the Protruserati. So those who listen to the podcast are called the Protruserati and it’s all down to them. All over the world who listens. So it’s really nice and we’re going to cover the theme of crown lengthening surgery. And you are someone who has taught me so much more than just perio stuff back in the day. You taught me about life, you taught me about communication skills, you taught me about how to navigate this difficult minefield of dentistry. So, I’m sure some of those nuggets, I might just say now and get a remember that time, you taught me this, whatever, so we might just like, you know, take lots of different directions, but for those very few people out there who don’t know who you are, Reena. Just give us a quick little intro of yourself and what you do. [Reena]Sure. So, yeah, I’m Reena, I’m a specialist periodontist and based in London. So, most of my week I’m at the clinic at 75 Harley Street where we’ve got a specialist clinic with me and a few hygienist as well, which I really love and enjoy. We recently moved to our new clinic, which has been exciting. And then once we come in the hospital as well at King’s and then the rest of the week I’m teaching, doing podcasts like these, and enjoying myself as well. So, it’s a really nice balance. [Jaz]Do you still do your Instagram lives? Remember once you’re doing loads? Nice to enjoy catching them. Do you still get time for much of that? [Reena]I’m trying to keep that going. I think I had more time during the lockdown to do all that, but I think its technology is amazing. I mean things like this, things like Instagram live, it’s a great way to connect with people and share knowledge and information. So, I’m hoping to do more of that going forward and now that the practice has settled down. [Jaz]You need to because your presence on camera, your teaching ability is something I model. I’m like, ‘How can I be more like Reena when I’m communicating something because something I’ve admired for many years.’ But today we’re going to really have something really well, which is crown lengthening surgery, which we’re going to start the very basics because over the last six months to a year or so, a lot more dental students have started to listen to a podcast from all over the world. So, let’s just even start with the very basics like WHAT IS CROWN LENGTHENING SURGERY? [Reena]Actually don’t underestimate the basics because with things like crown lengthening often if you don’t get those basics, that’s when things go wrong, which I’m sure will go into later. But it’s always great to start off with a definition. So, crown lengthening is basically what it says. Essentially, it’s removal of usually soft and hard tissue to gain supragingival crown height basically. It usually involves removal of bone. Sometimes it doesn’t, but essentially, you’re creating more tooth crown of structure above the gum line and you’re recreating usually what we call the biologic width, which is now called supracrestal tissue attachment. According to the new classification. [Jaz]Wow, I had no idea actually. This is new to me. So now it’s called supracrestal tissue attachments and no longer we’re going to be using biologic width. [Reena]Yeah, I do like the word biologic width have to say. I think I still kind of use it, but if you want to be perfect and textbook according to the new classification, it’s supracrestal tissue attachment. [Jaz]Okay, fine, Fair enough. Let’s go with supracrestal tissue attachment. Now, I think for the basis of this podcast, that’s not going to stick with me. So, if I say biological width I mean supracrestal tissue attachment. Okay. Right. Well one of the most basic things that I got exposed to crown lengthening early on was when I saw some cases on social media where else, right? Where someone had just come and like on one side like upper right canine to upper right central. They just started to use the blade to cut away tissue. And it looked amazing. It’s like WOW this right side revealing the true clinical crown of that tooth compared to whether the tissue was overgrown on the left. It looked amazing, right? And then I thought this is great, RIGHT? Let’s go to Monday morning practice. And the biggest mistake someone could make now, and we will discuss this very, very much detail now is you can just make a huge mistake by just cutting away the gum and then that’s it. It’s not as simple as that because you alluded to it already. You all seem to consider hard tissue bone removal. So, the most basic question, I think the most fundamental question everyone should be thinking is okay at what point is it can you get away with? Because I have in a few cases, got away with it. when can you get away with just simple soft tissue removal? Maybe you’re trying just improve the gingival zenith, which is the highest point of the tooth of a central just to match it before you do your crown. When can we get away with that? And then when can we not get away with that? And then we have to consider raising a flap, bone removal, sutures, blood like the T-shirt I’m wearing, that kind of stuff. [Reena]So, this is such a fundamental question and I think this is if you don’t understand the principles, this is where you’ll get it wrong and this is where when you do it, it might look nice for like a week or two and then the patient will come back and it’s an absolute disaster. So, it’s all about the biologic width. So, with crown lengthening, what you’re trying to do is recreate the biologic width. Now the biologic width is something very special or should I call it supracrestal Issue attachment. You have to respect it. If you respect it, it will respect you. That’s what I always say. So that biologic width, but first let’s define what it is. So, it’s the junction epithelium plus your connective tissue. According to Gargiulo, which is a person who 1961. Long time ago defined it. It’s two millimeters approximately. Now, practically if you include the Sulcus depth, we say it’s sort of 3 millimeters So the number for you to remember is 3 millimeters. Now, what you have to always check is, do you have that three millimeters? So, when you’re looking at your tissue margin or whichever your reference point is to the bone level, if you have the Crestal bone level- [Jaz]Can we make this really specific and tangible? So, let’s talk about the upper right central incisor and the upper left central incisor. Let’s say that the upper left one is just more gummy, right? And you want to check with the upper left one, how would you do it? [Reena]So, you firstly find your reference point which is going to be the same as the other one, right? So, you want to match it. So, if from that point to the alveolar crest, you’ve got three millimeters. Guess what? Great. You’ve got your biologic width. You don’t need to worry. If you don’t have three between your reference point and your bone, you will need to recreate it, which is normally the case. And if you need to recreate it, you recreate it by removing bones so you can shift that space up. So, the point is, if you’re probing or you’ve got a radiograph and your bone sounding and you’ve actually got three millimeters. Once you cut the gum, you’ve cut the gums where you want it, then you’ve got three millimeters. Till the Everquest, you’ll find great, you’ve already got your biologic width or your supracrestal tissue attachment. If you don’t, you then need to raise a flat and remove bone so that you then create that three millimeters. Does that make sense? [Jaz]Makes perfect sense. And please don’t try this at home unless you’ve actually done a course or something like that and we’ll talk about that in the end. But you mentioned bone sounding. Please explain what is bone sounding and how to do it. I’m familiar with it. I’ve done it. But maybe based on your description, I might realize, hey, maybe I’ve done it wrong a few times. So, what is the best way to do bone sounding? So, we’ve got the central incisor. You want to check is my bone three millimeters away or not? That’s called bone sounding. But tell us how to do it. [Reena]Bone sound is an interesting one. It’s a way of determining where the bone level is. So, you know, if you need to remove bone or not and you know if you need to raise a flap. Now there’s other ways also of determining where the bone level is like your radiographs or like actually just raising a flap anyway and seeing where the bone is. That’s the safest way of doing it. But bone sounding is a technique which you can use during your planning phase to get a bit more of an idea of this. And what you do is literally what it says. You could usually numb the patient up if you’re nice and then you literally get a probe, and you just push it right down until you feel the bone. It’s quite not like normal probing right down and when you feel that hard bone, that’s where you measure, and you say okay that’s where my bone level is. So that’s bone sounding. I have to say I don’t often bone sound; my kind of technique is I’ve pretty much always raise a flap unless it’s extremely obvious that you don’t need to remove bone because you don’t really know until you physically see the bone exactly what this, not just where the bone level is but the structure of the bone. Sometimes in crown lengthening, you’ve got this bulbous bone, right? And you want to actually recontour the bone as well. It’s not just about ostectomy, it’s about osteoplasty as well. So, there are many benefits of raising a flap. So, I always advocate usually unless it’s super obvious that you don’t need to being safer doing it properly the first time rather than making your patient go through surgery again, if it doesn’t work. [Jaz]I think we did an agreement as a special periodontist I think you know, you’re so comfortable raising flaps, you know, so that makes sense and how you do that and then you can control all the outcomes. Like you said, a real pearl you gave that is that sometimes periodontists when they’re doing the surgery, they have to remove the thickness of bone as well, which is something that people don’t appreciate. Sometimes that’s a really good tip there as well. With the bone sounding, like me is more restorative background. I’m more likely to do bone sounding than the number of the flaps I will raise in a year is way less than you. So, I am doing more bone sounding. That one thing that I might want to say, and you correct me if I’m wrong is sometimes when you’re starting bone sounding, you go in and you think you’re there, but you’re probably just at the connective tissue, you actually need to really go a little bit more and then you hit the bone. Is that something that you might find a beginner might make a mistake like that? [Reena]Definitely don’t be too gentle and you know, they’re numb so it’s not going to hurt. So definitely going to be a little bit aggressive with it. [Jaz]Okay, so let’s talk about the difference between for I know there’s two types of crowns lengthening I think there might be more, but as a general dentist there’s aesthetic crown lengthening and functional crown lengthening. Is there anymore? And can you just go over a little bit about each one? The differences. [Reena]So yeah, you’re right. So, there’s two major types of crown lengthening, aesthetic, and restorative. aesthetic is becoming more and more popular, I have to say. Looks like getting lots of patients interested in what they call the gum lift, which I find really funny. I like to call it. I think there’s a bit more than a gum lift. It’s quite like gum sculpting more than anything. But anyway, aesthetic lengthening, it’s getting more popular and it’s a great skill to have as a general dentist as well because if you’re doing all these beautiful smile cases, it just adds that extra bit at the end and I think you can’t forget about soft issues. The pink is part is really important if you put all that work into doing Invisalign and all the other bonding, whitening and everything else. if your gingival margin isn’t quite right, it’s going to affect the final result. So aesthetic crown lengthening is what it says essentially is to improve the aesthetics. So it could be, for example, like you described earlier, uneven gingival contours, RIGHT? So, one is slightly higher than the other and that slight difference can make every difference of the smile so small but significant impact. Other ones sometimes just generally gummy smiles and conditions such as altered passive eruption CAN CAUSE. [Jaz]I totally want to talk about THAT. So, you can just go into what that means. When I first came across that like two years at dent school it was just completely confused me. Now I’ve got some clarity on it, but I think this would be such a fundamental thing to cover. [Reena]Yeah. So, you want me to talk about that now in terms of also passive eruption show? [Jaz]Yeah. Let’s do that. [Reena]Yeah, sure. So altered passive eruption So this is quite surprisingly a lot of people don’t know about it and it’s one of the most common reasons for a gummy smile. And I have to admit I actually didn’t know about until I did my specialist training. So, it’s not something that’s really touched upon or usually at undergraduate dental school. So going back to basics basically you have active eruption which is when the teeth come out of the jaw was essentially in the most simplistic terms. And passive eruption is when your gingiva retract around the tooth and there’s an it’s four stages for you with the details, but there’s four stages as to how the gingiva you retract and that’s passive eruptions. Active eruption, passive eruption, altered passive eruption is when that process doesn’t go quite a plan and when the gingiva doesn’t quite retract to the level of the CeJ where it should be. So, what happens is your gingival margin is coronal to your C.E. J. And biology hasn’t quite finished its job. So, with crown lengthening, what you’re doing is almost recreating where it should, where the gingival margin should be. So, the CeJ is underneath the gingival margin and there’s different types of altered passive eruption. You get four different four types 1A, 1B, 2A. And 2B. And if you look at the classification, it depends on where the bone level is and the amount of keratinised tissue that you have attached gingiva that you have as well. So, you can then divide it up. But I think it’s extremely common. The incidences like 11-12%. So, it’s not uncommon and you might find that most of the cases that you see that gummy smiles are actually altered passive eruption cases. [Jaz]Reena because it’s altered passive eruption. So, no one has explained to me like active eruption, passive eruption. Cause I love that. So, with the altered passive eruption, because it really helps you to explain it because it’s a passive part that’s had an issue and not the active part. So, is active more like bone and passive more like gum, right? [Reena]Yeah, but active is exactly the tooth and the bone and then exactly. The passive eruption is a gingival part of it essentially. [Jaz]So, does that mean that someone who’s got altered passive eruption might be someone who gets away more with just the gingivectomy without the bone removal? Or is that not the case? [Reena]No. So, I would probably say that the passive side are just focus on gums and I would actually say periodontium structure. So, the bone in passive eruption might be at the right level. It might not be. So, there’s two different types and one type is at the right level. One type, it isn’t. So, depending on what type it is. So, if it’s, you have, I’ll just go through it, 1 A Is basically osseous crest is apical to the CeJ. And then 1B Is osseous crest at the Cej so for 1A, you would do a gingivectomy whereas for 1B, you would do a gingivectomy plus osteo surgery. So active eruption, I would say is the teeth and then passive eruption is gums and periodontium basically, I was just going to say it’s just good to know about it because personally. I think before doing any type of treatment, you need a diagnosis as to why you’re doing that treatment. It’s just important to highlight that you do need a diagnosis before you then do treatment i.e crown lengthening. So, knowing about altered passive eruption that could be your diagnosis, or a fractured crown, might be your diagnosis, but you need to know you have to have a diagnosis before you prescribe treatments. I think it is important to know about its condition. [Jaz]Great. And we were just touching on the difference between aesthetic crown lengthening, which how ape tied in so nicely with. But now can you just touch a bit on functional crown lengthening and then we might do that. And which is the most common tooth that you get referred for functional crown lengthening? [Reena]So functional crown lengthening, also called restorative crown lengthening is basically when you have inadequate tooth structure. it’s a strategic tooth You’re trying to say that, but you just don’t have two-millimeter ferrule. And by doing restorative crown lengthening, essentially creating that so you can restore the tooth. it could be that you’ve got a fracture, you’ve got a perforation, ended perforation in the coronal third. That’s key. You’re not going to do if it’s like in the apical third so something in the coronal 3rd and you’re trying to save that tooth, or an important point is if you’re trying to relocate the crown margin when it’s been impinged. Ie someone’s not respected the biologic width guess what, you’re now going to have to do crown lengthening to recreate it. So that’s actually really common and seeing it more and more. [Jaz]I said the most common the few times I’ve done, I have done it to get more Ferrule so that I can now make a tooth that was previously unrestorable. More restorable give it a better prognosis, which is the most common tooth that you get referred for this? [Reena]It’s usually a lower molar. From my experience, that’s what I’ve had so far. It’s usually like a strategic tooth they’ve lost already. Lost another molar behind it. Patients are really keen to save it and do everything they can. And don’t want to jump straight into implants and that’s usually the most common thing. I always say to the patient, you know, everything has a lifespan in dentistry. And so, if you’re going to jump to an implant, guess what? That implant also might have a lifespan. So, the longer you can keep your own tooth the better. And I’m not saying to do heroics, like if it’s a tooth which is completely broken down, has got like a 10-millimeter perio pocket, terrible endo. Yes, it may be better to extract that you have to be sensible, but usually nothing is better than your own tooth In my experience. [Jaz]Fantastic. What people really resonate with what dentistry resonate with when they listen to podcast is there’s little sayings, there’s ways that we communicate with patients. So that’s awesome. So yeah, you said lower molars are the most common that you found. I can see the rationale behind that. And I love what you say to the patients. Now, what is a fundamental difference between the aesthetic crown lengthening and the restorative crown lengthening? In terms of the surgeon when you’re doing the procedure. [Reena]So, in terms of the differences between the two, firstly, the similarities are that the principles are the same. So, you’re in both scenarios, you’re trying to recreate the biologic width and you’re using a reference point. Now, the differences are the reference point. So usually for aesthetic crown lengthening, it’s usually your CEJ, especially in altered passive eruption cases. Whereas for restorative crown lengthening or functional crown lengthening, it might be a certain crown margin, it might be that amount of sound tooth tissue that you need. So, it varies. The actual technique itself again, the principles are the same. I.e., we’re going to a little bit more detail but you remove the gum, raise the flap, remove the bone. stitched back up. However, for aesthetic crown lengthening, usually it’s just buccal because it’s you know, you don’t see the palatal or lingual, so it’s usually just buccal. Whereas for restorative it’s usually is 360 across the tooth. For restorative crown lengthening usually if it’s at the back of the mouth especially, I wouldn’t be worried about doing vertical releasing incisions. You know, not that bothered about it. Whereas anteriorly, I really would avoid it because you don’t want any scarring because you know, doing it for aesthetic reasons. So, we try to minimize and usually you don’t need it to be honest for aesthetic. You sometimes it’s usually a Kind of 4-4 case or 3-3 you’ve got enough access without doing a relieving incision. Often as well for your end goal is also different between the two while you’re actually doing it. But often for aesthetic crown lengthening I would also consent them for what I call it a revision surgery because when we go to the restorative phase, often these patients that they want a little tweak before the final restorations to make everything perfect. Or if you get gingival overgrow again, then you might need to do a bit more surgery. So that’s less important for restorative cases. So, I would consent for revision surgery for aesthetic crown lengthening as well. And I guess the other differences with the healing. I often use things like coe- pak for restorative crown lengthening because it really keeps the tissues down or as for aesthetic, I would not be putting coe-pak at the front of mouth. Coe-pak, just to explain is a dressing that you can use periodontal dressing. It looks a bit like pink chewing gum, feels like chewing gum and you just press it on the tissues and essentially just keeps the tissues in place. And then two weeks later, you remove it and take the stitches out it works beautifully but it’s not something you’re going to paste across someone’s from in front of their mouths. [Jaz]So anterior cases, those aesthetic ones. you’re not using a coe-pak, but you just letting nature do its job. [Reena]Yeah. You need to suture. You always need to suture. If you raise the flap, you have to suture. But apart from that, yeah, the gums will just heal, and suturing is really important. I mean, everyone focuses on the first few stages of removing the gum and bone. But your suture is where your tissue is going to end up, right? So, spend time on suturing as well and doing it well. [Jaz]Amazing. Good few pearls in that. I’m going to go really geeky now and ask you a geeky question which always bothered me about this subject, right? And I just can’t get my head around it. So now that I have you on the show, I’m going to be very selfish. Ask a question. I’m hoping it’ll help others who are thinking the same thing. Right? So, you mentioned about the similarity between aesthetic crown lengthening and restorative crown lengthening i.e you have to cut some gum away. You raise a flap, you remove the bone etc. You suture back which is so important. Now that scenario where you actually cut the gum away. Okay let’s talk simplistic terms, Right? the gingivectomy You cut the gum away. And yes, you got different goals. You know the CEJ being one and the other one just revealing more tooth structure. But everyone’s got a defined and finite amount of keratinised tissue. Right? So, let’s say you know, you’ve got some patients, right? And they’ve got like miles of keratinised tissue like thick meaty. I’d love to do crown I think in a case like that. But then you got someone who’s just got two millimeters of keratinised tissue. Right? So, what if for that patient who you’re doing let’s say a restorative crown lengthening on the lower molar they’ve got let’s say four millimeters keratinised tissue. And then you cut away three millimeters and then you do your crown lengthening and then you suture it back. What happens, right? Does it just stay as one-millimeter keratinised tissue for the rest of that patient’s life? Or does the apical part of it suddenly become keratinised? What happened? What the biology about that? [Reena]Yeah, that’s a really good question. So, I think the first important point is keratinised tIssue is important. It helps patients to comfortably clean around the gingiva, so it maintains health. So keratinised tissue, if there’s not tons of it, you need to be careful basically. So, in most cases you have enough to be able to do a gingivectomy, raise a flap remove bones, stitch it back up. But in the rare cases where you don’t have sufficient keratinised tissue and you know, by then cutting it away essentially there’s going to be hardly anything left. You need to change your technique. So, in this case you actually need to preserve the keratinised tissue. You need to raise the flap, right past the mucogingival junction and actually after you remove the bone apically repositioned flap. So, it’s a different technique for those types of cases. I have to be honest; I can’t remember the last time I did that. So, in most cases you will have sufficient keratinised tissue. But you are right to be on red alert if that happens, preserve the keratinised. And I’m biased as a periodontist saying that, but honestly is really important to have it there. [Jaz]So essentially, that’s the difference than therefore between what we call receptive crown lengthening surgery. Is it apically positioned? Is that the correct term? [Reena]Right, apically positioned. Using a different approach. Exactly. [Jaz]That’s the one that I’ve never done. Apically repositioned. Is that something you teach on your course? [Reena]It is, yeah, it’s something that I teach, but it’s so like so rare that you probably won’t need to, if you were starting out for the first time, I wouldn’t advise that as your first case. You want one with stacks of keratinised tissue as you said, so it’s more tricky for sure. [Jaz]Okay, Reena we’re taking like a little geeky detour covering all the wonderful things that you answered. My fault because I ask you, is geeky questions about altered active eruption stuff, but really I want to hear because I think what people find useful this podcast is hearing the steps, the little steps and what you taught me many years ago, Reena was micro steps. You taught me that the term micro steps out, and these are the difference between success and failure is not the big success but little micro steps you take. So, within the remit of the podcast episode, let’s cover a couple of minutes of what are the steps involved in crown lengthening surgery? [Reena]Yeah, micro steps. It’s so important. Honestly, some of the best clinicians, it’s not just about the macro steps, it’s about the tiny detail and doing it consistently every single time. So, it’s good to remember that. So, the first step I would say is assessment to plan your approach. And it’s all about planning, crown lengthening, the actual procedure, the surgical side of things is actually not that difficult. It’s the planning stage, as with anything in dentistry. So, you’ve got to plan a couple of things. So firstly you need to look at your periodontal health and I know I’m biased, but I’ve seen too many cases where someone’s got Periodontitis and they start hacking away and doing aesthetic, crown lengthening. It’s not appropriate. Cutting tissues that are inflamed and plus plaque everywhere. It’s going to be messy. It’s not going to heal well you could make it worse. So, step by step. Get the periodontal health super healthy patient. Plaque control needs to be optimal. Look at all the restorative factors. You know, do you need to redo the endo? Is there anything else you need to do restoratively before you then start your crown lengthening? Also determine your reference point. What is your reference point? Is that the CEJ That’s what is it? Because that’s going to be what you’re going to measuring from and you’re going to remember that three millimeter rule essentially. If you’re doing aesthetic crown lengthening, you need to plan your gingival aesthetics. So, know the gold standard, where’s that zenith meant to be on the canine? Where’s that zenith meant to be on the central? Is it meant to match? etcetera. So, you need to plan that out. I quite like what I’ve started doing now. I have my iPad and then I import the patient’s photo and I’ve got a little pen and I draw on and then I show that to the patient as well. I’m using iPad. It’s quite fun. Quite therapeutic. And then also looking at the amount of keratinised tissue that we discussed as well earlier and also where your bone level is. So, they’re all your kind of key components when you’re planning your case. The next thing is then your flap design and your incisions. Give yourself more room than you might think, especially with restorative crown lengthening. Don’t be too conservative. You’ve got to go one tooth either side of the tooth you’re treating to get enough access to the bone. So, flap design incisions. If you’re doing aesthetic crown lengthening, I teach that. The flap designs where you’re not going through the actually raising a papilla because you don’t want to risk having black triangle. So, there’s all these little nitty gritty things to be aware of. We then remove the excess gingival tissue, and you raise your flap and throughout all of this, you know you’ve got to have the right instruments don’t underestimate. As with anything in dentistry, good quality surgical instruments are critical. It’s all about micro surgical now as well. So, I’ve got a nice set of micro surgical instruments. Because perio is very delicate. It’s not like oral surgery, you’ve got to be very detailed and delicate. A completely different approach which applies in crown lengthening as well. Anyway, as I was saying you raise the flap and then you see where the bone is and you do your osseous management. So, at this point you remove the bone whether that’s using slow hand piece with water and a round bur. I started using a Piezo as well. You can actually get a Piezo which removes bone which is quite nice. So, I’ve been using that. Once you’ve got your bone levels sorted you then suture. [Jaz]I’m going to stop you there Reena, because you talk about the bone removal and talk about suture. But I’ve seen before when I was at Guy’s doing my D.C.T. Post that sometimes you get these like Essix retainers that was lab made to guide you. Do you use those? [Reena]Yeah, I used to quite a lot depends on who I’m working with. Often the cases are referred by dentists who gone to the effort of making a wax-up and sending a stent It can be helpful to give you a general idea and there’s different stents. Some stents just show you where to cut the gum essentially. You still need to use your own clinical skills to make sure you get it perfect. But it gives you a guide, it’s a guide. Some stents are very sophisticated. It also shows you where to remove the bone up to. So, it’s it depends. It can I think if you’re starting off, it’s worth doing. [Jaz]I’m trying to envision like doing a bigger case and you know, because you’re so experienced in this now is like, imagine you’ve done your gingivectomy. You raise the flap, you remove the bone. But then because the gum now behaves differently. Once you raise the flap, it becomes flappy, right? So, when you’re trying to approximate it back, just kind of measure. Okay. Have you, will it look, okay? Any advice on eyeballing that? [Reena]Yeah. What I’m generally do is quite simple. You just put the flap back, push your elevator against the flat and put your probe underneath and you just keep doing that basically. And that’s how I generally do so which works quite well. Yes. And then you suture. So, there’s different types of suture. I have to just say whatever works in your hands. I use vicryl usually five or six. So, but you know whatever works in your hands or whatever technique you can even just do simple interrupted. It’s just going to be good suture and get the soft tissue in the correct place. mattress sutures are good as well. And then if you need to put a dressing on, if it’s restorative crown lengthening you might want to use some coe-pak and then you let everything heal. And usually, it’s two weeks that then you then review them, remove the stitches. I usually get a Cotton pledget it dip it in Corsodyl I don’t like using the C WORD. It’s the only time I like using [cortisol] is after surgery where I literally wiped the gingiva and remove the sutures and then you just let it heal. And I guess timing wise in terms of cases. you’re looking at restorative cases that you need to wait three months prior to putting your definitive restoration on. You can put your provisional AFTER sutures out. You can go straight to provisional, but you need to wait ideally three months for aesthetic cases. The textbook answer. You actually have to wait six months, I have to say. So, me and my referrals, we wait 4-5 months and were usually okay. But what you need to be aware of is the gingival margin can continue to slightly change up to six months? So if you want to do it properly, get some good provisionals on possibly lab made provisionals, just let them be essentially for six months, once everything’s perfect, then go into your final ones because the last thing you want is you’ve got your finals and then like a month later gingiva ever so slightly higher up and the patients not happy and have to redo everything. So that’s your overall steps. So, you assess flap design incisions, raise the flap, remove the excess gingival first raise the flap, remove the bone. stitch up, let it heal and then move on to your restorative phase. If there is one. [Jaz]If you’re doing any revision surgery then does that reset the clock for six months? [Reena]Usually not depending on what it is. If it’s such as it’s usually the tiniest amount. So, I think it doesn’t really count unless it’s extensive then yes, reset the clock unfortunately. [Jaz]Got you. So, you’ve done your crown lengthening surgery with those lovely steps to talk through. What’s the post op care looking like for a patient? You mentioned about how long to wait for restorative, which is one of my next question. That’s awesome. So, we know that six months for aesthetic cases. Perfect. But post op wise, what do you say to a patient? [Reena]Yeah. So, in terms of any surgical procedure, they’re going to be on Chlorhexidine usually for two weeks. No brushing of the area because it’s technically a wound. So, if you can’t brush it, it’s a delicate area. Brushing the rest of the mouth as normal. soft foods, ideally for as long as possible, but ideally a week or so. Just be sensible. Nothing would like seeds and crusty things that’s going to affect the healing. And then just in terms of two weeks after once you remove the stitches, they then can start brushing the area. And crown lengthening is unique in the fact that unlike other periodontal surgeries, you can start brushing quite quickly and you kind of need to, so the gum doesn’t try to go back to where it was. So, with other types of periodontal surgery, sometimes for months they don’t brush. So, it’s quite different with crown lengthening. So, and of course after any surgical procedure, patients need to take it easy. No major exercise. I think that painkillers, regular painkillers are fine. I also include an ice pack that they can just put on their face, especially between a big case. The thing is give them everything they need. The last thing you want is you put your patients through a massive surgery and then they have to go to like boots to buy all this stuff on the way home. It’s Not Fun. give them a goody bag with everything they need ice pack, painkillers, straws whatever else they need mouthwash, gauze. So, they’re ready to go straight home. I think that preparation side is really important. I also send them an email the week before telling how to prepare. So, get your food’s ready. Soft foods, food replacement drinks, you’re really good, all those kind of things, get them painkillers, all of that. So, they feel prepared otherwise. They’re just, you know, they don’t feel prepared to get more anxious and everything goes wrong. You need a calm patient. If you’re doing these types of cases. [Jaz]That was brilliant. I really love the fuel reference, which I never thought of that, but I guess that’s something new. Right? We can start having these meal replacements. It makes so much sense. And also having a goody bag. You’re so right. You made it really clear that you don’t want this patient just had this surgery numb lips to go to boots to buy something. You’re so right. We should totally make a goody bag. Last question, last couple questions that clinically orientated I want to ask about which is the ideal case? Like imagine, you know, this is something you teach. What do you tell your students? Right, okay. When you go out Monday morning find a case which has which takes these boxes. [Reena]Yeah. So, when you’re starting off, I would say a restorative crown lengthening is good as the first case because it’s the back of the mouth. Something goes not wrong, but it’s not beautiful. It’s not going to be the end of the world. Lots of keratinised tissue, possibly minimal bone removal. So, you just kept practice on raising a flap and doing some minimal bone removal. Once you’ve got the hang of that, then you can move on to a bit more complex and possibly anterior cases with lots of keratinised tissue. But I get minimal bone removal. So, start off easy. Get your confidence because the last thing you want is you do a case, and it goes wrong and you know what it’s like. You just don’t want to do anymore. So, you’ve got to have an easy first case. [Jaz]Pick someone with a very low lip line and you do aesthetic crown lengthening on them. That’s the best person, which I don’t see the point of you see it down on the ground sometimes. [Reena]Yeah. And a nice, a nice, easy patient. Like not one that’s like, ridiculously nervous and difficult. If you see what I mean. Fidgety. Yeah. [Jaz]Geeky little, tiny questions. Now sutures facing buccal or facing palatal. Let’s say you doing some upper crown lengthening aesthetic. They’re not facing buccal or they’re not facing PALATAL or does it not matter? [Reena]It probably doesn’t matter too much. I always do buccal. I think it irritates some more when it’s palatally on the tongue and keep playing around with it. So, I stick to buccal knots. [Jaz]Okay, sweet. And then always the cold blade. Or is there a place for laser? [Reena]I absolutely love, I’m very traditional. I love the blade. But there is a place for laser, I have to say, I don’t use it, but if you’re doing simple gingivectomy cases you can use it is and it’s great because it stops the bleeding as well. So if you’re doing an overgrowth cases, actually, technically for removing the bulk, that is a type, I should never said, actually, that’s a type of crown lengthening technically if you want to be geeky, which you are, I am as well, so that is a kind of thing. And for those types of cases we can get a lot of bleeding. The laser might be really useful. [Jaz]Talking about this amlodipine induced gingival- [Reena]Technically removing that bulk, you’re actually crown lengthening, so that is technically the third type. But anyway, I mean it’s whatever works in your hands, I think at this stage it’s worth possibly starting off with a blade because it’s traditional thing to use and then exploring other systems. And why one thing I would say is don’t complicate things. Like if something works in your hands and you’re doing it well, keep things simple. Don’t have too many variations in what I call your micro steps or building blocks because then it just things start getting unpredictable. So, test everything out, go on courses and then see what works in your hands and then stick with that. [Jaz]Well at least you nicely to. Because I’ve seen so many good reviews on your course. Video testimonials, your videos that you may have been so crisp. Tell us about, I mean is it purely online? Is it a hands on as well? I mean how does that work with your course? [Reena]Yeah. So all of our courses are under perio school which I set up during the lockdown, which is really exciting. And originally perio schools all online because it happened because of the lockdown so I had to cancel my courses basically made everything online. Which has been amazing because people from all over the world have been access. We’ve got a massive community now which is really exciting. So, there’s lots of courses online. The crown lengthening one is hands on because there’s no way I think you can just learn it from watching a video. You need to come in person. We’ve got special models that we ordered from the U.S where you can remove the gum. It’s very cool. We’ve got pig’s heads obviously to get the experience of removing gum bone stitching all those kind of things. And so, the key crown lengthening course is a hands on course. It’s a one-day course usually on a Sunday. [Jaz]You’re such a geek. I love that. [Reena]Because, you know, you don’t have to give up a day of work, which is nice. And the next one’s on the 18th of July. And if you go to www.perio.school. [Jaz]And that’s on a Sunday? That was the Sunday, RIGHT? [Reena]Yeah, that’s Sunday. [Jaz]That’s good. That sounds so enticing. Okay. I will definitely take a look at that. Is that one just purely hands on? That is an online component as well? [Reena]It’s purely hands on and we literally go step by step. I mean we’ve had like new grads on that and it’s for anyone really. We’ve had people 20 years’ experience, people have just qualified. And what we do, there’s electric component and we’ll show you the bit and then you do basically explain it. Then I show you and then you do it on the pig’s head. So it’s step by step and at the end of the day you should be quite confident. Be able to go. My whole point is you go out into practice, and you can actually do a crown lengthening case. That’s the whole point. I have to say as well though there is mentoring after that as well. [Jaz]I was just going to ask about that, do you have like a secret group or something that you can post to? [Reena]Yeah, it’s just 1 to 1 to basically whenever you get case we’ll talk through it, we’ll do a quick video call, we’ll talk through the steps. Then we’ll talk about how it went after you take some pictures. It’s just till you get the confidence because the whole point of course is for me is I want the satisfaction for me is for me to you will say to me, you know, I’ve gone out and done my first case and then it’s like, yeah, I don’t want to say, oh, that was a good course and then that’s it. You want to be able to apply it. So yeah, it would be great to have anyone who’s interested on. Then if you want to go any questions just get in touch. [Jaz]I will definitely put the link on the website ASAP. So, guys check that out on a Sunday. That sounds amazing in London. And I totally echo what you said about try and get delegates through their first case ASAP and supporting them is the same with the splint course, which I set up and I just love our little community and every time someone posts a splint that are done and the color in a parafunctional analysis and stuff, it makes me so happy. And then now everyone’s taking videos of the patients saying, you know what, my headaches are gone or whatever. So, the same with you, I guess when patients send you, when dentist send you photos of their patients who they are and crown lengthening said, you must feel so proud and have that warm, fuzzy feeling inside. [Reena]It’s amazing. Makes me really happy. But also in the patients when you hear that, as you said, their reviews. Things like crown lengthening can be life changing. Don’t underestimate the value of it, whether it’s aesthetic or even restorative. You managed to save someone’s tooth. You know, the value of a tooth is huge. So, if you can have this skill, which I think is great for anyone in practice, you know, whatever specialty you and whether your general practice or it’s literally a key skill for everyone. So, it’s worth knowing about. [Jaz]We’re recording right now is June. And do you have any spaces available for July so I can message my community? [Reena]Yes, we do. We’ve got around six spaces left so it’s going to be a small group of 10. so, we’ve got a couple more spaces. [Jaz]Brilliant. I’ll get that out to everyone. I’m sure we’ll see some Protruserati on there. Reena, thank you so much for covering crown lengthening in such a great way. It’s always nice connecting with you. It’s lovely to see you there for a long while and thank you for giving up your time. We appreciate it. [Reena]Thank you so much. It’s been a pleasure. Jaz’s Outro: Well, there we are, Protruserati. I hope you enjoyed that episode with Reena all about crown lengthening. I hope you’re now able to assess your patients better and look at them with a different lens in terms of when you see someone with short clinical crowns got small teeth. Well, is it really that they have small teeth or is it that their gum never matured? Okay, so it’s a different way to look at someone. And then from there, when you make that diagnosis, some patients may actually desire, once you communicate the value of it to them, an aesthetic improvement in terms of crown lengthening or you may plan some functional crown lengthening to help improve your restorative prognosis. So, I hope you enjoyed that very much. And I’ll catch you in the next episode. As usual, please do check us out on Instagram and of course our telegram, Our special little family on telegram. It’s protrusive.co.uk/telegram to join our telegram group. Protruserati only. I’ll catch you in the next episode. Same time, same place.

Are you enjoying a fulfilling career? Is this how you imagined life would be in Dentistry? If not, are you going to do anything about it? My guest, Laura Bailey did! Growth and improvement is not linear. Taking MASSIVE action is the answer! https://youtu.be/nDloghDpYsE Check out this full video episode on YouTube! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl:  Write something down that you’re going to change in your life or your work, and then COMMIT to it until you get the desired result. I’ll say it again, commit until you get the desired result! Here with me is someone who commits to take a massive action, Laura Bailey, whom I work with on Fridays (we are both a little crazy and we love cricket – dream team!) “But you can’t expect to know everything and be able to do everything.” – Laura Bailey In this episode, we discussed: Principals taking risk with their young associates – business side, implementing treatment? Building healthy relationships with colleagues Signs to look in a clinic for young dentists/therapists to work in Taking a leap of faith Having a nurse support system Check out Laura Bailey on Instagram! If you liked this episode, you might also enjoy How to Win at Life and Succeed in Dentistry – Emotional Intelligence Click here for Full Episode Transcription Opening Snippet: Have you ever been in a situation in your clinical practice that you’ve been unhappy, or you felt something is lacking? Or you just think that where you need to be as a dentist, as a therapist, as a student, whatever you are, you’re not living to your full potential. Jaz’s Introduction: I’ve been through something similar before, and I guess I took massive action. And I don’t want to elaborate too much of my story because my guest today is just going to do so much justice with this episode and I want you to hear her story because it’s just so inspiring. I just love everything that Laura Bailey has achieved and you know, she’s going from strength to strength and I’m going to introduce her properly in a moment, but to just rewind the year a little bit with myself, when I woke up from my Saturday job was working in this mixed fixed practice, I got to a stage where I had this sick feeling in my stomach and I looked at my wife and I said “Sim, I don’t think I want to go to work today.” This is something that I’ve never felt this way forward, I’m a bit of a workaholic and I just I just felt like it was toxic, not because the practice was toxic, whatever it’s just that I at the time, in the system, in the place I was working, I felt that I was just overworked and I felt as though I was not achieving my goals as a dentist. Achieving my goals as someone who loves to learn and grow as a dentist. So, at that time I felt as though I had to take massive action. And I took massive action because I handed in my notice and eventually, we moved to Singapore, like we did something absolutely crazy. Okay, so the theme of this episode is to take massive action. Now, my favorite definition of massive action. What I mean by massive action is to commit to taking action until you get the desired result. Let me say it again, you commit to taking action until you get your desired result, and it sounds very easy to do, but how many people think of us about doing something? They toy with an idea, or the risk is too great and they and they shy away. What I mean is that you commit to something and then you work on it until it gets done okay? They make it even more tangible for you. Okay? Imagine you’re a dentist who has done lots of courses, now an implant, okay? And you’re just getting one or two implant cases a month and you’re like, whoa, this is I mean, I made this huge investment in time. I feel as though implants are my passion and I’m just not getting enough cases to actually make it worthwhile. And maybe then you lose your mojo, you lose your excitement, you lose your clinical hand skills that you paid so much money for on these courses, right? So what you going to do, are you going to just, like, you do like a bit more a marketing campaign or you fall into the trap of just continuing on and plodding on and not really getting the result you want. For example, Einstein’s definition of insanity is doing the same thing over and over again and expecting a different outcome or different results. So, if you just plodding along and you’re not really doing much, yes, you could be doing extra marketing campaigns, you could be spending an extra hour here and there doing something. But that’s not massive action. Okay, massive action for that dentist. In that exact scenario I mentioned, this is just me, just making it up. I’m just coming up with some suggestions is massive action for that dentist would be actually blocking out an entire day in their diary. Just blocking out and say this is for implants only. That’s it. I’m not going to see anything else but implants on this day. And what you would do then is on the first few days where you don’t have any patients book, right? Because you just implemented it on that day, you don’t start seeing emergencies. You don’t start going on other courses which are not related to implants. What you then do on that day is during that time slot, you work on getting more implant patients in your chair, whatever it is. Ok, whether it’s you having to then work on your marketing campaign or you having to speak to local dentist for referrals, whatever it needs to be. So, either you’re treating implant patients or you’re working on that goal to actually get implant patients to you. So that is the definition of massive action rather than just being comfortable and being doing these tiny little things which aren’t going to yield a lot of results. So that is one example. But wait till you hear this next example from Laura, you’re going to hear it from Laura. So, Laura is the therapist that I work with on Fridays. Me and her, we qualified 2013, so the same time she qualified from Manchester was in Sheffield and we met at where I work now on Fridays at the Richmond dentist with one of the, you know, the best people I could ever ask for as a principal. His name is hap, great guy, really, really forward thinking, excellent dentist, really high-end kind of stuff. We just have, you know, we have this like happy little family that worked together on Fridays and she is just so much fun you might have seen on Instagram, on TikTok. She’s just the bubbliest person. She’s just so enthusiastic and so much fun to be around. So, me and her do get along quite well. So, I’m excited to get this episode out to you. So, listen to Laura’s story. She’s a dental therapist, okay. She’s a hygienist therapist. And so, I don’t want you to think, oh yeah I’m a dentist or whatever and I’m not going to learn something. No, no, no, this is far from the truth. Okay? She is someone who went from doing very commonly hygiene only. Okay? And taking a sabbatical in her career and coming back with a vengeance. And now she’s doing so many composite bonding cases that actually that’s become probably a bigger part of the list. Then the hygiene. Okay, it’s a new problem. It’s a problem that, you know, every therapist would love to have. Okay, so many therapists they qualify and then they D skill and they stopped placing composite. Okay. Not only that but Laura like the number of courses she’s done in occlusion, in composite bonding of various different schools of thought is just inspiring. Okay so she has basically taken massive action. So, this episode, if anything, I wanted to inspire you to take massive action which is the Protrusive Dental pearl for today, you need to take massive action just like how I described. I gave you one example and now the entire case study of Laura where you can listen to now is an example of taking massive action. Take massive action today, write something down that you’re going to do, you’re going to commit to until you get the desired result. Protruserati, I’m Jaz Gulati and let’s listen to Laura on how to take massive action for success in dentistry. Laura bailey, my partner in crime, Welcome to Protrusive Dental podcast. How are you? [Laura]I’m very good, I’m so excited to be on this podcast and I was absolutely honored when you asked me. [Jaz]I’m so happy to have you on. to those that don’t know, me and Laura worked together on Fridays at the moment at the place called the Richmond Dentist, which has been our home for many years now. You started their first IN FACT I met you, I think I first met you at the Christmas party something, but let me tell everyone the story right, I don’t if you remember this, Laura. It was around about 2012 or 2013, I was newly qualified or about to qualify and I reached out to Hap as someone I really respected, we connected over twitter and he said to me, ‘Hey Jaz, why don’t you come down to our Christmas parties every year, we have a Christmas party.’ And then I saw you and we started to talk and you had just recently accepted the job I think correct me if I’m wrong in the moment you had recently accepted a job and then I found out you qualified from [manchester] thing and roughly same year and I said, wait how are you, how do you land working in this lovely private practice if you’re having a chat about that? Do you remember how I got it right, Laura? [Laura]Yeah, okay, so firstly I didn’t, I can’t even remember meeting you Jaz, I’m really sorry. If only I’d know. No, I am. Yeah, I think I just qualified for Manchester completely fresh out of uni, 2013 and moved down to London and thought I’ll just look for jobs and it’s unheard of to, you know, get walk into a private practice job. But I got this interview and I thought, why not just go along? And it was terrifying, obviously. But later that day I got offered the job and I couldn’t believe it. You know, I had no experience. But you know what happen is like he just sees an opportunity and you know, he could see that I would work well there and obviously- [Jaz]The rest is history. But you know what Laura that speaks a lot about you because you say about its unheard of to, you know, whether your dentist or like self a therapist, you know, doesn’t matter which niche within density you’re in, but you’re right, it’s very difficult to just qualify and expect a private practice role. So firstly, kudos to you for even applying, what was going through your mind when you’re applying like what would you at some point you like not click the send button because there’s no point or? [Laura]Yeah, kind of. To be honest, I did think, you know, why would they take me? I have no experience, but I think you’ve got to think. Yes, I’m just qualified and there’s probably a lot that I have to learn. But I also have you know, some good qualities in terms of like customer relations in service because I think sometimes, we forget that you know, we’re just like dentist or therapist just drilling teeth, cleaning gums. But actually, it’s so much more than it’s about building relationships, Rapport, empathy. And I think you know if you are out of uni focusing on something like that with those skills, you know, people will snap you up because you can learn the other stuff later, but having those core customer skills I think is really important. So, I think that’s what got me the job. [Jaz]You’re so right, Laura. And I think Hap really had his head screwed on, right and he still does [hap,] you’re still okay. He still has come on the podcast, he’s going to talk about how to absolutely dominate virtual consultations and stuff, so you know, he’s just making time with him. It’s funny, right, he’s my principal, and he can’t come on because it’s just such a busy guy, but he’s come on to speak about that. But with him being him, I like the fact that he had this sort of agenda to hire for attitude, right? So, he knew that he was taking a little bit risk with you and you know what? He took a risk. He took a risk with me as well because I actually interviewed for him before I went to Singapore, like informally I came dressed in my suit and he was like, ‘Jaz it’s not an interview by the way.’ I’m like, yeah, I know, but I just want to make a good effort. And he sort of said, look, I’m not because at that time, as a one man show. Him and the Endodontist, right? [Cesar. Hi, cesar.] basically he had never thought that at that time that his team would grow to what is now. So he’s now got three associates, yourself and [Lourdes,] now there’s a couple therapist. We’ve got a [Cesar, the endodontist, he’s got a big team now, right? So he’s doing a lot of the more complex stuff, which is great. And he never thought his team will expand at that time. He was the gill clinic, it was a one man show and he took a, he saw something in me, just like you saw something you and he took a risk on us.So, kudos to Hap and kudos to any principle out there who’s willing to hire for attitude and forget the fact that, okay, this might not be the fully polished article just yet. But I see a spark in that person. What do you have to say to someone who’s listening right now, who is maybe a principal and they’re worried about taking a risk with a young dentist or a therapist who’s fresh out of school? [Laura]Yeah, I mean it just goes to show, you know what, I started there in 2013, it’s 2021. I had a little sabbatical, but apart from that, I’ve worked that practice. So, when you find the right people work doesn’t feel like work, it feels like a little family. And have always says that and I think if you look for you know, the right traits and honesty, humbleness, all of that, I think you can develop that person and almost like be a mentor to them. And I think actually, you know, hiring someone straight out of uni is such a good opportunity because they have no preconceptions and you know, you can really guide them. So I would say it’s really, really great. You should definitely look in time someone. [Jaz]Brilliant. And I think I love working Fridays with you, Laura because you have such a great energy and I love your TikToks and I think we feed ideas of each other. We do stupid dances sometimes, it’s just so much fun. And one of the values of our practice is good vibes, right? And I think when I work with you and I work with [matt], when Debbie is on the desk, Lizzie, everyone’s there that day, there’s vibe like no other. So, I think every practice should aspire to that. What do you think having been in the industry while now. When you walk into the clinic, what is it that you’re looking for? that can tell a young therapist or young dentist? Okay, this is the clinic for me, any signs that you’ve noted that there is a hallmark of that kind of a clinic. [Laura]I would say obviously you don’t want, you know, a place that had a high staff turnover because that indicates potentially problems. So, you know, staff have been there for a while, years. I would say you can tell pretty quickly, it’s just good vibes. It’s exactly that you go in. You know, the reception is really friendly, really lovely and you know, they ask the right questions of you, you know, yes, they care. I think you can just pick up, it’s like 6th sense. But I think the biggest thing is the big staff being there for years and being really friendly with each other. [Jaz]I totally agree with you to staff turnover is a real shame. And it’s one of the reasons I’ve said on the podcast before, one of the reasons I joined that practice recently last year in Reading is they had this list on the front when I was interviewing of name of every single receptionist and a nurse and how many years of service they have done throughout practice and it’s like 34 years, 28 years, 24 years, 17 years, 15 years. Like it’s crazy. So that’s one thing that attracted me. And so therefore I completely agree with you, Laura, we’ll taking a little bit of a detour. I want to go back to your journey because I think your journey is so inspiring because the moral of your story. I’m not going to ruin your story. But moral of your story is you don’t have to have it all figured out so soon because one of the reason I have you on there is to inspire therapists and dentists because you do a lot of bonding cases. But most of the therapist that I know and work with and I love. So many therapists that I love shout out to Morgan from [cooper] in Summertown to love working with you and Louise. But what I find is that a lot of therapists, they are in a tough position. Yes, we will talk about the whole lack of a nurse assistance. We’ll touch on that because I think we should. I think you know this podcast has to touch on that. But I think you get into a habit of doing hygiene, hygiene, hygiene, and then the therapy this gets left behind. You don’t get to your restorations; you lose confidence and therefore you never do a restoration again. So, what I see in you is someone who had this interesting journey which we’ll cover now, but it wasn’t always, you’re doing bonding cases. You are predominately doing hygiene cases. Can you just tell us about your journey and how it evolved? [Laura]Yeah. So, I came out of university. I absolutely loved the therapy side of things. I was doing all these like buccal like restorations all incisal edges. I just love the creativity and all of that and came out and figured out that actually the world wasn’t set up that then for therapists really. So got this hygiene job. I worked in NHS practice as well as working at Hap’s space and I just felt like I was becoming a scaling machine. You know, there was no scope to do any therapy. it was just gums, gums, gums, and I felt massively out of practice. You know, the thought of picking up a hand piece was terrifying. You know, I had this fear of the pulp, which- [Jaz]That’s so true.[Laura]It’s honestly because in my final year at university, my last case presentation, I actually exposed and that haunted me and having, you know, not having picked up a hand piece for years and years and years. I thought, okay, well therapies obviously not going to happen. And I fell out of love with hygiene because you know, there is so much, you know, there’s only so much you can learn about perio and all of that and I feel like I want to constantly learn. So, I left dentistry basically. I thought I wouldn’t come back. [Jaz]That’s crazy Laura. So, what made you finally decide that, okay, that’s it? [Laura]Yeah. I think it was when I woke up in the morning and I felt like anxiety and stress the fact that I had to go and do this job and pretend to be happy to patients when I wasn’t enjoying it. And I just thought I just, yeah, which sounds, it sounds really like awful that, you know, it got to that stage, but it literally was, you know, my back hurt. I was working far too many hours. I felt absolutely drained and I just lost my passion, and I knew it wasn’t fair to patients, you know because it’s their health and all that. So, I just thought I’ve got to leave. So yeah, left and I still worked in dentistry in sort I was a clinical business development manager for a dental company. But I quickly realized that I really did miss you know patients and that interaction and you know the feeling of having a team and that family union and all of that. So yeah, so I begged Hap to give me his job back. [Jaz]I remember that, I remember that because at that point I started working for Hap and then he just sent me an email saying “Oh Laura starting in.’ I was like what? This is amazing. So, I was so happy to hear you are coming back but just to rewind a bit. Before you left dentistry, your runaway perio, your sabbatical, which is awesome by the way, I think that’s such a cool part of the story. You weren’t doing much therapy right? [Laura]None, absolutely none. [Jaz]Which is common place, right? which is like most, which is what most therapists doing, right? I think you’re in a better position to tell me. Yeah. [Laura]Yeah. Yeah there’s definitely like a movement now. But back then there was mainly just like NHS therapists and there wasn’t that many jobs going. [Jaz]My question is then, Laura, when you came back then tell me about Laura 2.0. Like what was your mindset coming back? Because there was definitely a shift, there must’ve been a change. Because when you came back you’re like right we’re going to start doing EMS Airflow, you begged Hap for it, you twist his arm and then you’re like right I’m going to do it, I’m going to do bonding cases like and I’m going to do him to the fantastic high caliber that you do it, I’m so proud of you, I love seeing your cases, but how can you give this Laura juice to all the therapists out there so they can, they can be like Laura. Like what is it like, how do you bottle that up? [Laura]To be honest, I think it was starting to see the Instagram scene, you know, people start to post more stuff and how you can market yourself and create a business. And I’ve always been kind of entrepreneurial and I thought this is really exciting, like I want to champion this. I want to do it. And I think it started it started with the EMS, the GBT, Guided Biofilm Therapy and I just thought okay if I can solve the part of hygiene, I just didn’t like which was the mindlessly ultrasonic scaling biofilm that you can’t see if I can solve that and make that really satisfying and then I can go on to maybe implementing some therapy. Then I could find a job that I’m going to be really, really happy with for a very long time for years to come. So the GBT was first because that was pretty simple. Wasn’t simple because it was obviously hard to get in but eventually it’s been amazing. [Jaz]Can we talk about that Laura? Can we talk about the conversations you have to have at work to really get Hap or get your principal to really put their trust in you to make such a big move, which is like a big business decision as well. So tell us what you guys have to do, what sacrifice you have to make or whatever to be able to make it happen. So that maybe some therapists out there now who want to maybe implement because I’m a huge fan of MES that you know, you completely converted me into just loving it what it does for our patients and our patients love it. But tell us about how it came with a fee increase, how the patients take it. How did changing the appointment slots go? Like how do you start implementing it? How do you have those difficult conversations? [Laura]I think I do find a lot of therapist hygienist they struggle with, you know, approaching their principal and all of that. And I’ve done a webinar with SDA online with EMS and it’s on their website. I think it’s about an hour. So, if you want to learn more about it. But basically, you just got to basically create your case so you need to understand all the clinical benefits but also the finances. I think we forget that dentistry is also business. It needs to function and make a profit. So, what I did was I figured out how much the room needed to make per day, how long it’s going to take us for us to pay off the machine and then how much increased price increase we need to go from there.And I think when you present it like that to a principal owner, it’s almost a no brainer because they can see how it’s going to be paid for. They can see the clinical benefits; they can see how patients going to be happier. So why would they say no, right? And in terms of increasing the prices I haven’t had one single patient complained about the prices once they’ve experienced it. [Jaz]That’s the key word once I’ve experienced it. So, they might have a little bit of backlash initially. Like what? Can you just give us a tangible. I’m like percentage wise how much did you have to increase it or just the actual numbers if you want? [Laura]Yeah, so it went from 59 for half an hour to 75. So, it is quite a lot. Yeah, and I think even now it maybe should have been a bit more and people would have still been happy to pay for it. So, I think to be honest price isn’t an issue once patients experience it. They really value the no pain, the warm water, all of that. So, I wouldn’t worry too much about price increase to be honest. [Jaz]Brilliant. Was our principal Hap concerned about the price increase or you know Hap’s mindset is pretty good when it comes to money. So I don’t know. I don’t know why how he responded. Was he completely cool with that? Yeah, let’s do it or was he a bit reserved? [Laura]He was like let’s do it. Like I trust you. [Jaz]Yeah, that doesn’t surprise us. Yeah, you need the principle with the right mindset about money because as you’ve seen the money is, there’s something Hap taught me actually that money is often a problem that the dentist has. It’s not the fee. The fee is something that is not bothering the patient. It is bothering the dentist more than anything. So that’s something that Hap taught me actually. Would you agree with that? [Laura]Yeah. You have to believe in your worth and the fees that you’re setting because otherwise patients, yeah, they sense that you know you’re not comfortable with that. [Jaz]When you came back to the Richmond dentist, and we reunited, and I’ve seen your evolution into doing more bonding which is amazing. Tell us about that. Like so tell us about how the process started, what you needed to do to get your [course cut] because I think essentially is about confidence, right? You have a sabbatical. So, okay you come back into it, you start using the EMS. Get your hand back into it. But then what made you do that quantum leap? And it is a quantum leap, right? To go, to actually outside of your comfort zone to start offering bonding to patients. Tell us about that. [Laura]Yes, so it’s probably the scariest thing I’ve ever done. You know, it’s terrifying. And a lot of it, we know when you’re starting out is faking it until you make it, you know, learning, doing YouTube videos. But you know, I just, I just booked on, you know, the top three composite courses that I, people told me about. I booked them within a very short period and I just said to myself, I’m going to deal with that and I’m going to go out the next week and I’m going to get my first patient and my first patient was my sister. [Jaz]Lovely. [Laura]Yeah. And then after that I still was a bit nervous. So, then I did a competition on Instagram. And this was not only obviously to make awareness of my treatments, but it was also to basically do treatment on a patient that would be happy with anything. That sounds bad. That was it. Like you’re getting bonding for free it’s going to be good. It might not be perfect. And yeah, and I just threw myself in the deep end and just try to learn as much as I could and obviously there’s still so much to learn. But yeah, that’s why I just took the leap. [Jaz]I love how you took that leap. And the things that really resonated me with that story and things I really want to just highlight again and repeat again is the big financial risk you took right? Initially, that okay I’m going to put these three big course. they’re not cheap right? Must spend over £3000 easily, right? To book these and time at work to book these courses. So, the huge investment you made initially and you know what a lot of dentists even go on the courses and they don’t apply what they know. So, A) you took a huge financial risk and you have to risk it okay. If you don’t risk anything, you risk everything. One of my mentors says that. And then the other thing which reminded me of a Thomas Edison quote, which is opportunity is missed by most people because it’s dressed in overalls and looks like work. Okay? And you got to work Laura, you saw this opportunity and instead of being like you know what it is going to give me sleepless nights anxiety which it does, which you will, you really just took it on board and you went for it. So, kudos to you and I love the way you did it in terms of treat someone you know, first treat a nurse, treat a family member. That’s a totally cool way to get your confidence levels up. You know, it makes so much sense and I love that you did that and then you have that competition. That’s genius. It’s truly your entrepreneurial side, showing there. That’s amazing. Anything more to add to that before we talk about then how you went further with that. [Laura]Yeah, I think probably the biggest thing is probably the occlusion side of things. I know obviously, but I think if I could go back, I would definitely learn more about that at the beginning. 100% because I don’t think I was clued up at the beginning and there was lots of like chips and little things I wish I’d know. [Jaz]Well done for telling everyone, for sharing that experience because it is so important. And I think you’re one of the only therapists I know who have gone on like a proper occlusion course. You know I’m going to put my feelers out there. If there’s any occlusion courses out there for therapists. if not that I would love to put, you know, you can do a little tag team Laura. You could do something like occlusion for edge bonding and bonding specifically for therapists because that needs to be out there, if there isn’t already. So, I think that’s such a great point. Otherwise, you will get chipping so you to appreciate that. So, tell us about which occlusion courses you’ve done and which other courses that you found helpful in your journey to be able to provide a bonding to level and the quantity that you do now. [Laura]Yeah. So, I think, so, my first course was the mini small makeover course with Depeche Palmer. That was amazing. It probably was a little bit out of my depth because it was the first course and they started talking about, you know, opaquers and tints and I was like, but then also like really, really excited. So probably that should’ve been my second course, my first and my second course after that was Monik’s totally composite. The to get two day course. I really like that. That was fantastic because it included posteriors as well. And then smilefast, which I’m a big champion of. because they have so much support for therapists in terms of the design stage. And I think that’s something that you know, therapists might struggle with a little bit because you know, we have to be able to offer the patient all the options. I can’t say to a patient, I’m offering a composite bonding because that’s all I can. Go you need to know is this patient an ortho patient? If it is, I can refer you. So smilefast have that system where they basically get told, you know, what’s appropriate treatment. So that was one of the best courses. And then Occlusion, I obviously did your occlusion 2020, but it was an absolute marathon. And then I’ve done, Raj’s occlusion day and that was so intense. Like, I’ve never heard the word like, centric like occlusion and all these things and he’s just throwing out there and I was just absolutely mind blown at the end of it. So, that was fantastic. I learned so much about cases red flags because I think that’s something that maybe therapists don’t know enough about is occlusion, you know, picking up cases that you maybe shouldn’t be treating, you know, full mouth rehab, step occlusion and all that stuff, TMJ disorders. So, I think, that was fantastic. And then recently I’m doing a postgraduate diploma in restorative aesthetic dentistry for therapists with a small academy. [Jaz]How far into that are you now, Laura? [Laura]Yeah. So, we just did our fourth day. I think we’ve got 10 over the course of the year. So, and we just did our occlusion course last weekend, which was amazing. We learned how to use face bows. [Jaz]Amazing. do you guys know any other therapist who does this level of courses? I don’t think so. So, it just shows, right. This is why Laura is doing what she’s doing. I’m going to really champion you, Laura because I love what you doing. I think it took some sacrifice. It took some risk. Okay, you are a risk taker. You are someone who is an action taker, Laura. I mean it’s clear to see that you are someone who takes a massive action. Whether it’s I’ve had enough, I’m leaving this profession to I’m going back, but I’m come back with a big vengeance. You make big decisions. And I think the key takeaway here is if you’re not happy with something, if you’re struggling with something, if you’re waking up thinking, you know, what is this really what I’m going to be doing? then take massive action, whether it’s, finding something else or going finally making a decision that you know what I’m going to do it, I’m going to take a huge risk and go on these courses to upskill and then start offering this to my patients because that’s really the, I didn’t actually title a lot of podcast episode I title before I record them. You’re one I left open because I really want to see which direction is going to go in. But it’s been so inspiring. So, I know I’m going to have a real fun time thinking about a really apt title for you. Is there anything you want to add, Laura? Because the next theme I’m going to touch on is just before we wrap up is about the whole nursing situation. But anything you want to touch on that regarding the bonding side. [Laura]Yeah, I would just say that, you know, you could never learn enough. I definitely think, you know whether you’re a dentist or therapist, I think therapists, you know, we’re trying to fight to be recognized. We always have. So, I think, you know, the more knowledge you have and the more you work with your team as well, you know, Jaz, you’re so helpful. I know I can always just walk into your room and say, hey, I’ve got this case, can we work together and all? I need your suggestions. I think being open and having good relationships with your colleagues and you know, good teamwork is so important. I know that you know, I need you guys not only just for prescription but also for your knowledge and all of that. So, I think it should always be teamwork, not just me solely working by myself because I’ll never know and now I’ll always have stuff to learn. That’s actually alright, Laura. And I think, you know you’re right, I think we do have a nice support network sometimes and I’ve got like a ceramic veneer case coming up really complex, an orthodontic case. I might just pitch it to Hap and like Hap, Am I going the right way? Equally with you we talk about bonding cases. We talk about perio cases together. And so it’s so nice to have that support network which is so key. So, if you’re, if you’re working and you feel isolated then find and that support network doesn’t necessarily have to be at the workplace if you don’t have one. There’s so many online communities. If you’re enjoying our telegram group, we’ve now got the Protrusive Dental podcast the Protruserati telegram group, which has been amazing. Like someone I like 2am asked a question about caries detection dye and by 5am. We have like five different like opinions on it like just like that. So, it’s really cool to have a-support network like that. Laura tell me about what is the situation nowadays with the whole nurse thing. Like I just found it shocking when I qualified and you know, year by year by year that hygienist therapists are working alone. Like how we even supposed to think about implementing EMS, implementing bonding when you’re working alone, it’s just not going to happen. That’s the first huge barrier. What is the state of play with that? [Laura]So, I think it’s still a little bit stuck. We’ve got a long way to go. People are definitely, you know, opening up to the idea of having a nurse. But I think, yeah, it’s still a long way to go. When I first qualified, I didn’t have a nurse, but when I came back, I basically said I want one, otherwise I’m not going to work. And I think a lot of therapists, we just need to just be firm and stand our ground and eventually things will change. You know, we shouldn’t be taking jobs that are paying, you know, really low wages and have no nursing support or anything like that because it’s just, it’s not fair on you as a clinician, but it’s also not fair on the patient. I worked the other day, I think one of our nurses was sick or whatever, so I ended up working the day without a nurse and I was exhausted. I couldn’t write my notes up properly because I was too busy cleaning. I was too busy cleaning instruments, like you need to be able to focus on the patient and the only way to do that is to have nursing support. So yeah, I think it has to be a must. [Jaz]You’re right. Last Friday was really tough actually. So, one of our nurses, she had flooding in the kitchen sort of that and I was like So, she’s coming. She’s coming. She’s coming and bless you, you have to sacrifice your nurse to come to me because I think so, thanks so much. But you’re right. You know, everyone should have a nurse and we can’t possibly tackle that in this episode. But maybe this episode will help to change the mindset of some principles who want to be forward thinking or some therapist, maybe what you’ve done here, Laura is given them that spark to help them, given that confidence is to stand their ground. Laura, this is awesome. You’ve covered all my questions. But is there anything else you want to just this episode’s been one of those inspiring ones I recorded. I really loved it. But can tell anything else? I feel like you got more in you. Is there anything any message you want about the therapist? Young therapists are starting their journey? [Laura]I think this is something that I did when I first decided to put myself out there, What you do is you’re speaking to a patient about, initially I like how you know what they want their teeth white or they want something changed and you have the conversation with them, you talking through some of the options and you tell them that you’ll write them a treatment plan, you take photos, whatever. And then when the patient leaves you go, oh my God, no, I got to learn how to do that. Because what you do, honestly, what you do is you basically set yourself here and then you give yourself two weeks to learn how to do it and then that’s how you learn and grow because that’s the only way to keep adapting. As always, I wouldn’t have done anything. You know when I first did you know 3-3 there’s I was absolutely terrified and I was as I said Googling, Youtubing asking all my peers for help. But as soon as you do it, you learned so much by doing it and you just need to put yourself out there. So, I would say, you know, take that leap of faith and just go for it. [Jaz]That was so, so, so real. That was so real. I loved it. It reminded me of another quote. Let me share this quote. Okay, so what you said there was this okay, it’s Richard Branson’s quote. ‘If someone offers you an amazing opportunity and you’re not sure if you can do it, say yes, then learn how to do it later.’ Like it’s not like you’re doing stupid stuff but it’s stuff that you have you been on the course of the stuff but it’s the first time that you’re going to do it wherever but you say yes but then you figure it out later and the same vein I’m a big fan of and this is the whole episode comeback courses and stuff I get asked by dentists all the time at which course I do blah blah. So, the main thing I want to message, I want to get out is the following that with the courses. There’s something called just in Time Learning because I know that there’s so many things, I want to learn out there. There’s so many things I don’t know and I need to learn but I can’t just like randomly wake up today. But okay today I’m going to learn about improving my root canals for curved teeth. But I haven’t got a curve tooth lined out for the next three years and I just refer them anyway. But if you actually do just in time learning i.e., you find that case who needs, who’s got that curve root first and then you say, okay, is this pushing it too much or is this slightly above and beyond my comfort zone? If you’re slightly beyond your comfort zone, you say to the patient, you can go to a specialist, but I’m happy to give it a go as well. And if the patient happy, then you go about okay speaking to mentor, speaking to endodontist, call Ammar Al Hourani and asking about curved molars, that kind of stuff. And then you give it your best shot. And in this world of defensive dentistry, I think there’s still a place for this because this is how we grow. [Laura]Yeah. You can’t expect to know everything and be able to do everything. [Jaz]Yeah, Laura absolutely love that. Thank you so much for coming to podcast. This has been absolute sensational. I want every single therapist, every single dentist in the world to hear this because this is going to be just next. I was going to get people’s people can be bouncing at the end of this episode, like, yes, I’m ready for the world, I’m going to do everything. So, thank you so much for sharing your journey, sharing your vulnerability, sharing your fears, putting yourself exposed. And I mean, that was such a lovely way. Like, thank you so much, because that’s how we inspire others. Like sharing our lowest lows in our weakest points and then and how we can build everyone up. So Laura, you’ve been absolutely amazing. Thank you so much. Jaz’s Outro:Well, thank you so much for listening all the way to the end guys. What did I say? Right. I told you Laura story would be so freaking inspiring. Like she’s just an amazing person and I just love how real she was. She was like, you know, real talk. So, I, I appreciate that so much from Laura. And if you’re a new listener to podcast, welcome. Thanks for listening. If you’re already one, the Protruserati thank you so much for returning time and time again. Make sure on our Facebook group, The Protrusive Dental community. We also have such a thriving telegram group. Initially, when someone suggested about having a WhatsApp group, I had my reservations, right? I was like, well, I just don’t want to be like another one these groups where people are just spamming the whole time or one of these dead groups where no one actually talks or whatever. And I had my reservations and then I made the WhatsApp group and it got completely oversubscribed. So now we moved to telegram, right? So if you want to join the telegram group, go to protrusive.co.uk/telegram PROTRUSIVE.CO.UK/TELEGRAM, okay. And make sure you actually have the app telegram download it. Okay. Obviously, and then that will take you to my group and you can join it and it is amazing. There’s about 270 of us at the moment and such an engaged group. People are just asking random questions, and everyone is so helpful. So, the reason I think the group works so well is that we have people who are cut from the same cloth, people who are just passionate about dentistry and just want to help each other kind of person who listens like you to this podcast. So, join the telegram group and one more favor please is if you listen on apple, would you mind giving this a rating? Okay, just give it a rating. Give me some feedback and leave a comment on Apple podcast. I really appreciate that. I’ll catch you in the next episode. I’m going to launch my podcast kind of soon and one more update is august will be a month of back to basics, like quite a few of you messages saying Jaz, I love the podcast, but some of them are really complex. Can you just dedicate some episodes to back to basics? So, I’m going to cover the perio, the basis of perio, basis of occlusion, treatment planning 101 and a few others and like the fund something fundamental like when to actually restore or when to actually drill a restoration. What actually defines leakage in Amalgams? At what point should you say? Okay, this Amalgam has failed and this amalgam is doing okay. Something so fundamental, but something that is so open to debate amongst different dentists. I’ve got a really awesome dentists coming on for that as well. Thanks for listening all the way to the end and I’ll catch you in the next episode. Same time, same place.