Protrusive Dental Podcast

Is it possible to be a Comprehensive Dentist on the NHS? How did Dr Devang Patel rise within NHS Dentistry to provide high level, complex care to his patients? https://youtu.be/Wy3NiZVa-3U Only on Protrusive Website Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl Free Communication course by Dr Devang Patel >>>click here<<<< Free for Protruserati! Sponsored: If you want to provide your patients with written treatment plans that looks amazing and are easy to understand, do a 21-day free trial of MakeMeClear and see for yourself why I love it so much. Use code ‘protrusive’ for 25% off MakeMeClear (it works after you submit payment credentials) In this episode we hear Dr Devang Patel’s journey from working in a 99% NHS clinic to now carrying out complex general Dentistry at a very high level. I quizzed him on how it’s possible in a public funded system? If you enjoyed this episode, you will like the Case Acceptance in Smile Design episode with Gurs Sehmi! Click below for full episode transcript: Opening Snippet: Because I don't think I’m still quite distant from that past because what happens I think that's what one of the issue is that everywhere you go like all the courses John West or whatever you know they all are aimed towards private dentistry. They all are either a private dentist I mean I have yet to see a mixed dentist, a dentist who's doing in a mixed NHS practice running a really big courses and promoting that. I'm sure there are out there but most of the big names are all private dentists and that leaves dentists with the illusion that okay you know we can't really do this in national health because we don't have the patience cohort and they can do it because they're NHS, they're private you know they can do whatever they like. Jaz’s Introduction: This episode is brought to you by Make Me Clear. Now makemeclear.com is a website I use to make really beautifully presented treatment plans for my patients so anytime I’m doing a bigger plan I will use make me clear you can slot in your photos your text all the diagnoses it’s got these visual charts which are nothing like the nasty ones you have on your uh software that you use at work. These are really easy to understand for the patients with a great way to communicate costs and different phases of treatment and if you haven’t already listened to episode 49 with the founder of Make Me Clear, Dr. Jorge Cardoso you should definitely check it out and listen to the value it can have for you as a dentist even if it increases your case acceptance by one patient for the whole year it’s totally worth it. So do check out Make Me Clear in fact one of the Protruserati, Robert Young had this to say Rob said “I’ve started using mmc the other day it’s a game changer for me and my practice patients love the report and communicating costs is made so much easier. ” So guys check out episode 49 and if you like make me clear do the 21 day free trial to get 25% off use the coupon code “protrusive”. So once again makemeclear.com coupon code protrusive for 25% off but see for yourself do the 21 day free trial, give the treatment plans to your patients and just see for yourself the impact it has to your practice hope you enjoy this next episode. Hello, Protruserati. I’m Jaz Gulati and welcome to this interference cast on NHS versus Private Dentistry. Now it’s not what you think it’s not the cats versus dog sort of fights that you see on social media where NHS dentists and private dentists are going at each other’s throats. None of that. It’s not happening. Think of this episode as NHS versus private in terms of is it possible to be a comprehensive dentist on the NHS? Is it possible to practice a high level of dentistry whilst also having an NHS contract? That’s the kind of burning question I want to answer today and to answer I’ve got Dr Devang Patel, who is such a brilliant dentist and you’ll hear his journey I mean he is very much a mix practice practitioner if that makes sense. He has an NHS contract but the kind of dentistry he does is definitely comprehensive, it’s brilliant. So I know that the number one issue or the number one burning problem that NHS dentists have is I want to be able to do more, I want to be able to do better for my patients but you have that blurred line that blurred boundary in terms of how can you deliver that care to the patient within the realms of the NHS contract. Now I know you know what I mean but for those of you listening from around the world you probably just listened to this and thought what the hell is Jaz talking about right? So guys this is a really an interference cast predominantly I think for UK dentists because we talk about this the way that dentists are remunerated in the UK for those who work in the public health sector which is the majority and the way that they experience challenges in terms of giving a high level of care while still being profitable or not losing money I mean it sounds really bad saying it this way but this is the truth I’m probably going to be for this reason making sure that this video is not available on YouTube publicly this will be an unlisted link. So that patients don’t come onto this because I’m not bad mouthing the NHS, we’re just going to be discussing about how we can do better while still having an NHS contract. So if you’re from listening from around the world I still think you will gain a lot from this episode and you definitely want to hang around for the Protrusive Dental pearl which is a free communication course but I’ll come to that in a moment but I think you should hang around because I think this episode does give you so much value maybe you are working in an insurance-based system or a public health system and you are frustrated then I think you will learn a lot from how Dr Devang Kumar Patel was able to speak to his patients in a way and get them on board with the fact that there’s only so much he can do within a public setting and give him options that are a bit more premium if you like. So do hang around if you think that will be valuable to you. Protruserati, boy. Do I have a Protrusive dental pearl for you okay? So this episode which is by Dr Devang Patel, he has a website and he’s got lots of courses for you to do. One of his courses which is communication in dentistry. You can get it completely free by doing the following okay? You need to go to www.protrusive.co.uk/communicationdp. The DP stands for Devang Patel. So it’s /communicationdp. When you sign in there you will get an email with the link to the course and the secret code to get 100 off the course price so this is an absolute gift so thank you so much Devang Patel for this amazing protrusive pearl you’re sharing with us today. I’ve been through a course myself. I’m actually working through it now and it’s really well set up, easy to access, bite-sized chunks, everything you want from an online course. So thank you Devang Patel to making this available for the Protruserati and now let’s dive into the main part of the episode. Devang Patel welcome to the Protrusive Dental Podcast, it’s so, so, good to have you, my friend. How are you? [Devang]I’m very well and nice to be here, Jaz I mean I listen to your podcast really all the time, I drive a lot and really good work really good product really good job. [Jaz]Thank you so much and it’s an absolute honor to have clinicians like you listening honestly it really, really, bumps up my ego a million times I guess when I think oh my god these awesome clinicians. Because one thing I was thinking about and we had a little chat beforehand, we’re emailing a little bit about your journey. And I was convinced I know I recognize this guy I think he’s taught me before and I remember that in Eastman they were doing these like what we call the section 63 or e wisdom sort of courses and it was all about taking beautiful impressions and soft tissue management around taking impressions and stuff and I really think it was you who’s doing it and it makes sense because your history between 2012 and 2014 you were teaching at the Eastman as well and I know so you really rang a bell and then to learn what you’ve been up to since then and it’s been brilliant but today’s episode we’re going to be covering a few different things. We’ll be talking a little about your journey because I think it’s very interesting journey. We’re going to be talking a little bit about the four pyramids that you sort of allude to in your email which I think is brilliant. Starting from diagnosis and the very last thing being actual that the treatment and the importance of communication which I think will be so powerful and useful. At the end we’ll talk a little bit about a very controversial subject which is how can you possibly be comprehensive in a mixed practice or a public funded system aka NHS for those of you in the UK? But before we get there just should we just start with your journey, Devang, should we just go into that because I think it’s quite special. [Devang]Yeah, well thank you I think well I graduated in 2004 in India and I wanted to do masters so I did at that time IQE to enter the UK and to be able to practice. It was a really tough exam and actually at that time I really first time experienced a nervous patient because I never seen a nervous patient in India and because they all come in when they’re in pain many times so they’re not nervous but yeah so I saw a nurse patient I mean we’ve gone through that then when I came here I realized that I had to pay sort of twice the fees if I want to get into a specialism. So I worked for six years in NHS practice doing 99.9% NHS work until I got my residency residence sort of status and then I joined, in that six years I was doing I did a one year sort of a restorative dental practice from Eastman which I really loved. I did another few couple of restorative certificates sort of a one year long courses MJDF. So I was quite active doing CPDs but the Eastman sort of rang really resonated with me their philosophy and the way they looked into detail things. So I applied for MSC in Cons which was or which is still I hope a quite popular course to go to this one. [Jaz]It’s also known as, were you married at the time? [Devang]I was. It was a marriage breaker, yes. [Jaz]It’s cool I was very tempted to actually do the conservative dentistry about four years ago but then it was also known as a divorce course so then I kind of shied away from that. So it’s a tough course for those who don’t know it is a very intense year you can tell us more about that. [Devang]Yeah I was there seven days a week but my wife was very supportive. I didn’t have my son at that time that was a good thing. Really struggled and because I was there seven days a week you know working from seven o’clock till ten o’clock. So if I basically placed an implant or did any crown prep. I made the crowns for those implants I made the sort of crowns, those simple crowns, I did the mounting, I did 100% of the work including their casting and everything. So it was a hard work but and then if you don’t do too much laboratory work you can’t do too much clinical work because it’s sort of combined so yeah it was a long hours but I mean I saw someone posted yesterday on Facebook and it was the best one year of my life really so enjoyed it and but when I applied actually Andrew Kroy still he actually picked up the phone and it was like all sides. So he talked to the course director it’s like oh you need to take this guy in so it’s like I applied it and you know he just told her can we take him in so I knew that I was in other ways it was very difficult competitive to get into there. [Jaz]Is this because of your prior study at the Eastman? [Devang]Yes because I did a certificate at Eastman and he stole my work and he was impressed with it and he actually suggested for me to do this MSC. So yeah it was good. So I did for one year and then my ego was really high you know I was like I know everything and apply for like literally 150 jobs. I didn’t get any of them because I don’t know probably because I’m not a specialist when you come out you’re kind of in the middle, you’re not a specialist and you’re kind of a bit too much for a general dentist but then yeah so I worked in a couple of prior practices a couple of days a week. I was at the same time then teaching at least last 2012 to 2014. I was a program director for restorative dental practice which I did but I was a sort of a program coordinator for certificate part and I was also deputy head of ORE for UK. So whatever I did I sort of flipped aside and I was on the other side of the spectrum and it was nice to see you know how it feels to be at the sun. I would rather be on the other side though. [Jaz]I mean oh I just want to say ORE for those listening who may not know what ore is overseas registration exam, so if you’re coming from a different country to the UK and you want to convert your dental license to a UK one so you can practice in the UK you have to do an ORE and actually Devang, a few weeks ago I did record with them with a really great dentist who actually is from Syria and he’s done his ORE and he really shared his experience about giving tips to people who are looking to do that or actually. So that episode will probably come just a few episodes before you so it’s good that you mentioned it. [Devang]Yeah it’s a tough exam not just because of the quality of the dentistry expect which is I mean I was told that we need to expect you know what general dentist would can do not the specialist can do but they’re tough is because there’s a lot of financial burden because I remember when I did my IQE which was ORE 15 years ago and it’s a lot of outlay for someone for coming from abroad, to pay from rupees to pound which is a lot of money and if you fail you have to pay a game and that’s a lot of nervousness comes from fear of failure which everyone has. But that’s a unique exam but to be honest that exam and preparation made me a better dentist because I was not very good when I finished my graduation it’s because you’re quite in a cocoon aren’t you? So you’re not really experience the outside world and all of a sudden you’re there and you need to really have a communication with patient and discuss a few things and it’s not at least in my time wasn’t taught very well. I’m not sure how it is now but when I came out all I had was a degree certificate but and some basic knowledge but nowhere near to start practicing properly. So yeah IQE prepared me up very well. So come here so I was a deputy head for ORE until my son was born so 2014 august and then I really thought okay I’m not going too much far I mean I’m just hanging about in you know doing couple two three days in practice doing teaching and I didn’t have a clear future. So at that time because I was still had two days free yet and I couldn’t get into prior practices, I sold my ego and I applied for mixed practices now because the whole point of doing MSC was I wanted to get out of NHS practice I want to do MSC, do a pro go prior practice but I’ll be really good and I can treat patients really well. So okay I sold my pride in this okay. [Jaz]But can I just stop you there because I think it’s a really great point to just interject there and just ask you for your opinion right? Because back then when I was considering doing the MSC in conservative dentistry it was also for a reason of to not only enhance my knowledge and skills but a ticket out of the NHS and into private practice but you’re speaking from experience and I know you’re not the only one I know you’re not the only one who’s done the MSC or done a significant program any MSC in the country whichever especially the Eastman one conservative and then you’re struggling to find the right job. What is that about? So what advice would you give to someone maybe you’re going to come on to it now with your experience in mixed practice but who’s but let’s do that. [Devang]Because I think when we chat about NHS and private I really want to highlight a few points but so basically I then applied for NHS sort of a mixed practice job because I was tied for cash because the thing is with the MSC I had a house, I was paying mortgage, I had no income and always there’s a lot of outlay for a year. I had really drained all my cash and I had nothing left after I finished my MSC. So I was quite cash tight and that was one of the reason I didn’t went for specialism because it was three years. You have to do three years full time and then obviously the MRD which is not a problem but three years funding mortgages without income is a difficult and job and I truly believe that if you really want to learn for me at least like I’m not a multi-tasker so I have to really concentrate on one thing. So anyway so that was the reason I applied for mixed practice and fortunately one of my friend spotted my application and he said he got me a job and he owned at that time I think. For now he owns 16 practices and that’s why I work in eight practices of his. I started working for him in 2013 late. 2013 and when I saw my son was born I went to him and I said look I don’t know I mean I’ve got these skills and I can’t really I’m doing one full month reconstruction a year. I placed like two implants last year and it’s I’m not going anywhere and it’s quite originally. He’s an ancient pangotra from alliance dental and he told me that “look you’re putting your foot into too many ships you need to really concentrate on one thing.” So then I quit Eastman teaching, quit the ORE and started visiting three practices and still working in the mixed setting. So I was contracted for 6000 UDAs a year and it was distributed into three practices and started going around and he taught me a lot of communication skills, a really fundamental communication skills and he was quite hard on me because he was my friend and he’s like a brother to me so he would literally shout at me he’s like how can you do this and so I would take it in because at that time I would like a sponge you know I’ll take everything in and I feel that I’m still am but then it improved and I’m at the stage where I’m doing two three full mouth construction every month its ongoing. I’m placing around 300 implants a year. So it gradually builds up but the skills obviously yes I’ve invested quite heavily into doing courses and I think youth was saying that you go abroad I mean I went to San Francisco so I learned endo from John West, the person who invented protaper. I learned Autogenous Bone Grafting from Kuri. So I’ve done a couple of times master class. I’ve done sausage technique from eastward urban. I went to Germany to learn soft tissue augmentation for otto and hersley were amazing so I mean the courses, they’re like ten thousand dollars a week but they’re all worth it. So invested a lot of investment and obviously here I am I mean still I’m general dentist, I’m not a specialist register, I do a lot of stuff as I was telling you I mean there was one day I remember and I took a snapshot of the day list in the morning I saw a patient for NHS patio and exam then I did autogenous bone grafting then I did a re-root canal for one of the patient then I did a composite incisal bonding then I did ortho we I had a fixed ortho so I just changed the wires and I did basically I did almost everything what dentistry involves in one day and that’s what I liked about 360 degree dentistry. Obviously I’m now more concentrated which I like as well but I felt that was really good for me to learn everything and then pick what I can do not because I can’t do the other stuff because I want to really concentrate on one thing and start improving on that because I also believe and it’s quite contralateral one point I’m saying we should learn everything. The other thing you need to concentrate on one thing and the reason is it becomes much more, more, efficient if you are doing just one thing. If you’re doing everything it does the efficiency is a tiny bit lost you know you can’t streamline things but yeah so- [Jaz]I think what you’ve achieved is the very reason why I, in the end decided not to specialize I mean for a long time if you ask me a year out of dental school I was very much looking at and making my cv and application geared towards restorative registrar training so I can become a restorative specialist because at the time I was like whoa I want to be a specialist in endo, perio right? That was like the dream but then the more I came across people like yourselves what I call super GPs, Lincoln Harris, people like you guys you’re not specialists but you guys do such high level dentistry and you guys have invested probably just as much money as someone who’s going to specialize but just in the private sector like you’ve said all these amazing people you just named in all courses you’ve done. But I also like the fact that you realize that you had to niche down so you actually found your niche so if I was to ask you what other, what is your niche now compared to a few years ago because that day list that you said highlights the variety that you could see and treat but what is your main niche now would you say? [Devang]So I’m mainly doing implant reconstruction. So implants complex bone grafting like as I said autogenous bone grafting, vertical grafting and a full mouth reconstruction restorative full mouth reconstructions. [Jaz]Do you do your own Endo? [Devang]If I’m doing a full mouth reconstruction I do my own endo, if it’s a re-root canal which is tricky I can do it if I spend like three four hours so but I record them because I think it’s fair for patients they get a better treatment quicker treatment mainly so I refer sort of a complex re-root canal treatments but all the normal and first endos I do and simple v-root canals I do myself. If I’m doing so I used to accept referrals like four years ago that was the whole point of doing John West course for endo and I used to just do simply that but again I think at some point you need to try and streamline. So I do full mouth constructions so if the patient needs braces like three of my patient currently needs ortho and I’m seeing more and more patient needing also when the full mouth reconstruction because the teeth are not in the position where you want to be and you like the heck the hell after them or just move them and just do a minor minimum dentistry so those cases I will do also myself. I still prefer fix but now I’m going into a bit more Invisalign because I’m working in eight practice it is a bit easier to manage if there’s a bracket. [Jaz]No more lost brackets. [Devang]It’s just no one knows actually in general practice how to stick a bracket in to be honest. So you know so Invisalign helps that way but again if it’s a very complex also I would rather refer patient to also don’t test the only reason I’m doing things is because it’s easy for patients you know patient coming to one dentist there’s less lack of community probably issue with communication and I know that I can give patients good results as soon as I think that there’s someone else who can get better result than me I’ll refer because it’s best for patient. [Jaz]Brilliant that’s a great little background and we’ve covered a lot of themes and just your background alone. You touched on your four pyramids before because it sounds a lot like you had a lot of hand skills and you invested in your hand skills but the point at which in your story and your origin story that it really took off is when your friend, your brother, your mentor if you like he really changed something about your communication skills. And then that’s when it sounds like you went from doing one form of full mouth rehab and two implants to doing more of what you wanted to do so tell us about what you were saying were the four parts of the pyramid because I think it’s a great analogy and where, what we can learn from that to do the kind of dentistry now you’re doing some dentists out there who say you know what I’m stuck like you were a few years ago and so I want to maybe focus more on one area of dentistry and do more of it to a high standard how can you help them? [Devang]I mean so the four I mean I would like to sort of say one thing like we’ve always seen a dentist who do lots of whitening, so another dentist will do lots of Invisalign, another dentist will do lots of onlays otherwise you’ll do lots of sort of full mouth reconstruction. How come like they are the pace they only get those kind of patients you know it’s tricky because like some people will in one practice someone will do a lot of whitening and another one will do a lot of Invisalign and it doesn’t crisscross and I think that’s because the way we want to look at the mouth and not the way we should look at the mouth because if you’re not doing ortho I can guarantee you that you will miss a lot of patient who needs ortho, adult patient obviously. If you’re not into whitening you will not feel comfortable or you will not even think about whitening as an option. These are the two most common things people miss in my experience at least. [Jaz]That’s a really great viewpoint, Devang, because it’s the same thing you see on social media as well how come this dentist is constantly posting the same treatment over again, why is everyone in Leicester in one practice in Leicester having so many of these veneers done when the other practice down the road in Leicester is just doing the simple whitening and not doing the veneers is because of you the dentist and how you see the world I completely 100% agree with you. [Devang]It is like that and I it took me long time to realize this actually you’re quite ahead of me but I think well that’s the reason and I thought that’s why I thought what’s the issue so quickly the four pyramids or four sort of pillars of dentistry I think is important is for and it is this works like this so the first is diagnosis, the second is treatment planning, third is communication and fourth is execution of your treatment. Now communication you need to think like a roof so it goes over all those four or three remaining pillar because that’s needed for every single step you can’t really just do communication on the communication bit and just forget about the rest of the time so it’s like an overarching thing and that’s why I feel the communication is the most important thing we should learn before even we could acquire the skill. Because we can always refer to person who who can do the treatment but the patient will get the best if you don’t communicate very well, patient will not get the treatment they should deserve and they will just they will not make no decision basically so and also communication is the least invested I mean how many thousands of pounds you invested in learning communication worse is how many thousands of pounds you learn that you spend learning the skills. And I think communication comes before the execution so I think that’s these four pillars are really important. [Jaz]You’re right and you can’t get your patients to because dentistry I always think dentistry is for a lot of patients a stress purchase it’s the same as when your tires in your car they need to be when you hate paying for a new tire, you hate paying for a repair in your car you just want to buy the car, you want any problems, you want to run smooth right? But when something goes wrong you have to pay a thousand pounds for your tire to get fixed. It’s a stress purchase on a similar scale dentistry for a lot of people. They crack their tooth oh a thousand pounds of crown they’re like well I’d say a thousand times a crown oh it’s a stress purchase but then when you can actually flip that around and diagnose and communicate so well that they you can make a patient realize that there’s so much more they could be having to improve their quality of life, their appearance, their chewing function, all these things and then when they realize actually yeah I want that Maserati, the Ferrari for my mouth because I want it and I want to look after it and I know what’s involved that’s when you can do the more fun dentistry. So that’s where communication comes in you know? [Devang]Yeah I mean that’s the reason I wasn’t doing many full mouth reconstruction because I couldn’t communicate to patients even though I think it’s not for aesthetic reasons it’s quite functional however we have this sort of in UK dentistry we have this we don’t want to promote too much cause because if you’re talking about cosmetic dentistry you kind of people you feel that people look at you, your colleagues that oh this guy is you know doing. [Jaz]But so do the British public. I find the British public the average patient Mrs. Smith 61 years old, who’s got a class two div two she’s always had it you know really yellow teeth, worn chipped edges, missing several teeth and you almost don’t want to raise that topic right? As a dentist you don’t want to make them feel bad about their smile because they’ve lived it with 60 years or whatever. How do you tackle that? [Devang]I mean I’ve got simple advice, take photographs and put it up in a big screen and just do say nothing just let them see it and most of the time like literally 90% of the time when patient looks at their teeth enough on the screen they are like ‘oh they are in a bad state and then now you go open gate and you can start communicating with patients. So photography is one thing which really changed my communication I really I mean tell all the practice, so I actually teach train the associates working in the practices I go as well so once I finish the day, six o’clock whatever we discuss cases because I’m there only once a week or something like that so we’ve got cases to discuss. So we discuss cases but all I tell newcomers is that start taking photographs. You can nowadays have a sim card or separate memory on your phone so you don’t need to even invest in sort of slr cameras you should but that’s a big outlay for some of the dentists just buy cheap retractors just take some photos connect it to laptop and then you know within a one month, within 15 days I think you will be able to purchase slr the top of the range because you will be communicating, you’ll be your case acceptance were will be high so I think photo, I’m not very good at I don’t think I’m very good at words in that way in that sense so photos helps me a lot and so I tend to take photos for every single patient I see. [Jaz]Amazing and I echo that as well I think photography we’ve said it before as well it’s just a huge thing and yet you still have dentists who just don’t do it. I just don’t get it I just don’t get it because I think even if you’re in an NHS practice. [Devang]Yeah I mean I had, I took a bit because you’re quite right because I think most of the objections I get from dentists like it’s time consuming. So I took a video for me to take full set of photographs, an extraoral, intraoral in three minutes and 40 seconds everything. Now I don’t take when I did general dentistry I took photographs but not every single shot for every single patient. I took six basic shots the smile photo, the retracted view, side views, occlusal and then take it from there you don’t need to really go too much until patient says yes when patient says yes with the treatment then you can take more photos later on. But so I think diagnosis when you if you go through the pillars, the diagnosis again photography is important when you’re diagnosing as well because many times I take photos and I tell patients like I’ll see you one more time because I need to really see this in detail I want to I want to sit down and really think about you know what’s going on here because sometimes when you’re really pressured with time, you really don’t want to think on the spot because you probably not doing justice to the patient because you can’t really think everything on the spot so but it’s a one thing which I think is underutilized as you said for taking photographs. [Jaz]Amazing and I think what you refer to there’s the treatment planning on the spot as Zak Kara called it a few episodes ago shotgun treatment planning and it’s not nice to be in that position and I yeah I loved it, I loved when you said that and I hate it like whenever I find someone who’s got more than one issue, new patient to practice and say yes it’s a young lady and she’s if she’s got one tooth problem or two teeth problem and generally everything’s working it’s so much easier to say okay you need this that the other communicate done but when they got multiple issues you’re really, you’re thinking and the patient’s looking at you and you’re looking confused and you’re like you’re not very sure, you don’t sound very confident. It’s so much easier and better say you know what there’s a lot of things going on here. I need more time. Let’s do this properly for you I’ve talked about already I don’t know if you heard the episode about makemeclear to make those treatment reports I’ve really enjoyed doing that as well so that’s when the fun and the beauty of it comes in so you touched on the diagnosis, we know about the treatment execution that’s all the courses that we go on, communication being the roof but really with that communication one I think you shared a really great tip there if you’re not already taking photos that’s the place to start right? [Devang]Yeah hundred percent, taking photos are the first thing even if you don’t it’s not a talkative person you don’t talk to patients much or something at least you take photographs and show it to them you they will do the most of the work patient will do the most of the work you just point and don’t speak and that will help really well and if you speak few words you know at least definitely increase the cases so but I think I cannot really stress enough and I’ve been banging about photography I mean I do teach photography as well at Eastman I used to teach but I still see it’s not really very well incorporated people are using intraoral cameras a lot now to be honest I am never a great fan of intraoral cameras in that sense. I always use slr because it’s just high quality resolution, it doesn’t take me that long to take photos. The only downside is that you need to then manually put it on the system and that takes time obviously but I think it’s a small price to pay for the quality of the photos. [Jaz]Yeah I agree I mean on that debate about intro vs dslr I mean I have both and when I’ve got Mrs. Smith in for her you know fifth time seeing her for a checkup every six months and things are good but there’s a crack tooth and I want to just quickly grab a photo and show her there and there to have a chat that’s invaluable you have to get all kit out dslr, load it, crop it to zoom in but for most for all your comprehensive cases really depends on me is your patient a general patient or are they a what we call I would call a complete patient basically and that also has a role in whether I’m just using intraoral photography but most of the time you’re right there’s nothing will beat your dslr photography. [Devang]I mean right now the intraoral is slightly better because of the AGPs how do you manage to cover the camera so I’ve got the plastic bag and all the stuff but if you have intraoral camera that’s nice to take a mid-treatment photos when you’re doing agp because you don’t want to really contaminate stuff so that’s why I think yeah it has more role now than ever before into mid-treatment. [Jaz]Brilliant before we now jump on to private versus NHS. Anything else you want to mention on the four pillars I think you really described it quite nicely you’ve given your biggest communication gem but is there anything else that you want to touch on that you think a dentist should know? [Devang]No, I think coming back to diagnosis I think diagnosis I feel is really important and I think generally dentists under treat patients because they’re not diagnosing things very well, not their fault, it’s just that it’s not very well taught as far as I can see because I can only give my reflection from the new graduate who come and join us and their skills of the teaching level because I don’t know how the teaching level of the country is but yeah diagnosis is difficult and main reason so some of them are they discuss where is one of the main thing people don’t diagnose very well if they do, they don’t do anything about it they just write down generalize where and that’s it. Full stop or maybe give mouth cut. Crowding is another thing diagnosing issues then crackling you are mentioning you know amalgam crackling but there are controversies you know and I don’t want to get into I know you really love talking about the crack teeth but but I think when to treat, when not to treat for me it’s pretty simple. I would treat it because you and I obviously tell patients give both options but if you don’t, I don’t want to be in the ship where the hole can appear any time and it will sink you know I would rather put an extra layer of a resin or something to protect myself you know so I think that’s another thing. The other thing people well diagnosed which is blatantly obvious which is Edentulism you know people have eventual spaces but I’ve seen a lot of patients who haven’t talked, they haven’t talked about implant the potential risk of teeth movement when they take the teeth out and I think this all needs to be discussed before even you take the tooth out to the patient because I think it’s just that some of the sort of a legal firms need to find out the loophole and it’s a disaster waiting to happen where patient will come to you and say why didn’t you tell me about the teeth movement when you took the teeth out, my teeth have moved now I need implants and you pay for it I had a patient actually sued the dentist for 15 year old tooth removal. So the tooth was taken out 15 years ago and everything were collapsed, so two molars were taken out on both the side the teeth were collapsed the supra eruption happened and I said well you know what I mean she had otherwise good teeth and I said well if you want to treat this space because there is a collapsed bite and everything we’re probably looking at orthodontic treat movement on the uppers move them and then potentially realign trim them and reshape them and it was a lot of treatment and the lower needed bone grafting orthogenous bone relaxation so the bill was coming into 20s 30 000 or something and she wasn’t very happy that she wasn’t told by subsequent dentists for 15 years the effect of teeth movement. She didn’t get anything for it but for her it was more like a moral issue rather than she wasn’t in for a money I told her from the beginning that look you’re not going to get anything out of it and she knows she said I know but I think dentists should be aware of this. [Jaz]Very fair point to tell. [Devang]So yes that’s I think regarding the diagnosis with the treatment planning again if you haven’t diagnosed you can’t go to the next step. If you haven’t even diagnosed the wear how you’re going to plan the treatment and when it comes to planning treatment I think most of the dentists are many times they feel that it’s their fault that the patient’s dentition is messed up and they take it personally and feel fearful again I’m talking about fuel in my experience from the dentist I teach so I’m not talking about the general dentist everyone but they fearful of telling patients that it’s going to cost tens of thousands of pounds to fix it and also the main fear they have is that if they tell patients that you’re going to need 10 fillings what if patients say yeah do all them on the NHS so because with all of the practice I visit they’re all mixed practices right so you could point out 10 things which have gone wrong and say you need 10 crowns and the patient might say okay do something. [Jaz]Let’s do it yeah absolutely it’s a bargain why not exactly that’s why one thing we’re going to talk about is how can you be comprehensive as an NHS dentist because there’s an and I don’t want to get into it too much now because there’s a few points on arrays based on some really key facts you said there I think some people some really good dentists listen right now I think they’ll need to look back at their notes template right for the examination or their custom screen whatever they use do they have a section there for diagnosis I bet a huge percentage a significant percentage of dentists will not have an area to write your diagnosis. So I think the most simple step like think of the micro step that you could do after listening to what you said there to be able to diagnose more is just simply having a box that says diagnosis because once you have a box called diagnosis then you can write your gingivitis then you can write your recession then you can write your missing lower right six upper left two upper left seven then you can write hairline cracks then you can write attrition and erosion if you don’t have that box where are you going to write it and then it gets missed it doesn’t get done and so it’s a vicious circle right but the other thing I want to ask you Devang is you’re very comprehensive dentist we can tell that because you’re diagnosing very thoroughly and you’re not afraid to tell the patient how it is like okay this is what you need and it might cost a lot of money but I’m sure you’ll you have two reactions from patients to you because if they’ve seen dentists before you who are not as comprehensive. A) they’re going to be like wow you’re so thorough I bet you get that a lot and thankfully it’s something that I get as well and I’m proud when people say that I don’t think that oh it’s because other than said that it’s because I’m trying to be as comprehensive as possible yeah but B) this is the thing I get challenged with right is that the next question they’re going to ask you is a why had no one else ever told me about this and then the other thing with that is that now when you present this suddenly big treatment plan there are some patients who think hang on a minute this page this dentist is trying to fleece me here right no other dentist ever told me this. This dentist tell me all these things, this dentist is going after my money. How can you go over that? [Devang]Yeah I’ll just quick one on the you know the you’re saying about the diagnosis thing what I because not everyone has exact I don’t know what system do you use because the exact is quite nice to write it down but what I advised every dentist is have like a sticky note and write down all the treatment like wear, whitening, ortho on the side of the computer and make sure that you checklist all of that a patient’s mouth so make sure patients have the patient go away has got this this patient need writing this so if you have all the checklist that is less likely that you will miss anything so I think checklist works really well and the dentist who used it not everyone says what I do/do what I say basically but someone people who have used it and they all are quite impressed. So coming back to your question regarding again I get that a lot that you know patients are like you know you’re very thorough and even though some most many times even if they don’t go ahead with the treatment they appreciate the fact that you’ve taken time you explain them everything and I think if you show patient photographs again I know I’m banging on the photographs but if you show patient photographs like if there’s a cracked tooth and if you show a patient a crack they can’t argue can they? They can’t say oh there is no crack. Now once you’ve done that you I’m giving them option from nothing or do nothing to do everything so I’m discussing option with patients all the options so there is no way the patient can feel that you know I had been given you know this big plan because dentist wants to make money out of me I actually had a patient I had an it’s an interesting story, so I said yesterday I saw a couple two weeks ago I saw a couple both were referred to me for consultation, implant consultation. So I saw husband first and he had the four lower and serious mobile which was patched up for a long time but the other teeth weren’t in great condition so I had a chat with him I’ve come gathered what he wanted and I said look for what you want implant is not the best thing for you, go to your general dentist have this 4 teeth extracted have a nice chrome made up and you can add the teeth in the chrome and because I cannot place implant where the other teeth are not doing really great but you can have a denture because they’re not terribly bad and they might, you might be able to hang on to them and then the next patient was his wife and I just presented to her yesterday around 42 000 pounds treatment plan and they both were sitting with me and you know they were like oh that’s a lot of money but then I told them that look husband that you came to me for implant and I think it wasn’t appropriate for you. Now what I’m telling her is appropriate for her and I mean that resonates they understood I mean before you when I spoke to them so I think if you’re genuine then you don’t get that you always get from people that oh it’s a lot of money because it is many times the treatment I do but I don’t generally get that I’m after that money because the communication because I’ve shown them the photographs do you know when I used to get that? Is earlier in my career when I never took photographs and I literally presented full mouth reconstruction cases, I only start taking photographs after patients said yes okay for my record-keeping and all the so before patients said yes I didn’t take photographs i just explained it to them and I used to get patient like I came for NHS checkup and now I’m going out with ten thousand pounds bill and this is a rubbish and all that so I should get that a lot but since I’ve started taking photographs and explaining them even though I’m taking the same amount of time probably less I don’t get that. [Jaz]Amazing. Brilliant but both points are comprehensive answer there which leads us to for the very saucy part of this episode where we’re going to try and extract from you a few gems in terms of if you’re working in a what we call in the UK a mixed practice, so there is a public funded element and a private funded element and I don’t want to get too much into the UK politics because there is an international audience here but I think the lessons we can learn you know it can apply anywhere in the world because in the US you have the insurance based systems which there are issues with that as well anywhere in the world, any system is always going to have its downside. So in the UK we have a system whereby you cannot be comprehensive because you do not get fairly remunerated for being comprehensive. So what advice can you give Devang to a dentist who wants to do more complex dentistry but they are in a run-of-the-mill busy predominantly NHS practice? [Devang]As I said before I think we were chatting and I don’t like to get into controversies so I really stay away from it and you love you say you don’t mind it so there’s a disclaimer that I’m not an expert into doing that or whatever advising I’m advising right now but what I can tell you is I can share my experience okay? So I did a mixed. I worked in a mixed practice until 2018 okay so pretty recently early 2018 so still sort of three years maybe ago and I as I said I had a 6 000 UDA target that used to pay for my left fees because I used to do a lot of implants and a lot of other work, so my regimen I’ll share what I did for my normal diary because I don’t think I’m still quite distance from that past because what happens I think that’s what one of the issues is that everywhere you go like all the courses John West or whatever they all are aimed towards private dentistry, they all are either private dentists I mean I have yet to see a mixed dentist, a dentist who’s doing in a mixed NHS practice running a really big courses and promoting that I’m sure there are out there but most of the big names are all private dentists and that leaves dentists with the illusion that okay we can’t really do this in national health because we don’t have the patience cohort and they can do it because the energy they’re private they can do whatever they like. And I had that as well but I’ve proven that wrong in eight different areas. So I’ve proven that wrong, I worked in half a share I worked in Devon. I worked in Bournemouth. So I’ve proven that because I had this limited mindset that mixed practice you can only do good private in certain areas where you have really that’s more affluent areas but perhaps exactly however it’s other way around. The more affluent areas, patients teeth are very well maintained so there’s not much work to do whereas if there’s less staff learned patient and desperate need to do have the treatment done so they will have the best treatment and if you explain properly so you’ll have more work, so I have more work in the practices which is in the less affluent areas because patients ignored their teeth and they didn’t have funding, now they have funding and they want to sort it out. So coming back to my schedule so I used to have 6000 UDAs, I did work long days. So I worked many time 8 till 8 or 8 till 6 because I worked in three practices at that time doing NHS or mixed and my checklist used to be 25 minutes so no less, sometimes 30 minutes if he’s a new patient and 30 minutes otherwise regular patient 25 minutes. In that time I used to take photographs radiographs, explain the treatment if patient wants NHS, MOD or occlusal I’ll do it there and then amalgam so it doesn’t really take that long to do amalgam. And to be honest yes you can carve the amalgam really beautifully but it’s still going to be black okay so it’s not going to just turn white if you carve them, I still carve because it’s my ego you know you really like it’s just for me patient looks at it and the thing is it’s sort of a metal feeling right so it doesn’t take that long. So I used to do 25 minutes that now if I’ve taken photographs and if I think as you say that patient needs comprehensive treatment I would tell the patient that look this is you need more than just a general dentistry. So come back and I used to see them in lunch time I’m quite renowned for not taking lunch breaks. So I used to see patient for a chat so the nurse can have a lunch and I’ll just have a chat with them and I’ll show them everything and I’ll go through all the NHS and private options so and I never told patient that the NHS is substandard because I think if you have committed to do NHS dentistry you have obligation to give patient a fair good treatment. So all my root canals NHS all private were to the apex if it’s not to the apex it’s not to the apex. It’s not because it’s NHS or private so you don’t have a card just because you’re doing an NHS treatment to do a rubbish job and I strongly feel about that and my nurses used to tell me that you know your patients are getting private treatment at NHS which because I like to sleep at night I like to make sure, good for patients. [Jaz]With root canal, Devang, I’ve just found with endodontics I found that the more you learn the more courses you do, the more you invest. You can’t unsee it. You can’t unlearn it. You can’t then ignore the fact that mb2 is right there no matter how you get remember you can’t not use your 17 edta, you can’t not do it. [Devang]Yeah so the only difference I used to tell patient is I used to do backfills I used to do you know backfill obturation for private patients and use protaper gold files versus the standard rotary files and electro condensation for NHS patients but that’s about it the rest the material was the only difference this the skill stays the same. I need to negotiate I need to negotiate the canal. So when patient comes to me initially I had that issue where okay patient’s coming now patients got number of cracked teeth and if I tell patients you’re going to need onlays for all those teeth patients might come back to me and say look do it under natural health you know why are you doing what I don’t want to spend privately and that limited me even discussing with patients unfortunately you know all that thing because I was scared if patient tells me do 10 crowns I will be ripped off basically. [Jaz]You might as well work in Tesco’s. [Devang]I have actually done in couple of patient four crowns and I’ve done four root canals and I’ve done lots of fillings in some of the patients but they are a handful you know I would say those three to five percent of the patient which sits in your head and you know just keep talking to you not the 95% which are you know you’re successful but that prevented me once I got that out of it I had one patient where I had to do the work and I thought you know what it’s not that bad you know okay yes I lost money on them but I’m making it in doing cervical you know fillings you know sometimes you do cervical abrasion filling and you get three UDAs and it doesn’t take you that long so you swings it. [Jaz]Swings around about? [Devang]Yeah you even it out um but um if you if you explain patient properly that look this is if it’s a full month reconstruction it’s pretty easy you tell patients that this is out of general dental practitioners limit I strongly feel that the fact that you invested thousands of pounds into learning something which NHS doesn’t fund you shouldn’t provide that kind of treatment under national health because it’s not your obligation to provide advanced care and I was quite strong to the patient as well I tell patients that look I can do everything I can do implants I can do autogenous bone grafting and it just doesn’t include that what NHS will include is a basic dentistry to keep your mouth going to keep it stable and this is very common known fact in medicine if you go to hospital, if you go to GP they’re quite open and upfront about NHS funding that this is not funded by NHS but for somehow NHS dentists are under illusion or given the illusion by whoever sets the rules that everything is available and it’s just minus the implant and that’s why it’s easy for me when I’m doing implant there’s no discussion but I think dentists forget that we are in a business we at the end of the day is a dentistry it’s a health business but it’s a there’s an ethical and moral dilemma you don’t want to over treat or do something to the patient just to make money but you have to struck a balance and you need to communicate that with patients so I used to tell patients like look I can do really nice crown for you. My technician charges I mean I used to use a technician from Italy so if my technician charges 280 euros and if I’m paying you’re paying me 260 pounds I cannot make money in this thing so I’ll have to use the normal technician who I can afford to use to do your treatment he doesn’t do a bad job but obviously that’s the difference and with the posterior teeth amalgams and metal sort of a non-precious or precious crowns the white crowns you can justify that is for cosmetic reasons for posteriorly and if patient asks why you just ask them why do you want white teeth for the crown at the back if patient says cosmetic reasons then it’s not available for cosmetic reasons. Protection is the same. So I think so that’s what I used to do so when I explained patient full mouth reconstruction I used to tell them that we don’t have a contract from NHS to do advanced mandatory treatment, you don’t get funded if you want I can refer you to hospital by all means and then see what they can do or I can provide you that treatment privately here. So there’s a clear distinct line there are some areas like root canal which is one of the big thing private NHS I never could convince that many patients to do private root canal because I couldn’t tell them that I’m going to do a rubbish job at NHS root canal and I never did the only I used to tell them the material I use more expensive and obviously I can’t afford to use it in the national health if I’m using I’m getting paid whatever 50, 60 quid and the other issues is obviously the correct when to intervene what to do and communicating that with patient but it’s really communication a frank communication with patient telling them that we have limited funding in that sense that what NHS can fund, NHS won’t be able to fund your full month reconstruction a really nice smile. It will give you good treatment so that it keeps ticking it’s good to keep you alive basically. So that’s but you need to have that conversation with patients. [Jaz]That’s amazing. I mean that’s probably the I’m being very honest here that’s probably the best explanation because I always found it very difficult to have that conversation even with dentists like different dentists do it differently different dentists have their own theories of and let’s be honest the way you do it is yours is the way, you saw the world and it’s the way that you made it work not in terms of just your interest but in the patient’s interest as well so they were able to choose the superior option that will you know might be more complex as well. So I think every dentist does it differently and this is because every dentist learnt to do it differently because there’s no unified guidance I mean the only guidance there is from the people high up who say there’s no difference, NHS is awesome everything’s included and that’s a pipe dream so I really like the fact that you shared that with us all I think hundreds of if not thousands of dentists in the public system will listen to this and say you know what I could do things a bit better I could spend a bit more time to explain things with better take photos and hopefully they will get better results because yes we’re working in a sub optimal system and I hope no one takes offense and saying that I think we can all take raise our hand and say okay it’s not perfect let’s agree to that okay but if we can take a few leaves from your book and read be able to apply things in a better way then that’s amazing. So, Devang, thank you so much for sharing a very diverse your journey and education to these the four pillars if you like and at the end they’re just giving us a very from the heart, from your hands, from your experience how you’ve communicated with different patients. How you can help your patients to understand that there is a difference between complex dentistry and what is maybe possible under the NHS. Any closing comments, Devang? [Devang]No. I mean I’m glad to be I mean as I said thanks for inviting me to be honest to share my experience the only thing I would say is that you know the four pillars which I said invest equally in all of them make sure you have a diagnosed treatment plan even if you can’t execute that treatment I think you should treatment plan as if you can and then refer patients to the dentist who can’t execute but don’t stop there I think you need to then learn from that dentist how to do it. So you can start doing and I’m 100% sure that whoever you’re referring cases to they will be more than happy to teach you or that you know shadow you the case you’re doing so you know go there and have a look at them communication as I said is a big thing which changed my perspective and that’s why I can really have that frank NHS private discussion because I build that rapport with patient you can’t just go and discuss that kind of thing with patient out the front you’re building rapport, patient knows you very well you know the patient and you can set the tone up as to how you are going to communicate you know you choose your word carefully because everyone thinks if you say the same word they will think different things about that word you know so you have to be very specific as to what word you’re choosing and then of course execution of your treatment so learn all the skills which I think dentists are generally good at doing or good at improving, it’s the fourth pillar but the other three it comes first that’s the whole point. Jaz’s Outro: Thanks so much. Shout out to Rishi Joshi, thanks so much for helping this happen. I really appreciate you buddy thanks so much. Well there we have it I hope you enjoyed with Dr Devang Patel as always, I really appreciate you listening all the way to the end. Now listen if you have a colleague who you think will benefit from this episode because maybe it meant a lot to you, maybe it’s got you thinking a little bit differently in terms of how you can do things differently on Monday morning with your patients and you think that this has helped you surely, this could help another one of your colleagues so please send them, WhatsApp them, email them, print them this episode. Show them how they can listen and learn from Dr Devang Patel as well and I’m sure they’ll really benefit and thank you for that. So thanks again for listening and back to straightpril now on the orthodontic episodes the website is protrusive.co.uk/communicationdp for the free communication course by Dr Devang Patel. Check it out and thanks again for listening as always.

Our views on Retention have changed over the decades – it is now regarded as a lifetime commitment and Dentist are getting good at letting patients know this from the start. In this episode, I ask Dr Angela Auluck questions from the Protrusive Dental Community as well as talking clinical steps of fiddly fixed retainers. https://youtu.be/BoZyHo9RGjY Dr Angela on Orthodontic Retention Protocols Need to Read it? Check out the Full Episode Transcript below! Protrusive Pearl: The Harridine paper helping to explain that wisdom teeth likely do not cause lower incisor crowding. In this episode we discussed: Fixed retention vs Removable Retention Why retention is individual to every patient Tips on placing Fixed retainers correctly What is the best retention on expansion cases? When should you consider a Hawley Retainer? I hope you are enjoying the Straightpril series of episodes! If you liked this episode, you will also enjoy Dahl Technique Part 2 with Tif Qureshi! Click below for full episode transcript:  Opening Snippet: Sometimes i send them back so they know that she's fussy, she's you know i'm not actually you know my therapist doesn't put my fixed retainers on for me i do them myself i'm that fussy about it so i think it's just really making sure that your technician knows what you're expecting and you're expecting a well adapted passive fit... Jaz’s Introduction: Imagine you’ve hired some builders to create a building view maybe let’s say you’re building a new dental practice okay? So these builders come and they start building the foundation and then they build the building upwards for your new dental practice. And while they’re doing this maybe they put some scaffolding everywhere to support the structures as they’re sort of building everything up and making everything join up. Now imagine the building is now complete, it’s all done but as the builders are leaving you say to the builders, wait what about all the scaffolding you know you need to get rid of the scaffolding right? It looks ugly it’s done you know take off the scaffolding and the builders say to “No if we take the scaffolding away the entire building would collapse you.” You’d freak out, you’d be like what the hell is this? What kind of building is this, that’s not stable. Well someone once explained orthodontics to me in this way we’re using that analogy and they said to me that orthodontics like what is that about? Like they get everything straight, they get everything aligned but unless you wear your retainers everything will just collapse and go crooked again and that’s when they told me this building analogy. They said orthodontists are like these people who are leaving this scaffolding behind because without the scaffolding, the building will collapse. Well our understanding of retention has changed a lot over the years. I know back in the day it’s probably the reason why we see so many relapse cases is that back in the day we thought or rather orthodontists thought that if you put everything in a stable position and everything is class one and you get the correct inter incisal angle et cetera, that everything will remain stable and retention is not really needed long term and we all know that this is completely false and that retention now the thinking is, is that retention is for lifetime. Welcome, Protruserati. I’m Jaz Gulati to this episode all about retention with Dr Angela Auluck. I mean this is a mammoth, this is a huge topic in orthodontics and in general dentistry because if they’re going to an orthodontist guess who they’re coming back? To their general dentist to maintain their fixed retainer or their attention. So I think as general dentists even if you’re not doing like orthodontics we need to be well versed in retention because this is something that affects so many of our patients. In this episode we’re going to talk about the very nitty gritty details of placing a fixed retainer about which is the most superior retainer, removable versus fixed or do you always have to do both. So I know this will be very impactful episode for those who are interested in learning more about retention protocols. Protrusive Dental pearlThe Protrusive Dental pearl I have for you is a communication one. Very often our patients will blame their lower incisor crowding on wisdom teeth they will say when my wisdom teeth came through I started to get crowding, so is this true? Well you should tell your patients, NO it’s not true because it was proven in a study by Harridine. Now in the group of Harridine et al what they did is they did a randomized controlled trial. They took people with extraction of wisdom teeth and they took people without extraction of wisdom teeth who had orthodontics and they followed them up. And they found no statistical difference in terms of the relapse that they had. So this is something that we need to explain to our patients. Now if you’re wondering if I also know a study to help disprove the lady that says that the her children sucked all the calcium out of our teeth, I don’t have that study at hand but you know what when a lady just says that to me I just ignore it I nod and we move on because what are you going to gain from arguing right? I mean what can you possibly gain from arguing in that piece of history. Just suck it up buttercup and move on is my advice anyway. Let’s crack on with this episode with Angela Auluck all about retention protocols. Main Episode:Angela Auluck, welcome to the Protrusive Dental podcast. How are you? [Angela]I’m very good. Thank you, Jaz. I’m very excited to be on your show. I listen to you a lot. It didn’t come up on my Spotify 2020 but you will in 2021. I discovered you quite late. [Jaz]We talked, we gossip about almost like GDPs versus Orthodontists and when is it okay to compromise. And that was a very controversial episode no one’s heard it and by the time this comes out people will have heard it but you know what there’s so much controversy and the same thing I said to goss is I’m going to say to you as well that when I as a GDP I started doing my diploma. In orthodontics I thought that in restorative there were different camps different opinions but the world of orthodontics is just polarized in a way there’s so many different camps and different ways to skin a rabbit and I realized that more and more when I did orthodontist. Do you feel that when you got into orthodontics that was the case as well? [Angela]I think when you’re, when you go through your orthodontic training, you actually leave there with very indoctrinated views about how you should be treating something. So I trained at the Eastman so I do things the Eastman way and you come out very confident and you’re right as soon as you come out in the big wide world. It’s almost a revelation because you then realize that actually all the orthodontists around you are all doing lots of different things and sometimes can lead to a little bit of sort of loss of confidence or questioning yourself but I think that’s a great thing. We should always be questioning ourselves, questioning what other people are doing around us. But it should always be in a collaborative manner. It should be okay well you do it like that, why do you do it like that? Is that a better way? Should I be doing it like that? So there’s nothing wrong with everyone doing things differently but I think as long as our results are good and of a certain standard, you’re right. There’s in orthodontics there’s many different ways. [Jaz]Absolutely. And just like in restorative I found that my mindset improved and I like what you said there and I’m saying that my mindset improved and I became a happier dentist once I accept it. It’s a beautiful thing in our profession, that there are so many different ways to do it. And we if we see the beauty of that rather than see the frustration then I think we can be much happier with ourselves. So definitely when I learned more about orthodontics I was like oh my goodness, I thought restorative had polarized opinions, different occlusion camp stuff but now I learned about orthodontics, I was like oh my goodness this is so varied but it’s in a beautiful way. But just a little bit about yourself Angela and just setting the scene. Tell us a little about where you practice? How long you’ve been a specialist orthodontist? For a little bit about you Angela. [Angela]So I carried out my undergraduate training at King’s and whenever I do these kinds of things I love mentioning sort of where I studied because I find it gives me a connection to other alumni so you know hopefully after people have watched this somebody might connect and say oh I went to Kings too and there’s another friend on Instagram so my undergrad training was at King’s and they were the best years I think of my life. I had such a great time there made great friends and my mentors I would still say are from there. And that’s where I was inspired to learn how to move teeth, that’s where I decided I want to be an orthodontist. After that my post-grad training was at the Eastman. I’d always known that all I wanted to do was walk through that archway for three years of my life and so I did everything I needed to do possibly do to sort of get my place for orthodontic training there. And so I’ve been an orthodontist now for 15 years and I own a practice with my husband in Wimbledon village called the Dental Rooms. It’s a specialist referral practice so we have all the specialties in one under one roof. It’s my second home, my team is my second family and all my time effort everything goes into that place and it’s the fruits of our labor, that place and I thoroughly enjoy seeing my patients there. It’s a perfect platform for me to be able to do what I really want to do which is multi-disciplinary, being part of a multi-disciplinary team, helping the others achieve what they need to achieve with their work to. [Jaz]It’s so great to be able to work as a team and you working alongside restorative dentists. What percentage of your patients are adults and what percentage of these adults that you’re treating are actually part of a bigger picture that actually after your orthodontic intervention they’re going to need a rehabilitation implants or significant restorative work? Can you just give us an idea of that? [Angela]Yes so my practice is a completely private practice and kind of leads to being seeing more adults than children. And I would say about 80% of my patients are adults and of those I would say probably about 30 to 40 percent of them are referred by one of the other specialists in the practice or are referred by somebody external to the practice but requires input from either the periodontist or the prosthodontist endodontist. But a lot of prosthodontic and also cases come together I find in our practice. It’s quite nice of the patients, Jaz I was going to say that they can sometimes end up with two or three specialists in the surgery with them. It just helps to make decisions faster and it was the patience. [Jaz]I had George Cardozo on the podcast who said very similar thing to you. He’s a prosthodontist and he just opened my eyes to the fact that I actually myself need to work more with specialists as a multi-disciplinary team because you get to have more fun as a team. But there are a few little downsides to that as well I guess. So I’m going to ask you what’s your pet peeve? What’s the thing that annoys you the most about working with restorative dentists, of prosthodontist? What’s the annoying request that you get that actually this is completely unreasonable or this is really annoying, anything you could share in that light? [Angela]So it’s always when me as an orthodontist with my orthodontist hat on thinks okay I’ve done it I’m finished I’ve got the teeth to exactly where he said he wanted them. And then they come in with their mirror or their shim stock, I hate shim stock, and they come in with their shim stock and they’re like but can you make this contact like a little bit lighter? And you’re like really? What are you talking about? It’s going to settle. Leave it, it’ll settle. And so we sometimes have that kind of banter going on in the practice but you have to respect each other’s philosophies and provide for them what they want. So yes we don’t have any arm twisting going on in the staff saying you have to say that case is finished when we see that patient together I never do that. [Jaz]I really like that example you gave because essentially the prosthodontists ask you to intrude by eight microns but it’s hilarious actually. I quite like that one. So I mean let’s dive into the massive, massive, topic of retention. So this episode is for everyone orthodontists, GDPs, students, whoever you are because retention is huge it affects everyone. So I want to start with bit of contextualizing it going back in time because you probably get the same and please tell me if you don’t, the orthodontics that I do as a GDP and yes I have a special interest got a diploma. A lot of the patients come to me most of the patients come to me and a lot of them have relapses so they’ve had relapses and I’m treating them as a second intervention of orthodontics and they all have the same kind of story like oh you know what it wasn’t emphasized enough to me or my orthodontist didn’t really encourage me enough or I didn’t know or my dog ate them and I didn’t realize I needed to wear them. Do you think there has been a generational shift in terms of what orthodontists are saying 30 years ago to what they’re saying now regarding the view on retention or are our patients lying to us? [Angela]They can’t be lying to us so the studies are actually showing us that 70% of adult patients are coming to us because they have had orthodontic relapse. Not age related changes but orthodontic relapse. 70% that’s a lot. That’s like a huge failure on the part of whoever carry is carrying out those treatments and yes I would say because they’re adults and they are mostly patients who have had their orthodontic treatment in their teen years. There has now I think been a change. Do I think historically even when I was doing my training we were taught if you place the teeth in a certain position in terms of the occlusion, in terms of the soft tissues and the periodontal tissues that it will remain stable and it was all almost sort of a hierarchical thing you were only a really good orthodontist if you could keep, if the teeth stay stable after you treated them without retainers like what madness is that now when we think about it. So there was definitely a problem in that in the way that orthodontists were taught but that those were real beliefs that that we as orthodontists as a group that we had. But I think now there is a real big realization there, the research now is so much better. We have controlled randomized, controlled trials to show us that teeth don’t stay straight so there’s a lot more research and I think less head in the clouds so yes there has been a generational change and I think actually probably a really big realization that teeth don’t stay straight, they don’t. [Jaz]Awesome. I wasn’t expecting what you’d say to that maybe I thought you would say that actually we were doing all along but no it’s good of you to say that actually there has been a change in thinking changing the evidence and that’s what we’re seeing and you’re totally right I mean so many of these patients that I’m treating with orthodontics are relapse cases adults and it’s always just the same stories you have. So I’m going to jump on to the next question and someone say if you had to have I mean have you had orthodontics Angela? [Angela]No ,well I’ve had extraction orthodontics so I have no canines. [Jaz]Okay. [Angela]No low premolars but that was it. No never a brace. [Jaz]Do you wear a retention? Do you have retention? [Angela]I don’t have a retainer. I’ve never had orthodontic treatment. I don’t have a retainer but my teeth are moving and I am on the verge of having some aligner treatment. [Jaz]Okay so let’s hypothetically speak now and let’s say you’ve had that aligner treatment for yourself, for your own mouth what would be your retention protocol and why? [Angela]Okay. So I would go for a lower fixed retainer because whenever I place a lower fixed retainer for my patients they always the reaction is always like oh that’s okay, it’s comfortable, it’s not invasive and there’s always a very positive reaction. However when I place the upper no one ever is, patients generally you can tell if you read their sort of emotions or read them the initial very first reaction it’s not comfortable or it doesn’t feel as good as the lower one. And that’s obviously to do with the occlusion and also the anatomy of the upper incisors so for the uppers I would go for a removable retainer to be worn on a part-time basis. And I think that’s also to do with the fact with the amount of risk in in which teeth are more likely to move. So in my case, my lower incisors I’ve got one that’s beginning to rotate that’s going to be more unstable I better hold that one. Also age-related changes, I’m still quite young just and I’m going to grow older and my teeth are going to move in terms of age-related changes we know it’s the lower incisors that are going to lose their alignment so why not hold those. So I would go for lower fixed and upper removable. [Jaz]Brilliant and I think I totally agree with the my patient’s perception after an upper fixed retainer and also in terms of if I was to count up all the retail fix retainer failures I’ve seen, I’ve seen disproportionately more upper fix retained fixed retainers fail than lowers even though you’d imagine that there have been more lower fixed chain is placed so it could just go to show that is there any evidence to say the failure rate of upper fixed trainers is higher than lower fixed retainers? So as far as you know I mean I don’t expect you to be an academic in any way I know you’re very wet fingered but as far as you know because that’s a difficult thing to study anyway. [Angela]Yeah it’s a difficult thing to study and in terms of retainer research I think a lot of the things that we as clinicians do when it comes to retention because there’s not that much research is it’s mostly based on our clinical experience, what works in our hands and what doesn’t so and also individual patient preference right? [Jaz]According to the evidence which is better? [Angela]In terms of fixed versus removal? [Jaz]Yes absolutely fixed versus removal which is which is the ultimate evidence-based formal retention that you would recommend or the evidence would recommend? Is there one that’s more superior significantly than the other? [Angela]Yeah so i mean there are a lot of factors when you’re looking at what’s more superior and what’s not right okay. So firstly you’re looking at how stable do the teeth remain over a period of time with either a fixed retainer or with a removable retainer. So the clinical outcome essentially so that’s one thing that you’re looking at in terms of comparing the two and the other thing you’re looking at is how is it for the patient. What is the patient preference? What is their experience? What are they more likely to get on with? So if we were actually looking at the research I’d say probably the best research that we have so far is a randomized controlled trial that’s come out of the royal London by Al Margari and all that orthodontic team they collaborated with a periodontist there and they compared stability and periodontal health with fixed and with removable retainers over a period of four years. And they did that quite recently so that paper came out in 2018, it’s a randomized control trial and they did everything perfectly. And what they found was that actually over four years the fixed retainer is better clinically in terms of holding your alignment so the clinical outcome. And in terms of periodontal health because a lot of concerns with fixed retainers is that we may be compromising the periodontal health in terms of patients aren’t able to clean properly right? But there was no difference. So the periodontal health was not great actually in both groups. So I think it goes to show that it’s important to educate our patients even in terms of oral hygiene after they’ve completed their oral orthodontic treatment but from that, and from my clinical experience I would say fixed retainers if you want to really ensure that you’re going to hold the teeth and you’re not putting it in the hands of the patients, fixed retainers. [Jaz]Brilliant. So that’s really useful to know. And actually from the periodontal literature we know that just because someone has crowding that it doesn’t necessarily mean that their periodontal health will be not as good as someone without crowding and it’s down to the patient who an actually bother so if you’re a good brusher you’re a good cleaner routinely that’s going to be true whether you’ve got crowded teeth or not. Ao the fact that you said that hang on even if they’ve got a fixed retainer or they don’t have a fixed trainer their periodontal outcomes are similar it just shows this is the it’s actually the patient themselves that need to take it upon them to do the hard work. So this leads very nicely to a clinical question. Now is if you can just because most people are listening at the moment to this while they’re chopping the onions, gardening washing dishes or whatever let’s talk about one of the most difficult things I found is when you’re newly starting to do it is a very fiddly fixed retainer that you’re placing now. I’ve tried various methods including lab made on an acrylic jig and that is really quick and easy actually but for those who have got the wires and those that sometimes you need to bend and those like the flex set ones that you don’t need to bend can you just run through which you use? And talk us through your clinical technique to placing successful fixed retainers on the lower arch? [Angela]Okay so I’m glad you said lower arch because that’s probably it’s the easiest so you don’t have the occlusion to think about right? So what I use usually well what I always use is lab made stainless steel twist flex multi-strand wire and what I asked my lab to do is to produce me a molded wire so they bent it by hand and it’s customized with a jig and it but it’s not an acrylic jig where it’s held on both sides with the canine, on the canines it’s basically a memosil jig you know? The soft memosil? So they basically make the retainer and then they position it with this memosil that hangs just over the incisal edges of the centrals yeah? So I can then basically take that off the model and then hang it exactly the same way on the lower incisors in my patient and then it is just sitting there very passively and that’s the most important thing for me is that the retainer is passive. I’m not having to push it or hold it down when I’m bonding it to the teeth okay? So now I’ve got teeth that have are prepared so I clean them I use a sandblaster after that they’ve been cleaned. Love my RONDOflex I actually have so many of those that they’re my favorite thing we have them all over the practice so I clean the teeth and then we go ahead and we bond it but I do not hold it down anywhere so I’m very particular with our lab that it should be made well. [Jaz]And just to make it really tangible and very like so we can visualize it once you’ve got the memosil on with the fix retainer in place, essentially? [Angela]Should I do next steps? Because you want to know exactly like what do I do then right? Okay so now imagine I’ve got clean teeth so I’ve tried this retainer on, I’ve checked that it’s fitting nicely I basically hold it against each tooth and make sure that it’s not having to displace, to be sitting on that tooth okay? Then I remove it we etch the teeth, on the teeth I then hang this retainer back on intraorally and I start to bond so I use light flow composite and I just start with the so if I start with the most distal tooth so if it’s canine usually you’d go lower three to three right? So I just I place some bond on that canine and my nurse cures it that’s it done. Then we do the lateral. Then I remove the memosil jig and then I just go around all the teeth centrals and then the other side. And that way you’re just really ensuring that it is passive and it’s comfortable for the patient and the teeth aren’t going to move. [Jaz]So you’re attacking and you’re putting the flowable composite on the canines first and then removing the- [Angela]I don’t do, this canine and then this canine because you can then introduce flexion in your fixed retainer so I go canine-lateral-central-central-lateral-canine I go round like that. You’re not going to start to then introduce flexion forces yeah? [Jaz]That is a real gem right there that is a real clinical pearl right there. [Angela]Then hold the wire there then you start to then hold it here it could lift up in the middle right? Then you’re going to have to push it down onto your central it’s not good. Go around. [Jaz]Well as you’re bonding it on one canine and let’s say your lower right canine and then the lateral just before you put the composite on the lateral, are you gently pushing the wire up against the teeth with the flat plastic or not at all? [Angela]No I just, at that point I would just hold the memosil jig and just make sure it’s not lifting up as in coming up but no. Don’t need to push it if it’s made well and this is where you’ve got to really get to know your technician and speak to your technician and once sometimes I send them back so they know that she’s fussy. I’m not actually, my therapist doesn’t put my fixed retainers on for me I do them myself, I’m that fussy about it. So I think it’s just really making sure that your technician knows what you’re expecting and you’re expecting a well-adapted passive fit. [Jaz]Amazing. Thanks so much for that description. Now here’s a little curveball, you’ve got your fixed retainers and you’ve beautifully described how we’re going to place it and I’ve learned something that actually just be careful not to bond the canine then the canine, it’s a great point you raised there but what about people who have had expansion because we know expansion can relapse but your fixed retainer is not going to protect from that if it’s canines canine, So what would you do, adjunctively, for these patients who’ve had expansion? [Angela]Okay so I’ll tell you what I do, right? Because there is actually no fixed or correct way, there’s just probably so many ways but I use dual retention for all my patients. So what I recommend to my patients is let’s have a fixed retainer especially if you’ve expanded everything and nothing’s going to be stable really so a fixed retainer followed by wearing a vacuum foam retainer at night time on a part-time basis so I say okay “So you’ve got your fixed retainers but we need to support the posterior teeth.” It’s all about sort of explaining to them why you’re doing and why you’re asking them to do so much. So the fixed retainer is on and they then for four months wear a nighttime retainer every night, they will then be, I’ll review them and then based on sort of their experiences because usually they haven’t worn it every night, they may have skipped tonight and they will then explain to you how tight it felt the night after they skipped tonight and you can kind of gauge by questioning them how much stability there is and then if I feel comfortable I’ll ask them to reduce the wear to alternate nights for the next four months and then eventually by the end of 12 months because I review my patients for forever almost but at the end of 12 months I would be hoping that we could get them down to one or two nights a week but it’s really, really, customized, Jaz, it’s so different for every patient because of so many factors as you know. [Jaz]Well i appreciate you giving us a like a guideline answer because that’s really helpful but then you totally raise a great point, retention should be specific for that individual patient because certain movements are always going to be less stable severe rotations and stuff you got to so that’s covered. That really nicely I appreciate that when would you, do you ever use a Hawley retainer or is that something that’s really quite old-school and there’s no place for it? Sorry if that’s a bit controversial. If you describe also for those listeners who don’t know what a Hawley retainer is as well. [Angela]Yeah good idea okay. So a Hawley retainer is a removable retainer that’s made of acrylic as the base plate and then there are stainless steel wires that are molded as cribs to hold it in for retention. So on the sixes, on the fours or the fives and then essentially there’s a stainless steel wire which is called the labial bow that runs from three to three and so you know that is traditionally what retainers were made of before we came across these vacuum formed Essex type retainers and there is still a place for them I think. I think if you’ve got a patient who has a number of teeth missing and they’re going to have a time before their prosthodontic work then Hawley retainers are quite a nice way to add context pontics to it to maintain and hold spaces you can like use little wire spurs on either side of the gentler spaces to really make sure that you don’t get closing in of the teeth into that space so retaining spaces it’s really good. It’s also really good for, if you need settling because your teeth, posterior teeth can still sort of move I would say those are probably the most times that we would use it but actually I don’t because patients who have gone to length to have treatment that’s invisible or unnoticeable or discreet and not going to thank you for giving them a Hawley retainer and you have to actually really be sure that your patients are going to wear their retainers right? I mean you’re relying on them and I just feel that in terms of aesthetics and comfort and speech dysfunction, they’re not popular. [Jaz]I agree and no one will ever thank you for giving you one of those. So I’m glad you agree with me with my views on Hawley as well. Angela, you’ve covered my main questions and I’m going to take a couple of questions from the Protrusive Dental community Facebook group. Actually some really cracking questions have been sent in. Zak, my buddy Zak, who’s done some great episodes on comprehensive care, he wants to know about he said well I’m going to actually read it out because what Zak is very wordy English you know, okay? “Can you ask about the psychological aspects of retainer wear?” I’d say he thinks it’s a grossing neglecting problem I never thought about this before, “so I rather give my patients three sets of removable retainers okay?” Design dependent on biomechanics than a fixed retainer because what he’s found, what’s Zak saying is that for fixed retainer wearers they think that oh that’s my retention done and then five years later if you get arch form collapse and then they’re relapsing all over the show that’s his own words there what could you say to Zak as an interesting sort of debate or a discussion about his viewpoint on the psychological aspects of having a fix retainer and the patient thinking that’s everything but then you can get an arch form collapse what would you say to that? [Angela]Okay I think it’s all about patient education. So the way that I handle retention is from the very first day that patient comes to my into my surgery, I talk about retention a lot at consultation probably half of my chat is about retention and it’s the first part of their treatment plan that I explained to them that okay if we move your teeth this is what we are then going to have to do in terms of maintenance, are you happy for that to happen? Are you prepared for that to happen? Because if it’s a no that conversation may either need to stop or you need to then change tactic and explain to the patient well that your teeth are going to move because there’s no other ways of guaranteeing it. So it’s a lot to do with patient education, you’ve got to consent them for moving their teeth and knowing that the risks are that their teeth will relapse if they don’t play ball with the retention part of the treatment but we’re still as orthodontists we’re still responsible for their retention I don’t think we can just put the fixed retainer on and expect them to see them in five years and think that everything’s going to be fine. So yes that’s right, they will still sometimes you can see a patient with a fixed retainer but really walked arch form because the teeth have been firstly moved in very unstable positions and then fixed retainers can also fail along the way. So for me I think the best way is to give them the fixed retainers, give them the removable retainers and then ensure that they are coming in for regular maintenance. So in my practice I have an orthodontic plan that patients join, it’s included in their package in the first year and then following that they sign up to a plan and therefore I then know that they have committed to maintaining their retention and then I do everything I can to ensure that their teeth then stay straight so they come in I check their fixed retainers I replace them if they need to be replaced we check their removable retainers and we keep re-educating them at every point. So the psyche of my patients is not that same psyche that they think they’re getting their teeth are going to stay straight once they’ve been straightened ,they are absolutely freaked out that their teeth are going to move if they don’t carry on with their retainers so I think it’s a lot to do with how we educate our patients but that’s a lot to do with how we educate ourselves and what we understand about retention and I think that’s probably one of the biggest problems at the moment but we’re all learning how to move teeth but there’s very little emphasis placed on retention. It’s actually the most important part of the plan if those teeth don’t stay straight you’re just going to keep getting patients coming back to you it’s just highly frustrating. So that’s probably you know the way to do it joint responsibility. [Jaz]Amazing. Education, joint responsibility and not just relying just on a fixed retainer there’s also that removable component to help with the arch form. Richard Mckindo actually on the group also has a different mentality and we have to respect different mentalities. Richard’s mentality as a GDP and a very good one that, Hello Richard, I know you’re listening buddy, he provides his patients with I assume it’s vivera he said three sets of removable retainers. So let’s go, let’s just talk about viveras okay? He gives his patients viveras because he feels safe in knowing that should there be a failure of retention it’s easy to then point the finger at the patient for compliance right because he feels as though if a fixed retainer fails silently then he feels that the patient will be able to point the finger at the dentist, it’s an interesting viewpoint as well. What would you say about that? [Angela]So I don’t think there should, I don’t think one should feel that that somebody’s blaming somebody else there is a solution for this. So if when you give a fixed retainer to a patient when you place that if you give them then a removable retainer that is their secure blanket okay and this is how I explain it to the patient that your fixed retainer can fail so when we get to the point where you’re only wearing your nighttime retainer one night a week, you’re doing that so that you’re actually checking your fixed retainer you’re putting it in and if it feels comfortable that’s fine your fixed retainer is doing what it needs to be doing if it feels tight you need to pick up the phone and you need to organize to come and see me because there’s something wrong your teeth are moving and it’s probably your fixed retainer’s broken and they get that in writing too. So I would say that is the way to deal with it otherwise yeah you can just put it all on the patient and give the member for their own retainers but think about it from your shoes, if I when I finish my treatment I’m not going to want to wear vivera retainers 24 hours a day for six months and then every night for the rest of my life because that is actually how they’re designed to be, retaining the teeth. I don’t think my patients would thank me for making them wear their aligners like that it’s not what I would want for myself. [Jaz]I appreciate that and also I think the answer to or not an answer but just a good valid point to this question and the last one is a belt and braces approach right? You want your fixed tension and your removal and they do their tasks together and it gets amplified and the whole patient education. So that’s all wrapped within that as a package. So last question out from rob- [Angela]One more when it comes to sort of orthodontists and GDPs it kind of feels like sometimes fixed retainers are the bane of our lives right like so patients are coming in. It’s broken again and you know then you’re having to fix it but I tell you what, if you put them on this if you have some sort of a plan where you know that you are being renumerated for fixing their retainers and they know that they’re not paying every time for an emergency appointment the psyche of psychological feeling about fixed retainers it really changes and it just becomes about okay we’re all in this together and we’re going to look after it together and you’ll get the odd patient who has come in a number of times but then you also have the odd patients who can maintain a fixed retainer for three years and nothing happens. So I think the psyche about fixed retainers has to change and it’s actually about the amount of time that we have to spend in our diaries looking after them and how we’re enumerated so I think everyone should really think about a plan, it really changes everything. [Jaz]When you said it about to seven eight minutes ago you mentioned the autonomy plan I was like oh my god this is amazing and I got sidetracked but you’re right, this plan so that there’s joint responsibility and the patient doesn’t feel like they’re paying a suddenly like a higher fee when they’re coming in when it’s broken and they sort of feel protected it’s like an insurance policy for them and it also means that you as a dentist, orthodontist are remunerated as well along the way so then it doesn’t feel like sometimes you come in and maybe it’s been seven months since you’ve placed a fixed chain and then you feel like okay I can’t possibly charge this patient because it’s been so soon but I think there’s something in it for both the dentist and the patient to have an orthodontic plan. So that is a real gem so if you guys out there are doing a fair amount of orthodontics as Angela says consider having a plan component because that will really get rid of those issues I guess. [Angela]Yeah and making sure that your patients know nothing’s for life they don’t go and have their hair colored and think they’re going to do it once and then that’s it, it’s done they need to understand there’s maintenance involved. It’s an aesthetic treatment always going to need maintenance. [Jaz]It’s the same with a composite polishing, it’s the same with teeth whitening, so it’s the same with that so I appreciate that. Last question now is for saying from Rob Arden. Hi Rob thanks for listening buddy, “does everyone have a good rule of thumb for upper anterior bonded retainers?” See Angela we couldn’t go the whole episode without discussing this very annoying thing about upper fixed retainers he says especially when occlusion means space is limited so he knows that Tif on courses and he’s just been a great guest on the podcast before and we’ve sort of discussed this a similar topic about using restorative composites. So like your nano hybrid or something like that instead of flowable and DAHLing the patients in. So Dahl as in Dahl chap who came up with the concept of bonding things in high at the front and letting the posterior settle intrusion at the front. So please refer back to episodes 16 and 17 I think it was if you guys want to listen to more about a Dahl but essentially it’s sometimes difficult because you want to make the patient as comfortable as possible so you want to actually shave that composite down so it’s not too proud but at the same time you want to have the strength but I’ve been thinking in my diploma we never discussed this technique and I’ve got a feeling that orthodontists don’t routine routinely dahl upper anterior techniques and my thinking is because and that’s actually goss as well to thank because when he came on as a guest is because part of the objectives of comprehensive orthodontics is to get the overbite correct enough so that you actually have your space right? [Angela]Yeah that’s you’ve just hit the nail on the head. It’s a great question Rob because it is like something that bothers every clinician at some point in their working time but as orthodontists when we’re training we never get really taught about short-term orthodontics or every patient is treated comprehensively which means that we are finishing them to the ideal overbite and the ideal overjet. So essentially you should always have enough space to put on a fixed retainer without it affecting the occlusion okay but in real life now we know that there are patients who are only going to who are going to request anterior alignment only maybe only upper arch treatment and firstly I think the most important thing is to know from the outset how you’re going to be finishing the inclusion and to let the patient know don’t promise them a fixed retainer when then afterwards you can’t put one on that’s really important but if are hell-bent on putting on that fixed retainer or the patient is really convinced that’s the only way they want to retain their teeth and you don’t have the space occlusally to do it then I don’t see a problem with carrying out the Dahl technique I work very very closely with prosthodontists and so I see a lot of restorative stuff going on in the practice and I see the Dahl concept it works amazingly.Sso I have no problems, sometimes for my patients when I’ve had problems with the occlusion the prosthodontist has just put on canine ramps with composite so palatally building up the palatal surfaces of the upper canines so then that that opens up the bite a little allows me space to put on the fixed retainers and then there’s a little bit of that dahling going on and again it’s just making sure that your patients understand that they’re going to have a little bit of tiny open bite at the back and that it’s going to take months for that to resolve. [Jaz]That’s fantastic and I think you raised two good points there many of many good points but the two highlight I want to highlight is a patient communication sometimes from the outset as a GDP we do compromise treatment just look on instagram right and you know that you’re not going to fully correct his overbite without committing to a comprehensive route of treatment which I think we should all open our eyes to it’s really good to do that but if you know and the patient knows that you’re compromising and then they’ve had a specialist consultation and they know what they’re getting themselves into then you know from the outset that you probably won’t have enough space so then A) communication and recognizing that and then B) you actually mentioned a really good tip about adding a composite on the canines there but if anyone’s going to do it make sure you design it in a way that the load is transmitted into the canines along the long axis which should actually help and again patient communication so that they understand what it’s going to feel like in terms of at the front and how long it’s going to settle, there are review protocols that be sort of arranged with that and a bit of contingency planning what happens if it doesn’t happen and we know it’s quite predictable but you have the odd patient where it might not happen so just have all that upfront in a really good conversation with the patient is key. Angela you’ve been absolutely fantastic I knew this would be brilliant and it has been about retention I think we’ve really covered. I’m sorry I threw some curveballs out there.. [Angela]There’s so much to talk about with retainers right? [Jaz]Easily go on, we can easily go on right because we can talk more about technique at the top we can talk about when I’ve seen some case before where the twist flexes that started to talk the teeth some years from now and stuff like that but we’re running out of time but I just want to say thank you so much for coming on to sharing all these gems. If there are some people who want to learn more from you what, where can they find out more about you’ve done quite a few lectures on tubules and whatnot do you offer any educational programs, any study clubs for dentists? [Angela]So we have the dental rooms academy and that’s part of our practice and we regularly carry out lectures there we have an in-house training facility and so we quite often once a month with pre-occupied times once a month, we were doing case discussions with every time there’s two specialists. So quite often I’m there but that’s my favorite place, my other favorite place is tubules. I love speaking on that we’ve just started an aligner panel there we’re going to be called the a-team and we’ll be talking a lot about and with Goss and a few other great clinicians so those are probably the main channels for me. So through the dental rooms academy and through tubules. [Jaz]And your instagram handle, please tell us your instagram handle. [Angela]Dr Angela Auluck so please please message me. I love that platform, it’s my favorite thing at the moment. [Jaz]And one of the reasons I also want to get you one is because you like me are a big cricket fan. [Angela]Yes I love cricket. I love cricket so it’s my children. [Jaz]I need yes I remember so I know you you’re a king’s 11 punjab fan and the ipl but your children and I think your family are Mumbai Indian fans. [Angela]They are indeed. They are indeed so they took it this time but that sort of helped keep the peace but Jaz we’re getting there that kings 11. I feel like next time is going to be our time. [Jaz]I feel like Liverpool fell for like 30 years next year is our season you know so but I’m hoping it will come true and next year it will be our season in the ipl. So Angela thanks so much once again really appreciate you coming on the show. [Angela]Thank you so much, Jaz. Jaz’s Outro: I hoped you enjoyed that with Angela. Thank you so much for listening all the way to the end. If you’re not already part of it, do join the Protrusive Dental community Facebook group where we’ve got such a a thriving community. It hasn’t got like thousands of thousands dentists, it’s got a small group but it’s all the Protruserati who enjoy the podcast and I just feel the love and the connection and the chemistry between everyone I think we’re all so helpful in this group because I think it’s like a safe little place because we’re kind of like-minded like if you listen to this you are similar to someone else who listens to Protrusive Dental podcast so if you want to find that community do join the Protrusive Dental community Facebook group I look forward to seeing you there anyway I’ll catch you in the next episode which is all about elastics in Invisalign. The do’s and don’ts of elastics and I’ll catch you same time. Same place next week. See ya!

When it comes to direct composite restorations, shape is more important than shade. Mastering primary anatomy with well defined line angles is the difference between mimicking nature or ending up with flat white blobs with no definition. In this Group Function I’m joined by Dr Matt Parsons who answers the following question from the Protruserati: Once you have drawn on the desired line angles, how would you suggest to really define them? When using bur or disc I tend to find I get a result which is rather flat and lacks line angle definition. Dr Devin Firstly, if you don’t already follow Dr Matt Parsons on Instagram….you will now, and therefore you’re welcome. It’s dental porn. https://youtu.be/CFvmFm5FhQk Dr Matt Parsons on Nailing Line Angles Need to Read it? Check out the Full Episode Transcript below! If you have any other questions that would make a good group function, please do message me on @protrusivedental Instagram page or the Facebook Page If you enjoyed this, you will like my 3 reflections on a Composite Veneer case. Click below for full episode transcript:  Opening Snippet: Hello Protruserati. I'm Jaz Gulati and welcome to this group function all about line angles this was inspired by Dr Devin Mandalia... Jaz’s Introduction: I’m going to ask Devin’s question now. So in episode 52, I gave a Protrusive Dental Pearl about the use of a pencil on its front and on its side to reveal different things about the line angles when you’re doing direct composite restorations like veneers for example. And on that YouTube video of the Protrusive Dental Pearl Dr Devin Mandalia, Devin thanks so much sending your question buddy. He says once you have drawn the desired line angles, how would you suggest to really define them? When using a bur or a disc, I tend to find I get a result which is rather flat and lacks the line angle definition so I got someone who’s absolutely phenomenal at line angles I look at Matt Parsons cases on instagram and every single case he’s absolutely nailed the line angles. And I think that is really the most fundamental thing about what defines the anatomy of your in sciences is about getting those line angles crisp and perfect so they don’t look like flat tic tacs. So Devin, I hope you enjoy and everyone hope you enjoy this group function with Matt Parsons all about how to redefine those line angles. Thanks so much. Main Episode:For those listening we need to congratulate Matty Parsons I want to say your name now so you can introduce yourself in a moment but congratulations will be becoming a father to little George who’s seven weeks old. Describe the last seven weeks for us. [Matty]A roller coaster of nappies, no sleep, screaming kind of the moment where you get home from work and Meg just looks like she’s had hit constantly all day and just kind of like throws him at me like get him off me for half an hour at least. But and he was so annoying at the same time. So he can be just crying for no reason for two hours and you’re kind of saying what is wrong with you and then he just gives you one little smile and it’s like oh you’re so annoying because now I can’t be angry with you. [Jaz]So it sounds like George might have what my son had like the whole colic term right I mean my son was pretty colic for the first three four months crying for no reason and stuff. I’ll never forget that. But don’t worry the end is in sight eventually they will grow out of it don’t worry. Well George’s awesome. [Matty]Hopefully sooner rather than later. [Jaz]We’ll have to do a fatherhood podcast another day because today is about it’s a group function about nailing those line angles. Matty your work that I’ve seen on social media is just stunning like even the full protocol cases that you post on mini smart mocova and the before and afters that we see on instagram those line angles and the anatomy is just absolutely brilliant and that’s what we need your help with today. Just tell us a little bit about yourself how you started to get involved with being the go-to guy in your area for these kind of composite restorations? How did that journey evolve? [Matty]Great question so I qualified the same year as you I think we were both presidents together you were Sheffield and I was Liverpool. And then I think maybe we went a little bit similar, I did VT and then moved abroad for a little while, so lived in Australia for a year and traveled for a little bit and by the time I then came home I’d kind of seen a different world of dentistry so rather than the six months worked as an associate before I went was UDAs and oh my god I’ve done four UDAs today that’s an awesome day and ah god that crown didn’t fit, I’ve lost myself UD and it’s just that constant treadmill of clocking these UDAs and I went to Australia where I was seeing like a dozen patients a day and taking my time and getting to know patients better and it was just like wow this is what it can be like so I got home and started basically thinking what I need to if I’m going to do this I need to up skill. And the first thing I did was go and do the Dipesh’s course, so mini smile makeover which I know you’ve done as well and like it sounds dramatic but it really isn’t that. It just changed my career I just started doing a few cases and then it snowballed and friends of those patients would come in and you know people saying oh put some stuff on instagram and I was like okay I’ll set up an instagram and then it just went from there and before it’s you’ve got to be careful that doesn’t become all you do because you’ll burn out if it is all you do. So try and still maintain a bit of a mixed bag but yeah it kind of just snowballed really and it’s nice because it’s the kind of stuff where every case you do you feel yourself learning something so it’s that exponential the more you do the better you get the more you do and it’s good. It’s nice. [Jaz]It’s been absolutely brilliant to see your evolution in the last few years. It’s good to hear your origin story and how you did one course but you know what, Matty? You know that there are so many courses out there and we go on them and the number one thing that we’ve all you and I are both guilty of and every dentist listening to this right now has been guilty of at some point in the past is they don’t apply or they don’t apply what they learn quick enough soon enough because I do think all courses and all knowledge comes with a kind of like an expiry date and if you don’t apply it soon enough then you lose your confidence, you lose your mojo, you lose that sort of enthusiasm for it and so I think part of what you said really resonates with me is not only going on the right course but then applying it and then that sort of snowballs into referrals right? Because I think it’s pretty much it started off as word of mouth before it blew up on instagram right is that fair to say? [Matty]Yeah absolutely you know treating nurses, their nurses friends and then friends of nurses friends and that kind of thing yeah but yeah. And I totally agree it’s hitting the ground running that’s the most important thing and when you go on these courses I think it’s worth maybe having a case lined up for when you get back that you think it might help you with. Make sure you get the equipment that they use in the composite you might have to spend a few quid but you do have to hit the ground running otherwise it was pointless going and then you go the other lovely thing is that then you build on it so after Dipesh’s course I went and did Andy’s course, Andy McLean and which is kind of specifically composite veneers and he works. He’s a blooming genius of what he does but he works totally differently to Dipesh so then what you start doing, it’s going well. I do like that about the way that I have been doing it from what Dipesh has taught me but that’s pretty cool Andy does so I’m going to bring that in as well and you end up finding your own kind of niche in amongst all the others. [Jaz]That’s a real gem right there because a lot of people say to me “Jaz, why did you go on so many different occlusion schools of thoughts?” But there’s no unified theory right? If you expose yourself to different theories different way of doing things you’ll be able to build your own version of the way you see the world and it’s that saying again that I said a few episodes of the Allen Matthews in Scotland, listen to everyone but do what feels right to you and that’s exactly what you do, you listen to Dipesh, you listen to it Andy and then you do you’re doing Matty and we could see that. We see your signature in every case, your photography like I could see some photos now without even seeing your name on instagram okay that’s Matty’s photography right there. So by the way if you haven’t seen Matty’s photography you have to check him out on instagram and just look at his photos look at his cases. So what we’re going to ask you today is a question sent by Devin Mandalia. Devin thanks so much sending this buddy. It’s on YouTube episode 52. It was a little video I made about line angles and basically he asked the following Matty he says, “Once you have drawn on the desired line angle,” So I think what he means is using the front end of the pencil and just drawing where you want in your mind’s eye the line angles to be. “How do you suggest to define it?” So make that pencil become the reality of the line angle and what he’s found is that when he’s using burs or discs he tends to get a result which is rather flat which is happens to all of us, happened to me loads before. What is your best advice to really get those lovely well-defined line angles? [Matty]First of all you just you touch on photography and I just need to shout out Minesh Patel, I wonder his course and he taught me everything but moving. He’s very excellent. In terms of drawing on the line angles, it is an awesome question because you see it on social media where people have drawn on where they want the line angles to be and then the next slide is that’s where the line angle is and there’s no real explanation of how they got from one to the other. Do you know this is a really kind of rubbish answer but don’t do that. Because your pencil line isn’t going to define where your composite is it should be it’s the other way around when you’re carving your composite in the first place, when you’ve got full ability to manipulate it you can nudge it this way, nudge it that way and if you go too far one way you can bring it back. As soon as you start going at it with discs and burs if you take a little bit too much out of it when you’re stuffed because then what you’re going to do you’re going to re-sandblast it, re-bond it and it’s just a nightmare so you want to really get 99% of the way there while the composite is uncured because you’ve got the flexibility and if it takes you 10 minutes to get the line angle that you want or if it takes you an hour that’s okay. We’ve booked a long appointment we know it’s going to take a while and we’ll get there while the composite is uncured then use your pencil to almost shade where the line angle is and show you exactly where it is. So use it I think you– [Jaz]So using on its side? [Matty]Exactly and you’ve picked up on that because you’ve specified about drawing with the tip of the pencil and that’s the key thing is that maybe if you look at trying to get your line angles right before you cure it then cure it then shade with the pencil kind of on its side along roughly where the line angle is and what it will do is give you a pencil line of where your line angle is right now rather than where you want it to be and then you look at that and then you modify that. So if you want to– [Jaz]So let’s go in two directions Matty, so we can talk about once you have focused a bit more time on getting the light angle while the composite is uncured and then you can shade it in and then how do you define it at that point? And then we can go back a few steps and any tips on actually how you’re managing the interproximal areas to nudge the line angle in the direction that you want and how you want it to look? [Matty]Yeah cool okay so once you’ve got the line angle on you want to change it. You need to be polishing on the side of that pencil line away from the direction that you want the pencil line to move, does that make sense? So this is tricky because this is obviously a very visual thing trying to describe with words but if you can imagine your line angle running down the tooth and let’s say this lovely arc or an exactly where you want it but in the mid third of that that pencil line. [Jaz]Let’s talk teeth. Let’s talk about an upper left central incisor and we’re talking about the mesial line angle. And then maybe use mesial and distal as or cervical and incisor as your reference points in terms of how you’re going to how we can do that would that help? [Matty]Yeah cool. So upper left one we’ve got our mesial line angle and it’s running from fairly close to the mesial incisal edge and it’s starting fairly parallel with the long axis of the tooth before then starting to curve towards the center of the tooth as it comes towards the gingival margin. That’s where we want it. Now let’s say we’ve put our line angle in and we’ve shaded with the side of the pencil and that line looks pretty good but halfway up it kind of deviates towards the midpoint of the tooth before coming back out to where you want it as an example okay? And you want to polish so with one of a few things an enhancement is really good by Dentsply and the blue flexi points are really good by Cosmedent or Enlightened you can soft like this if you rather and you know whatever you’ve got really whatever works in your hands. But you want to polish on the side of that line angle opposite to where you want it to go. So you want to be polishing kind of closer to the center of the tooth and as you polish you’ll see that line angle starts being transported kind of towards the midline if that makes sense? [Jaz]So if you’ve got a line angle that’s too far into the middle of the tooth and it’s curving too soon then you would use it more on the distal side or towards the middle of the tooth and you’re sort of using your disc or orber in that situation you tell me which is best for that situation to move the line angle closer towards the midline right? [Matty]Exactly and vice versa if you’ve got very narrow line angles that are very kind of straight and you want them curving in a little bit more and that’s where I definitely use discs. Because as soon as you, that kind of that area on the, if we’re talking about that mesial line angle of left one that area of composite mesial to that line angle is really precious like once you if you pardon my french cock that off you’ve really cocked it off and it’s difficult to come back from that so you want to when you’re just in that bit you want to take it slow and fine discs, nothing too coarse and just take your time and be patient if you’re moving it the other direction but yeah that’s it. So don’t be scared to practice will be my top tip get some models or whatever and put some composite on draw your line angles and have a play polish it this way polish it that way you’ll see draw on with your pencil polish it let it move draw on again you’ll see what you’ve done. You’ll see that it’s changed and yeah in terms of what to use I would say that the best two in my hands are enhanced burs, the disc ones. So it’s like a little five pence piece and you don’t use so it’s like a five pence piece but you don’t use the queen’s face. You use the edge of the coin if that makes sense? Are you with me? So you run it down you run it down kind of with the edge and pull down the tooth with that. All the flexi points are really good buy by Cosmedent as well for a similar kind of thing and what you get out of those which is quite nice is a little bit more random vertical texture which just adds a little bit of life likeness the enhancement you can get something that’s really perfect and homogeneous but it can sometimes look a bit too flat whereas the blue flexi points are a bit fiddlier and are going to do less but if there’s less to do then you get the advantage of a little more vertical texture and kind of randomness if you like without going over the top. [Jaz]Sometimes with line angles I’ve done it before where I’ve got it a little bit too pointy like you can almost feel with your glove finger it’s sharp almost because you’ve done all that sort of negotiation and where you want to be and then you’ve looked at his sharp point so at that point, what’s your top tip to just soften it and get that sharp point to a rounded point would it be the enhanced just running across it? [Matty]The enhance might be a little aggressive that I’ve maybe used like a fine soflex disc and almost roll it from mesial to distal over the line angle so you’re almost kind of shaving off that sharpness but saying about making a sharp angle and then softening it that is absolutely the way to do it and the way that I do it, you want when you kind of well I come back to this in a sec but it’s much easier to soften a sharp line angle than it is to define a kind of lacking line angle if that makes sense? So what you’re doing is the right thing though in my opinion that’s the way that I do and the way I find quite simple to do. [Jaz]Perfect that will help. So let’s talk about last thing then so almost going back a few steps and when you’re actually adapting your composite and you’re getting that line angle, you’re doing that 99% of the work to make your polishing easier and get that well-defined line angle. What top tips can you share with the Protruserati on that point? [Matty]As a proud member of the Protruserati if I can say it. The main thing for me is making sure that when you’re kind of placing that composite on the tooth. So we learned at uni that, let’s stick with an upper central it’s got three planes so it kind of tucks in towards the cervical, quite flat and then curves back in again at the incisal edge. When we’re working from mesial to distal we don’t have that so much, it should be flat so when we are kind of creating that, well flat-ish when we’re creating that labial aspect, we only really want to be working in two planes. So when we’re applying the composite we either want it flat on the tooth facing directly at us or say 45 degrees or so sloping away from us. So that if you were to cross-section that tooth, it would be well that composition it would be a kind of a trapezium shape if that makes sense and that the top of the trapezium so the smaller length of the trapezium should be really, really, flat and it’s really kind of a top tip is that when you’re doing this kind of work that view from the incisal edge looking in your mirror is crucial because that’s where you’re looking at have I domed the kind of restoration? So is it really kind of dominant across because then you’re not going to get that point where the composite suddenly changes direction because that’s what gives you that line angle and it’s going to be a lot more gradual into the embrasure then into the contact point so you’re not going to have that definition you might get a hint of a line angle but it’s not going to be exactly as you want it. And so as you’re applying the composite, your instrument, a little bit like when we did bridge perhaps at uni fixed bridge, your bur stays in the same angulation while you’re working you don’t deviate from that, similar kind of idea. So you’re whatever you’re using I like to use an OptraSculpt Pad to do the kind of the main labial aspect as I’m moving around the tooth that’s staying in the same plane I’m not curving it from mesial to distal, I’m smearing it left and right rather than rotating, if that makes sense? Then use something like an ipcl so a really fine carver to then almost tuck the composite then down towards the contact point and again with that what you want it in the same plane so you want it kind of then angling about 45 degrees away from that labial aspect and then once you’re there it’s very you know you have the main shape there within a minute and then you spend 20 minutes tweaking and perfecting and getting it right and but it’s much, much, easier to tweak it if it’s most of the way there already if that makes sense? [Jaz]That does make perfect sense. What’s your main method of interproximal management i.e. Mylar pull technique or do you like to put matrices in? or like most cases I guess it’s case dependent any advice you can shed on that? And that’s the last thing I’m going to really squeeze out of you. [Matty]Yeah case defendant. Mylar Pull is the kind of the go-to especially if there’s already a contact point there. that we’re kind of conforming to if you like all I’m trying to do if the teeth are already touching I’m just trying to get some composite into that contact I’m not trying to create this lovely contact because the contact’s already there and the kind of exception to the rule would be diastema closure, where we might use like a curved matrix for the gingival say third and then a mylar strip for then the rest because if you use a curved matrix for the entire thing you end up with that kind of console point where they curve down really nicely touch each other and then as you get towards the incisal edge they start curving away again and so there’s two parts to a contact point the curved aspect of the gingival margin then the flat aspect. And but yeah I’d say nine times out of ten, mylar pull and there’s loads of stuff on YouTube if you just look for mylar pull technique on YouTube there’s loads of good examples of that. [Jaz]What I’ll do is I’ll put it on the Protrusive Dental community Facebook group so people can be familiar with those but you’re right they’re Bud hopper all these people have got really good videos. I think– actually got one as well on the mylar pull technique so I’ll find that and I’ll link it. Matty, I’ve really got some great value from today and thank you so much for coming on to, to really help Devin and everyone basically with that really important daily sort of issue that we find with composites and guys if you haven’t already do check out Matty on instagram. What’s your instagram handle? [Matty]It’s ddr.matt.parsons, the classic. [Jaz]You guys should check it out. Honestly, it’s absolutely phenomenal. Matty, thank you so much I will let you go and be a father to George again. I hope you got nice things planned with him this weekend just lots of cuddles and love I’m sure. [Matty]Oh, Jaz, thanks so much. It’s an absolute honour to be on this. Jaz’s Outro: Amazing thanks so much. Thank you Matt for coming on the podcast to help us with nailing our line angles. I hope you enjoyed that guys like always follow @protrusivedental and if you have a burning question, a small issue that’s a big problem in your life then do share it with me and I’ll find someone to nail it for you so you can be a better dentist Monday morning. Thanks guys for joining me and I’ll catch you in the next episode.

How does Orthodontist Mandeep Gosal feel about GDP ‘Alignment Only Orthodontics’ – in this hilarious episode (where I compared Orthodontists to builders) Mandeep ‘Gos’ shares his thought provoking views on how Orthodontics should be carried out (and how it shouldn’t!) https://youtu.be/eH_gfNc0IqY Need to Read it? Check out the Full Episode Transcript below! This episode will be ‘unlisted’ on YouTube so it cannot be searched. For lots of reasons. Protrusive Dental Pearl: For better portrait photos (Extra-oral) – point the ring flash to the ceiling! I use F8.0, ISO 800 with my Canon 60D body, 100mm lens and Canon Ring flash. This is the difference in lighting compared to point the ring flash at the face: One of the best bits from this episode I thought was Gos’ description of the 3 types of consent being carried out for Orthodontics. Which one did you identify with? If you enjoyed Mandeep Gosal’s style of teaching, do check out his Orthodontic course for GDPs. If you enjoyed this episode, you will also like 5 Lessons from Lincoln Harris where we also discuss consent in Dentistry. Click below for full episode transcript:  Opening Snippet: The first statement I'm going to make is you cannot do any kind of compromise treatment if you don't know what the comprehensive treatment entails.. Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome to the second episode of straightpril today we have a specialist orthodontist Dr. Mandeep Gosal following on from that last episode with the general dentist, Dr. Nick Simon, who does a lot of ortho. Let’s get the specialist perspective in because what we’re talking about is alignment only orthodontics, right? How does that sit with a specialist? What do they think? And more importantly, how can we serve you the dentist listening to this who wants to do more orthodontic cases, but you’re having to accept “compromises” right? Compromises in orthodontics, I explained it a little bit in the last episode. It’s like imagine someone’s got a large overjet and they got crowding but you only treat the crowding but you leave them with a large overjet, that is a compromised, that is potentially alignment only orthodontics, but is that the right thing to do? That’s exactly why I had Mandeep on today to speak about really saucy, really controversial, really cool topic and I think ‘gos’ as we call him did a fantastic job today I think you’re in for an absolute treat. He’s no stranger or he’s not fearful of the the beautiful controversy this poses and I’m know you’re gonna find this episode really entertaining. The Protrusive Dental pearl I want to share with you is to help improve your portrait photography, right. So if you’re doing orthodontics, you’re probably already taking portrait photos, I use my normal setup my Canon body, my ring flash, my lens, my macro lens, so I’m just using it for also my portrait photography. Now, a tip that I learned from Dr. Alina Ruzanova who’s an Estonian dentist, and she creates content for ripe global, and she has this fantastic several hour anterior dentistry series on ripe global, which I highly recommend you watch and I’ll put it in the show notes. So you can click on it and find it when you go to a protrusive.co.uk website. The tip that she gave me which really improved my portrait photography with a ring flash is the following. So without having to change my flash system is instead of pointing the ring flash at the patient, when you’re taking the photo, you actually detach the ring flash and you point it to the ceiling. And that gives you a much softer lighting like just look at the photograph I’m showing you now on the screen. This is before I started using this trick. And now this is after I started doing this trick now the annoying thing now is the poor before and afters I’m getting of those patients who I saw before I change the technique. It’s annoying because the lighting is not consistent. But I think for me, this is the best way forward because now generally, the portrait photos are getting are coming out much better, much nicer to see. So the trick is to detach your ring flash pointed up at the ceiling instead of pointing straight at the patient. Now if you’re wondering what settings I’m using? I’m using f 8.0 at ISO 800 and that’s what I’m using to create my portrait photographs like the one you saw. So let’s dive in. I don’t know waste your time because this is such a brilliant episode. Hope you enjoy on catching the outro Main Interview: [Jaz]Dr. Mandeep Gosal, Welcome to Protrusive Dental podcast. How are you my friend? [Mandeep]I’m really good, Jaz. I’m really good. And you know, I’m a big fan of your podcast. So, you know, it’s an honor to be on here. I think I’m gonna really flip out I’ve written down a few phrases that if you say them, I’m just gonna absolutely lose my shit. [Jaz]Wait, that’s fine, but I can’t wait to know what the these phrases are. But honestly, I really appreciate people especially I mean, wow, you’re I mean you’re I can’t even fathom that, you know, specialists are listening to my podcast like I did from episode one. I just thought when I made it to help people transition to Singapore, and then it grew and grew and grew and honestly it’s an absolute honor that you know, a great dentist or specialist like yourself, listen, so I really appreciate that. But when you were talking with a very and I really appreciate you coming on for this, a very controversial, very saucy topic. So you know, no one likes controversy when they’re recording and stuff so I really appreciate you agreeing. You’re scaring me now. I don’t want to scare you but I think it’s really good because it is a very contentious subject. So guys, we’re talking about GDP-Ortho, and we’re talking about compromising, right. And I’ma let you tell your backstory to everyone in a minute goes but compromising is like such a nasty word that you’re compromising, you’ll give him a second grade treatment, you’re not doing good thing, but just go on Instagram and look at all the gdps that doing ortho, not all of them, but you know what I mean? Like before before I did my ortho diploma, I’d look at these cases. But all that looks great. It looks good, beautiful smile, it looks great. Now that I’ve done my diploma all still got a deep bite, oh didn’t collect the overjet, oh the canines a half unit class two like, it’s completely changed the way I look at them, which is insane. So if I’m doing that, specialists must be. I don’t know what you guys are biting. We might be biting something off every time you see this. But tell me, Gos, tell us a little about yourself and your background and where you work? [Mandeep]Well. Okay, so a bit about me, I qualified in 2003 from Sheffield, so, you know, Sheffield University alumni. And yeah, I then worked as a GDP after my brief stint in community. Or for about seven years, I worked as a GDP for seven years. Wow. I then at that stage we just had our first daughter. And it’s, and I know you’re, you know, a fairly new father as well. But it makes you reflect on your career, what kind of father figure you want to be, you know, what kind of what sort of things you want to inspire in your children. So I just thought, you know, I really always wanted to just do something, maybe specialize in something. And what I was finding was I was getting bored of single tooth dentistry a bit like yourself, you know, thinking more sort of full mouth. And it was the patients I was referring onto orthodontist that they were coming back, the sort of outcomes they were getting the sort of joy and the kind of this sort of stuff was changing their lives. And I thought, you know what, I would love to do that. Even though I had no experience I had done no, orthodontics myself. I was felt that was my calling. I had done quite a lot of PED. So I did a lot of PED and community. I actually, then when I thought you know what orthodontists might be for me, I took up a teaching post then pediatrics at King’s. So I was doing that traveling down from Nottingham to Kings just to beef up my CV ball to get a bit more experience. Because you know, I hadn’t done the DFT post, the hospital post or anything like that. So yeah, so I kind of stuck out like a sore thumb. Really, everyone else had a good career progression, you know, but life’s not like that for everybody else. You know, there’s a lot of people we leave dental school, we don’t really know what we want to do. And you kind of find something, you fall into something naturally, instead of having, you know, some people, year three of dental school, will I’m going to specialize in there. So I’m going to go do maxfacts and that’s great, but that wasn’t me. So I felt like you know, because I had then really thought through my career I thought about just make up stuff and start teaching some pediatrics and I really enjoyed the teaching side of it. I thought it was awesome. So I then applied to do orthodontics, I have to go through two years of applying to finally get on it’s very kind of cutthroat, very competitive, you know, hugely popular, you know, rightfully so. And the training is just absolutely awesome. However, the only place I got was in London, so we had to move down to London. You know, and I was just talking about yesterday with my wife, the sort of personal sacrifice you have to make to other family, not just me, you know, we had to come away, or both our families were here in the Midlands, you know, you have to go back down south in London, you know, for three years. But we carried on, you know, building our family as well, because we were both in our 30s you know, life doesn’t stop just because you’re on a specialty training program. So by the end, I started with one child, and then when I took my mo exams, I had three. So and in fact, I sat my exams and my youngest daughter was three weeks old, so and she really got me through my exams because she wouldn’t sleep at night, I would have to hold her, and I’d be revising, I’d have like, you know, profits textbook in one hand and hair on the other arms. I literally didn’t sleep for weeks. But it usually helped me because then you know, I sat my mo exams, and I ended up winning the gold medal. [Jaz]Oh, well done. I mean, I love that story. And also the personal sacrifices that you made. No one talks about that, they are so real. I mean, I recently recorded it’s not published yet with a refugee, Syrian refugee that came through UK as a dentist in Syria and then he just had the ORE exam. And just listening about the sacrifices he has to make, to be able to become a dentist in UK and then organise yourself a specialist. Having to relocate and stuff. It completely throws a spanner in the works in terms of finances, living situation, family life like wow going from one kid to three kid and also what we can learn from your story is that so many of my friends who became orthodontists, they did the very much a traditional route they qualify maxfacts, PED post, next year they applied and then they got in or whatever or the year after they got in. So that’s the traditional route you see a lot nowadays, but you know, there’s something in it for all of the people listening today who maybe are five years maybe even 10 years qualified. One of my buddies, Albs Al Moogie in Sheffield. Hey, you might know Albs he might qualified same year as you? [Mandeep]We did. Yeah, me ABS Drew, we were all in the same year. [Jaz]What a legendary year. I mean, he is now a restorative I think he by now he might be restorative specialist now. So 11 years as a GDP and then he did his registrar training in restorative. So it’s never too late. It’s got such a long career. So I mean, any regrets? [Mandeep]No, not a single one. Not a single one. You know, all the way through maybe early on if you spoke to me a few months after finishing and we had moved back to Nottingham, we had no money I had no job. I had no connections. And I was literally working you know, a few afternoons here and there. I probably would have said oh my god, I regret this. What am I done? But now you know, seven years removed after becoming a specialist then yeah none. Zero. [Jaz]Amazing and gold medal amazing. Shows your work ethic. Gold medals, like given to the person who gets like the biggest, the best results, right? [Mandeep]Yeah, that’s right. So you know, Mo Al Museun is another gold medal winner. So you know.. [Jaz]Only gold medal are on the podcast guys are only gold. [Mandeep]Honestly, you know, spoken about in the same sort of breath as Mo I think he’s pretty special. So yeah. [Jaz]He’s a really cool guy. So Mo if you listening to this, I doubt, you’re such a busy guy. But it’s great to have people like you on and so let’s dive in Gos and talk about compromising in orthodontics, GDP orthodontics. And one thing before we get into the meat of it is you spoke at that between 2003 and 2010. Now as a GDP, you didn’t do much orthodontics. Now, I’m going to pose a hypothetical scenario to you, do you know how many of your GDP friends and colleagues were doing orthodontics between those years? And if you look at it now, in the last seven years, maybe how many gdps are doing orthodontics? There must be a big difference. Do you think that in a parallel universe? If had you qualified some years later that maybe you’d be going down the GDP orthodontic route? [Mandeep]It’s funny, isn’t it? Because I’ve, I think I have posed that question to myself. You know, I’ve kind of looked at it thought when I qualified Jaz, you know, there wasn’t much in the way of courses. There wasn’t, you know, and if they were, well, how do you find out about those things? There was no social media, there was no, you didn’t have a network of dentists like you do now with tubules, and all sorts of things. You know, so it was hard to tap into things. So now I think it’s so much easier, which is great. Yeah, if you want to build your skills in a certain thing, you can do it. You don’t have to make the huge sacrifices and go sort of specialize as such. And so what I have done sort of things differently, maybe I would have dipped my toe into orthodontics first. Yeah. So maybe I would have you know, under mentorship, or you know, certificate or diploma program. You know, took on a good mentor, learn the sort of basics and then if I liked it, then gone on to do it. I think financially that would have been better. And location wise, obviously, you know, you just sort of stay where you are and you can incorporate into your own practice. But I definitely don’t regret it and in terms of the part your question about gdps doing orthodontics then and you’re doing it now, it’s exponential, it’s completely different Jaz, like it wasn’t rare at that time. Definitely not there was loads of people doing it. But it’s huge now and it’s you know, and it’s not necessarily driven by GDPs wanting to do it I think even back then, you know, GDPs want to do is it’s more accessible now, maybe wrongly or rightly driven commercially, you know, driven by companies so you know, Invisalign, huge, named as other sort of clear aligner companies out there who are you know, pumping in a lot of money. I think Invisalign advertising direct to the consumer. Yeah. So they are interacting, that they are so unique in that way, you know, you don’t get calls You know, advertising composites to patients right? No, they target the dentist. So they are this is a quality product, you need to be offering this to your patients for x y z Invisalign, or just literally go straight to the consumer. And so the consumer is coming to you asking for Invisalign. Yeah, and that’s there code for ‘give me straight teeth’ . But that’s the sort of the word really. So that’s really changed things. But also, you know, there’s I think there’s not a lot of regulation around companies. Yeah. So anyone I today between us we could develop, you know, something, it’s got brackets and wires, you know, fast braces got three wings. Traditionally, we have four wings. The speed has two wings. Well, why don’t we do five wings? Yeah, so let’s do five wings. There’s no one’s done that yet. So we’re calling the five wing, five month brace. You know, something like that. We could just do anything. [Jaz]If it’s anything like five guys is going to be awesome. [Mandeep]Yeah. You know, yeah, exactly. You know. So, I mean.., [Jaz]The one thing you haven’t mentioned that I’ve been thinking is the attitudes. I hope you don’t take offense or anyone any orthodontists like BOS take offense by this. But the attitudes of orthodontists and specialist orthodontist societies have become more tolerant. And what I mean is from following debates over the years, GDP orthodontics especially specialist, before, it was very much of a war. I felt, I mean, maybe you felt it as well, but as a GDP just watching standbys that, hey, these guys are at each other’s throats, there was publications and newspapers, you may remember all this sort of saga and whatnot. But now whether you guys want it or not, and I don’t mean it in that way. You guys have become more tolerant of that, hey, you know what they got these guys are going to do orthodontics. Let’s just now let’s become friends. And let’s help them out. And then when they need to refer, we’re here for them. Do you think that has come into it? [Mandeep]You know, you this is what I love about you, Jaz, you’re very perceptive kind of guy, you know, you’ve hit the nail on the head. In many ways, you know, a bit of a history about sort of orthodontist versus gdps. You know, under the the old fee per item program, especially in the 80s. There was a lot of GDPs doing orthodontics, mainly with removable appliances. So you would probably now see your own patients in their 50s 60s maybe even 40s, who would come in that have all premolars missing. Yet, you know, their teeth are hugely crushed in and they’ve got massive deep bites. Yeah. If you chat to them. “Have you had orthodontics before? Oh, yeah. As a teenager had some teeth out and either, but I had a removable brace.” [Jaz]Yeah. hear it all the time. [Mandeep]Yeah. So you can hear, you hear that all the time? Right? And so that and the history of that is it was a fee per item system. And in the 80s, the amount of money you got for removable appliances was huge. Yeah, he got a huge amount of money. So it was very profitable to do. And this could probably even span into the 90s. Right. But then, so what you had is gdps without much training, putting in removable appliances. And yet there was no way of monitoring quality. Yeah. So then what happened was, you know, a group of specialists in Cardiff, Manchester developed the occlusal index, like a par index to measure quality. So then they looked at past treatments, and graded them and then actually found, look, we’re doing x percentage of removable appliances. And the outcomes are absolutely rubbish. And in many cases going the opposite way. They’re going from good to bad. Because people are just doing awful treatment. So this then led this kind of loggerhead sort of, you know, moment where you had orthodontists going, hang on, this shouldn’t be right. So that’s really a bit of the sort of history. Yeah, so they then have to I think there was a court, it went to court or something, there was some sort of thing where they had to then put a stop on this kind of renumeration or removable orthodontics on the NHS. So that’s just the brief history so obviously, you know, establish orthodontists lived in that time. So they associate the GDP orthodontics with just this poor outcome removable appliances, and this that the other. I think now fast forward to 2020 Yeah, so now if we think about things, and GDP, we’re still doing lot more fixed appliances. Yeah. GDP is now for me, it’s the orthodontics they’re doing is privately driven. Yeah, there’s no more kind of, there’s not a lot of orthodontics done by gdps on the NHS. So, you know, if you’ve got patients now paying for treatment, they want a great outcome. Yeah. So it’s kind of almost this kind of circle where the outcomes got to be good. So the quality is got to be good. So now the pressures now on the GDP to go right, is this within my scope of practice? How do I now teach myself how to do this, how to teach myself how to do that? So I think, you know, and that’s the modern way of sort of thinking. So I think things have evolved. You know, the old guard is now moved on, you know, it’s the new Young Guard moving in. And I think we’ve all realized that actually, with all these companies now coming in, you know, people like, — huge when I sort of did it, you know, and for me, I’m hopefully they’re almost disappearing, because this was, you know, I am going to be on it, we’re going to be controversial. No, tell it, Jaz, the people doing — 10 years ago, are now promoting other sort of product. They don’t do — any more. Ask yourself why. It’s awful. Yeah. Because there is no, there is because within that it is just a lab driven, commercially driven system. Yeah. And you take impressions of anything or anyone, you take impressions of your dog tomorrow. You know, your Punjabi you probably haven’t got a dog. You know, but if you take the impression of your dog and you send it to that lab, they’re gonna fit it with braces. Yeah. Because there’s no one overseeing it. There’s no mentorship there. You know, so really, you know, so those days are gone. [Jaz]I think that was such a diplomatic answer, but then I only came to the end. I love that you said that. I love everything you said. I love it. It’s from the heart and I appreciate that but I will probably have to get my producer John Can you put beep makes it a company name I don’t want Protrusive Dental podcast get sued. But I love it. You know and for those who are not in our close circle, you can ask me which orthodontic system he was referring to, I’ll tell you but so that we don’t get into trouble here gos. I’m probably going to beat that one out. But hey, look all these terms right like SEO, short term orthodontics. I quite like the term AAO alignment. AOO, Alignment only orthodontics. Call it what you like different brands out there. CFast, Six Months smiles. What’s premiers ones called? Quick straight teeth. Quick straight teeth, and all so many around the world. So many of these systems. What do you think, Gos, about gdps and alignment only orthodontics as a sweeping statement? What’s your feeling as a specialist about that? [Mandeep]Personally, I think there’s too many terms. Yeah, there’s, I know you like anterior alignment orthodontics. Yeah, that’s fine. Hopefully I’m gonna change your mind in a few minutes. Yeah. But then you’ve got cosmetic orthodontics you even a few years ago had the European Society of aesthetic orthodontics. What the hell is that? Yeah, of course. Why? Because orthodontics is its aesthetic. So why do we need another kind of like? So it’s all this all, and also, if we as clinicians find it confusing, imagine if you’re a patient. Yeah. So you’ve Corinne and you see someone and you’re like, Okay, seeing a specialist. And he’s told me I need x y z. I’ve now gone and seen this other guy. And he said, he does cosmetic orthodontics. Awesome, because that’s what I want. This guy obviously knows much more than this person. So for me, and I always say it on Facebook is if someone like brings up these terms. orthodontics is just orthodontics. Yeah, that’s it. So if you’ve what you’ve done, if you’ve done we’ll come on to what pure anterior alignment orthodontics is, but if you believe you’ve done it for a patient, well, what you’ve done is you’ve gone through right these are my goals. These are the patient’s goals. For the health of this mouth, I need to do X, Y and Z or you know to produce a you know, a comprehensive sort of smile makeover, I need to do X Y Z and you’ve then done that treatment. If within that treatment, all you’ve done is align the front teeth, then you know, so be it you know but why call it something else? It’s orthodontics should just be orthodontics, because if we just call it orthodontics, then I think empowers people to then have more knowledge to sort of respect certain things and do things within their scope of practice. I think as soon as you start saying you know, alignment only orthodontics, cosmetic orthodontics or Then people start throwing their Well, it’s going to do this quick. [Jaz]STO. I mean, can you know six months smiles For example, let’s name an example. Like isn’t the name right? And you know, there’s so many issues with that. You believe very strongly that it should just be called orthodontics now, and I appreciate that. But there is a difference between like, what six months miles, what these anterior alignment, orthodontics, the aims of what they’re trying to achieve and what a specialist orthodontist is trying to achieve. Most of the time, not all the time, we know that in terms of a comprehensive results, so for those listening and be like, what do you what do you mean comprehensive? What do you mean compromise? What is the compromise? I don’t get it. Because not everyone knows that. Gos just explained. In your terms, what is comprehensive orthodontics? And what we might see nowadays, even if you don’t know you’re doing it is compromised orthodontics, which sounds terrible. But please in what do you think that is? [Mandeep]Jaz, if it was easy to explain, we would know the explanation already. Right? That’d be a definition out there that would all know, and would all sort of respect. So it’s the same question I tell you, all my delegates asked the same normally, so a few months in, they always they always turn around and say, could you explain like when we do compromise treatment, and when we do comprehensive treatment? And it’s a real head scratcher. Because it’s like, you know, every patient is their own beast, you know, so if you just kind of, you know, if you learn how to do things properly, yeah, then you can, you can also appreciate the downsides of having to achieve certain things. And then only then can you go through that with a patient and decide what sort of treatment that patient needs. Alright, so let me try to sort of break this down a little bit. I, the first statement I’m going to make is you cannot do any kind of compromise treatment if you don’t know what the comprehensive treatment entails. Agreed? Yeah, let me give you an example is let’s think about single tooth dentistry. So let’s think about extraction versus RCT. Yeah. So you’ve got a molar tooth, you know, your options, your compromise option could be well, let me take this molar out, I’m gonna leave a space, the upper cannot rub the teeth adjacent can, you know tip in words, obviously, you’re going to lose a tooth, or let’s do something to try to save it or let’s do an implant. If you didn’t know about those options, then how can you consent someone? or How can you actually take that tooth out? If you don’t know what the alternative options are? Yeah, so you know, let’s pretend someone a raised RCT out of your mind. And now all you were doing was extracting, because that’s all you knew, then you’re not doing the right thing for that patient. So I would say no one should be doing compromised treatment, if they do not know what the comprehensive treatment entails. So you know, people, so, you know, just to explain what compromise treatment would be. Loosely. Yeah. Let’s just sort of define it a little bit. Yeah. Let’s just say less defined compromise treatment as orthodontic treatment where you are accepting either a compromised occlusion. Yeah. compromised aesthetics or compromised health? Yeah. Okay. So occlusion. Yeah, so, lack of interdigitation. No overbite reduction. Yeah. So you are compromising because you are accepting an increased overbite. You’re exceptional. [Jaz]What’s wrong with an increase overbite, let’s go into it, let’s go here. I told you before, I’m going to go here. So look, if you’re going to try and achieve two millimeters of overjet, two millimeters overbite, that’s your like. That’s what the textbook says. What if you, What if I finish a patient with a five millimeter overbite, and so many of our patients have a five millimeter overbite, let’s say or let’s say percentages have a 55% overbite, and they’re happy, their teeth are aligned or whatever, and these are just non orthodontic just normal patients. Why do we, why is it important for it to be classed as not a compromise and the head towards more comprehensive category if you like, that you don’t finish with a more than 50% overbite. What is the rationale behind that? [Mandeep]The rationale here would be I would say three fold. Yeah, so one, let’s think about envelope of movement. Yeah. So if you are increased overbite that you’ve now got this anterior interference, you know, so it completely you’ve changed, especially if that person didn’t have have an increased overbite or didn’t have any anterior contact. And now you’ve, you know, without, because you’ve not decreased the overbite you have now, given them some anterior interference, right? So you actually, you’ve done that thing we were talking about in the 80s, where you’ve gone from healthy to unhealthy. Because you’ve not recognized that I need to do that. Yeah. So that was one. And then the other thing would be, you know, if you are aligning the top teeth, we always plan for retention. Yeah. So now for me, ideal retention in the upper arch would be fixed retention, and a removable retainer. Yeah. Now, without overbite reduction, where is that fixed retainer going to go? Yeah. So often people approached me going, Oh, I’m having trouble putting a fixed retainer around in the upper, you know, the patient is biting on it, or there’s no room for it? Or it’s come off? Or, you know, or some people go, Oh, I don’t believe in fixed retainers only. You think, yeah, the only reason you don’t believe them is because you know.. -You’ve already have space for it. -Yeah, you’ve already have space for it. So for me, like, that is the crux of it. So if we’re talking about adult orthodontics, let’s stick with adults. You know, overbite reduction is an absolute must for a fixed retainer. Absolute must, and it’s the is probably the one thing I always look for is an overbite. Because if you’re leaving an increased overbite at the end, you’re kind of encouraging tooth where you’re that fixed retainer is not going to last, you know, the envelope and movement, you know, it’s all over the place. So that’s the biggie. -Okay. I appreciate that. If you really yeah, if you really want to annoy an orthodontist, just send them before and afters with increased overbites that we’ve just read. [Jaz]That’s when you go on Instagram, and you’re not liking this post with the beautiful line teeth, with deep overbites, because after studying some orthodontics, I can’t stop noticing that and I look back, my old cases are like, Oh, my goodness. Not that. I am correcting all these overbites to the degree that you are, and I’m being very honest, here I are. And I love what you said earlier that and you read justified me doing my diploma, if you like and doing further education, because I did have this feeling that hey, was it really necessary to do spend money and spend time and spend hours studying when a lot of my colleagues have no formal education on orthodontics, and they and they’re doing an A loving and they’re doing great orthodontics and stuff. Compromise cases, fair enough GDP-Orthodontics, and they’re doing great, and I thought, hey, was this necessary? But then I think exactly what you said that now I feel so much more confident doing an orthodontic assessment. And I don’t feel the need in the majority of the cases I see now to have to refer to the specialist, for them to hear from the specialist what the compromise or the what the comprehensive option is. Because I feel totally confident say okay, if you want the comprehensive, it will take two and a half years. There’s our aims. Okay, but here are some things that we could compromise. And maybe you’re cringing as I’m saying this, and I do and patients will always pick the easier quicker route, right? So this is the toughy. This is the real tough thing about orthodontics, right, patients, whether they know what’s good for them or not. But so often they’ll say “what looks good? What’s easier? One year versus two years. Extraction vs non extraction? So it’s tough. It’s such a tough one to consent, even as someone who has further education, orthodontics, it’s just a minefield, isn’t it? [Mandeep]Is it but you know, that’s for me, you know, there’s three types of consent, right, with a patient like that there’s, you know, proper consent procedure, and I’ll come to what that should be. Yeah. But then there’s the other two types of consent that happen in most GDP-Orthodontics, Jaz. So maybe this be a bit controversial. There’s the sort of blind, leading the blind consent. Yeah. So the GDP, I have no idea what the comprehensive plan would be here. I don’t know how I’m going to correct this centerline shift or overbite, so I’m just going to tell them look, I can refer you to a specialist. It can take two and a half years. Yeah, two and a half years seems to be that magic kind of number. Right. So you know, yeah. I know how many adults in two and a half years with a treatment? Yeah, probably about 10%. Yeah. So I don’t know where who came up with that number. That’s the one that we’re keeping. Because maybe someone did some sort of test on the public and thought that if you want to put them off orthodontics, say two and a half years. -Not two, but the extra half. -The extra half fills it, right? If you say two, that’s like they think oh, that’s doable, because they can’t let, that’s just two Christmases. That’s all right, two and a half is like whoa, three summers, man. That’s two Christmases, three summers. Forget about it. Yeah, so there’s that the blind, leading the blind consent. And, really, you know, that is not a proper consent procedure. Yeah, cuz you just thrown in something there. And I’ll tell you I was on a course recently, and the guy standing out well known, you know, in a lot of respect for him. But he, you know, he was saying that, you know, the course was all about selling more Invisalign, basically saying he was saying, obviously, Look, you’ve got to consent your patients properly. And I tell all my patients that if they want to achieve the gold standard treatment, they should have surgery. Now, that is excessive. I was like, Whoa. [Jaz]Wow, even I yeah, you saw me I raised my eyebrows,’what?’ [Mandeep]Like, really everything. And then he said, proudly, I’ve not had a single patient take me up on it. I’m like, because you don’t see you can’t just throw things in there. Like that is just, you know, that’s the blinding the blind, you don’t be, if you don’t know what the comprehensive plan is. You cannot consent for it. So your consent is for me invalid. Yeah. And putting in the notes, I offered them referral to a specialist. You know, actually, you know, it doesn’t mean anything. It means zero. [Jaz]That is gold right there guys, because yeah, that is Wow, that is really powerful you said that so because this how lots of gdps operate what we do orthodontics, say in the note, referral offer to specialist, patient declined. Didn’t fancy two and a half years patient offered six months of treatment to align the front teeth patient happy. That’s a concern over because then that in the GDP feel safe that hey, you know what I offered? I’ve done my duty. I’ve done my due diligence I’ve offered right. So that is a great way to put it. [Mandeep]Yeah, no, completely right. And now let me bring to the other type of consent. The other consent that is even more dangerous, is a loaded consent procedure. Yeah, now we’re loadedconsent procedure is where you kind of have an interest in one procedure, because you can do it. Yeah. And you are now consenting a patient again, you probably don’t know what the current comprehensive plan is. But what are you going to do in that consent? Are you, part of you is now their salesperson, right? Because you’ve got Invisalign on your back. They’re saying, look, go platinum, go platinum, like, come on, you go platinum, you need another like 10 patients this quarter, go, go, go, go go. Yeah. So literally, you are now in a loaded situation where you’ve got this undue pressure from a company, or, you know, other sort of financial pressures. Or just lack of knowledge of anything else, right. But you can do something. Yeah. So you are now more dangerous, because all of a sudden, you know how to do something, you know how to use the system. [Jaz]To make it tangible. You said it already, so someone who can only offer clear aligner treatment, and they’re doing it, any company, whatever, but they’ve never done fixed appliances, MBT, prescription brackets, that sort of stuff. And they can only offer all be it to an nth degree, but only offer one system which may not be able to achieve the ideal aims. Like for example, we all know it’s possible. But we all know it’s more difficult to correct the overbites with a clear aligner systems, right? So you’re saying this situation where the GDP is very fluent in one language, one system, but because they can’t do the other systems then putting all on the one system? Is that what you mean? [Mandeep]Exactly right. Yeah. Because I, you know, you’re now the GDP, you only know how to use this. So you’re now going to talk about how we’re going to do this compromise, and we’re not going to be able to correct this, but we’re going to do this really well, we’re going to do that, we’re going to do this. And you know, you kind of it’s a loaded consent procedure, because what is the patient going to choose? They’re gonna choose whatever option you give them to you, you’ve really got to put the interest of the patient in front of you. You know, and that’s number one in our GDC sort of, you know, and also our ethical code, right? Yes. So it for me, I the way I approach things now, I don’t do any pre surgical or surgical orthodontics. Yeah, so I don’t do any of that. I also do very little of just restorative treatment. Yeah, I do a lot of post orthodontic restorative treatment. So now when a patient comes into my chair, and they’ve got spacing, but you know, a nice smile. And yet the teeth are undersized. So I’m like the spacing is due to you know, microdontia. So really, this patient really needs you know, either, you know, composite buildups of those spaces, or you know, other treatments apart from orthodontics. I would then Go through my consent after taking records and measurements, I would go through my consent procedure and I, my consent would be look, you know, to get a really good smile, and an excellent result, you can have this done. So let’s say that’s restorative treatment only. Or, you know, you can have a little bit of pre restorative alignment, and then some, you know, restorative treatment, if that made it easier and give you a better result, however, you’re then going to need, you know, retention, lifelong retention. So you know, a compromise to that would be, you know, accept that this tooth might be slightly larger than this tooth this, this and this, and maybe you’re planning digitally and all that sort of stuff. And then the patient says to me, and I have loads of these where they go, yeah, that’s the one for me. That’s what want to do. I then say, excellent. Let me send you back to your dentist. Let me send you to this person. Yeah, I don’t tell him beforehand. But I’m not going to be able to do it. Yeah, I, these are your options. This is the benefit of this, this is the benefit of that. What do you think? So and I think we should approach our orthodontic patients in exactly the same way. Yeah, we should know what the comprehensive plan is, we should present it in a way where we give all the benefits. And health wise, we give a realistic time that can be achieved. So maybe as a professional, we should just say, look, let’s get rid of this two and a half and start saying 18 months to two years here. We then consent the patient without them knowing that we’re going to have to refer them out for them to have one procedure and not the other. Yes, and it’s the same with surgery. In my practice, I would then say, look, we know you can have this done, but the outcome is going to be no x y z, it’s going to be exponentially better. You know, you’ve come in complaining about this. However, I think you don’t like your smile, because you know, your jaw is too far forward, or you’re too far backwards. So I really think this is going to be better for you rather than just the aligner fix but the other. And if they go for it and great, I then break it to him that brilliant, I’m going to have to refer you on to hospital. So you know, that’s how consent should be done. You know, so the loaded consent procedure is just wrong. You know, it’s hard to get out of that habit, especially when we’ve become a bit too salesy. It’s not a dirty word, selling is not a dirty word. You know, but there’s too much focus. Now, if you look at Instagram, or you just flick for your dentistry magazine, you know, it’s all about, you know, how to get more clear aligner patients? How to get more fixed appliance treatment? Yeah, if I run a course tomorrow, about you know 100 patients a year, I said, you know how to get 100 clear aligner patients a year? [Mandeep]I tell you, you know, I’d have I’d sell out in 10 minutes. Yeah. If I decide to run a course on , right, let’s spend 18 months learning how to, you know, do fixed appliances and clear aligner treatment and how to treatment plan to a certain degree, you know, people are going to come rushing. Yeah, so you know, it’s people want as a profession, all of a sudden, we want quick, fast, we want to be able to offer the best to our patients, but in a real kind of efficient route. We want to do it as quickly as possible. So in a way, it used to be our patients who were you know, wanting things easily and fast and but now as a profession we’ve done it and I tell you be careful what you wish for right? Be careful what you wish for. Because if you are then going actually I can get you know this many patients I can do it without any training. I can do it hang on a minute I can now do it contactless. Yeah. The whole COVID thing has taught me is Yeah, I can do video consultation. I could do it over photos. I can even deliver the aligners straight from Invisalign to you, all will use this monitoring system so you just do it on the phone or hang on a minute. Oh, that someone’s bought in attachment less aligner. Guys, guys, we’ve got an attachment less aligner. Come on. Let’s get on board. Let’s do this. What have you just created that you’ve just created smile direct club? [Jaz]Absolutely. I’ve thought about that. You’re totally right. I mean, all these hands off systems that were what’s the difference between us and direct smile club? [Mandeep]Yeah, so you know, how many orthodontists in this country are sitting around going ‘Ah, smile direct club, What a joke.’ We’re not because I’m not losing any patients to them. Yeah, the GDP is. So a lot of orthodontists let me be controversial again, you know, are just sitting back laughing their asses off. Yeah. Because like, no, because they were in the same Position 10 years ago, GDP-Orthodontics went whoosh, you know, STO, or alignment only this that the other day we’re like, Whoa, like without I’ve just spent three years, man. I’m just like I’m about two kids. And, you know, a bedsit in Wimbledon, you know. And I’ve been studying hard like and you know, no sleep. And now you these people can offer x, y and z and they’re bragging about I’ve done 100 patients, I’ve done this many patients, or you know, you’ll get someone on Facebook, or I’ve got like so many clear aligner patients. Now I’m thinking about just quitting dentistry and just doing clear aligners. It’s just a good idea, guys, like, you know, it’s like come on by you just random. So we’re seeing back and just laughing our asses off now. Because now is the dentist, all of a sudden going, Oh, but how come they provided these clear aligners to patients without any, like no dentist overseeing it, it’s like, come on. [Jaz]I never thought about that. It’s so true, because that’s what the orthodontist must have been looking and feeling. When GDP-Orthodontics boom, it’s amazing that GDP is can now look at direct to home orthodontics and thinking the same way. I mean, that’s really fascinating. Wow, that was awesome. I love that controversy there. I’m gonna really pick your brain now say that people from listening to this will not suddenly stop doing compromise treatments, because that’s a daily, It is his daily GDP-Orthodontics. But my first put my hand up and say, We do it all the time. I mean, the evidence is on social media, right? So no one’s gonna suddenly stop. But maybe after listening to you Gos, today, it could be a bit more reflective, right? And maybe take a step back and identify the need for education where we feel we need to and I love your three types consent, that is gold, right there. So I really thank you for sharing that with us. But so we can leave now as a reflective practitioner, but also go away with some really tangible gems here is, can you think of one or maybe two scenarios, maybe you have loads, I don’t know, where perhaps the GDP should, you might even help someone really in a lot by telling them these are a couple of situations where you definitely should not compromise in this case, or that kind of case. Because this will really save your butt if you refer or if you yourself, choose to arm yourself with knowledge and treat this type of case comprehensively. [Mandeep]So yeah, I think everyone’s off the gems, right. Everyone’s often like, right, you know, what case? Don’t I compromise? What should I compromise? For me, you know orthodontics operates in the fourth dimension. Yeah, is what I mean by that it’s one of the only treatments you can do to a patient whereby you are making an adjustment, you are not going to see the benefits or the you know, the outcome of that adjustment for six weeks. -Long game. -And when they come in, yeah, so it’s a long game, right? So then they come in, and then use it. So if you don’t know what it’s gonna look like in six weeks, then you know, there’s something wrong, because then how can you communicate that with the patient? So, for me the cases, I would always have a plan B. So now, do you think I don’t do any compromise treatment? Yeah. If you think like. [Jaz]I mean, Mo taught me on the, you know, Mo taught me and, you know, I know that specialists had need to compromise. Now and again, and it’s sometimes it’s patients opt for that, they sometimes the patients who wants it, and when it’s safe to do so, you guys obliged, right? [Mandeep]Yeah, exactly. So you know, it’s like a patient centered treatment. Yeah, this is an elective treatment, the patient’s in charge, you know, they’re not going to no one dies of, you know, Malaligned teeth or not having class one on molar or anything like that. So, you know, so let me empower you guys a little bit. Yeah. I’ll give you a little bit. Yeah. [Jaz]Thank you. [Mandeep]Yeah. But the way I would sort of think about it, you’ve got to think about treatment, like a dartboard. So this is how I do it in my head. So high, you know, when you’re teaching something, you’ve got to break down what you do in a, into protocols and the system. So the way I broke it down for me is I look at it as a dartboard. So your comprehensive outcome is the bull’s eye. Yeah, that’s the bull’s eye, to get things in that bull’s eye you need you know, your overjet down to about two to three millimeters overbite reduction class one molars you need the teeth, the correct inclination. You need you know, interdigitation, midline, correct. Nice smile or good tooth show on smiling. Teeth of the correct shape, color. Yeah, good. You know, connector lenghts, good embrasures you know, so when I think about, you know, comprehensive assessment and outcomes, I’m not just thinking about orthodontics, you’ve got to think about the color, you’ve got to think about shape of teeth. – The face. – Think about the face. Yeah. So, you know, you always talk about, you know, going from single tooth to full mouth dentistry. Well, what about full face dentistry? Yeah, orthodontics is full face dentistry. Yeah, it’s, for me, it’s the holistic and analog grandfather of smile design. Yeah, you know, so if we think of it as a bull’s eye, those are all your outcomes. So you’ve got to then plot where the patient is with regard to the bull’s eye. Yeah. So what I mean by that is, you know, what is their tooth show on smiling? If it’s, if you can only see two millimeters? Well, then they’re really far from your bull’s eye. Yeah. Because you want about 100% to show with a millimeter of gingiva. So the further they are away from the bull’s eye, you plot it. Yeah. Right? Interdigitation, plot it. Overbite, plot it. Yeah. At the end of that treatment, you would then know, okay, they’ve got, you know, my 10 features and none of them are in the bull’s eye, then you know, this is a common, whatever you do, you’re going to compromise. So you’ve got to pick the worst feature. And try to get that as close to the bull’s eye as possible. Yeah. If you can get it in the bull’s eye. And then all the other ones, you’ve got to get him close to the bull’s eye. Yeah. So you’ve got to, so even compromise treatment should be assessed comprehensively there. And you know, it’s the outcome that should be a compromise, not your treatment mindset. Your treatment mindset should be comprehensive, usually comprehensively everything and loads of people, you know, because the word compromise is encourages lazy orthodontics, yeah, encourages, you know, poor outcomes. So I don’t like the word compromise, saying I this is compromised orthodontics or you know, because don’t set out to do compromise orthodontics because even a compromise outcome is amazing. And should be approached comprehensive. [Jaz]Sometimes it’s the most patient centered, and I’m being very controversially, I’m not saying orthodontists aren’t patient centered at all. But sometimes that’s a perception that gdps have that, hey, you know what the ortho wants, they want to get everything, you know, class one and whatnot. But really, we as GDPs were giving the patient the smile they want in a timeframe that’s realistic to them. That’s a theory that GDP, well not a theory a viewpoint that GDP is have. But I think you’d, orthodontist would argue that hey, the most patient centered is the orthodontist because they are doing everything by the book to get them the long term stability, for example, we don’t talk about stability enough, right by getting the overbite helps with that as well. All these things. So you know, I think it’s such a fascinating debate. And I love your thought on that. [Mandeep]Yeah, look, and then, you know, that’s it. So you plot all those things. Now, in some people, the size of your bull’s eye is tiny. Yeah. Because they’ve got a skeletal deficiency. Yeah, they’ve had previous extractions, they might have perio, you know, stable, but, you know, history of periodontal disease. Yeah. And you know, and they might not have the finances. Yeah. So that every, with all those factors that the bull’s eye is time, what are your chances of hitting that bull’s eye? Near enough or zero? Yeah. So those are your compromise cases. Yeah. You know, I’ve got a skeletal too know, patient doesn’t want surgery, or, you know, they’ve had previous extractions. So I’m left with this half unit class two molars, you know, further extractions are just now going to crush the facial profile. We’re increasingly labial face, nasolabial angle, you know. So those are the cases where you think actually, you know, my outcome, what your assessment should be comprehensive, your outcome you’re compromising on a few of those points that you plotted in your head. But the rest you try to you know, correct now in terms of orthodontists you know, not being patient centered or you know, too focused on this that the other it’s a bit like you know, in the matrix, right? You get the option of a blue pill or the red pill. Is that right? Was it blue and red and he take a Neo takes blue, right? I need to rewatch this film with my 12 year old but he picks the blue. Yeah. [Jaz]I’m not helping you because it’s one of my secrets. I haven’t seen the matrix. So there we are. [Mandeep]Painful. This is painful. I’m never gonna listen to you again. Anyway, you’ve got to watch the matrix. Yes, so anyway, so I’ll tell you the story, right? I’m not going to tell you the whole story, just about the pills. [Jaz]I know about the pills, because if somebody means about it, you know which pill your [Mandeep]He takes a blue pill, but the key is, you know, he gets warmed. Yeah, he’s warned, if you take the blue pill, it’s going to open your eyes up to everything, and you are not going to be able to unsee or to deprogram your brain again. Yeah. So it’s just like the blue pill. But now you can see it, you’re almost going to want to unsee it. Yeah. So and now there’s someone else within Neo’s team who also took this decision, but decided God, this blue pill life is rubbish. Yeah. Catch me back to the matrix. Yeah, he’s like, just put me back in the matrix, you know? Because I just don’t want to know all these things. So with orthodontist, with specialist orthodontists, you know, they’ve taken the blue pill. Yeah, they can’t unsee it. So unfortunately, when the patient’s in the chair, even though you’ve had that chat with them, oh, yeah, don’t worry, this is going to take nine months, we’re going to do this, then this and this, you know, you cannot bring yourself to leave them with a deep bite, you cannot bring yourself to accept, you know, poor interdigitation on a certain area or a tooth that slightly slanted or a slight black triangle, you just can do it. And it doesn’t matter how much you try how much you look at your bank balance and think, Oh, my God, I know, I need to just restart reducing my appointment times and start just, you know, D bonding x, y and z cases, they want to be debonded. I’m only treating myself goddamnit. You know, you can’t stop. Yeah, because you’ve taken the blue pill. And I’m sorry, you can’t reattach yourself to the matrix. It’s not gonna happen. [Jaz]This is amazing, because obviously this analogy is just because you I totally agree with you having done a diploma in orthodontics. Wow. I mean, that’s exactly how I feel. We’ve just summed up how I feel. Because now when I come to seeing treatments, I mean, yes, I still compromise. I still compromise on midline, there’s still do all these things. But I’m so much more aware of it. And I have that feeling that, I can’t unsee it. You’re so right. I can’t unsee it. And it’s the same with endodontics. It’s the same with endodontics. The more endo you learn, right, and the more protocols you start using your attempts and EDT or 17% EDTA. Because you want to get rid of the, you know, open up the tubules and whatnot. When you start doing this part of the protocol, when you start sterilizing your GP points, you can’t go back to not doing it. You can’t go back to not using EDTA you can’t go back to not following the full protocol, because it feels like you’re cheating. It feels like it feels wrong. It feels wrong inside and you feel like you’re not doing the best of your ability. Wow, that is really powerful. Yeah, yeah, you feel dirty, right? You’re like that. – As much as anything as an ortho endodontics. Endo is the first thing that came to mind. Oh, my God, that’s exactly how I felt about endo. The more I learned I couldn’t unlearn it. I couldn’t unsee it. I couldn’t then do my endos in 45 minutes. I couldn’t. And now they take me for molars, take me at least two, two and a half hours in over two appointments. Okay. Whereas before I could easily do in an hour, what’s the difference? And I now see all these things, which I didn’t see before. And I can’t bring myself to do it more profitably. I can’t because it has to be done. Right? Wow, that is amazing. [Mandeep]That’s it. It is true, Jaz you know, and there’s that analogy isn’t isn’t there? You know, you can’t treat what you can’t see. Yeah, but I would say you know, once you see it, you cannot unsee it, and you cannot help but treat it, you are going to treat it because you’ve seen it, you know, and you can’t unsee it now. And I even you know, it’s all about rapport, I would say a large amount of my adult patients leave with very comprehensive outcomes, they, you know, invariably end up wearing their braces for longer than we plan. But you know, what, guess what, they don’t complain, because, you know, I would over egg how much it’s gonna take. Yeah, and I’ve because I’m not there to sell them. And I would even say to him, if I wanted to sell you this treatment, I’m telling you, it is going to take six months, but it’s not going to take six months, it’s more likely going to take this, this and this. And you know what? They’re on board because they trust you. They like you. They appreciate your honesty. So loads are too many GDP are too scared to say, look, it’s gonna take you this time. And you know, one of the biggest sources of complaints in GDP-Orthodontics it’s time, that you promised it’s gonna take six months now, why have you promised it’s gonna take six months? Because it’s in the name of the system. [Jaz]Well, I like the way you put it in that suggests a communication gem right there that you know, it’s a great way to put it if I’m going to sell you this treatment. I will say this once, but it’s not. I just really like that one line. I just think everyone should use it. I think it’s great. – Yeah, I use that all the time. – I like that but you’re gonna hate me for one thing I say to my patients, Gos, you’re gonna hate me. I’m sorry. Okay, I go. I say orthodontists are like builders, okay? They’ll tell you it takes 15 months, but it take two years. I say that all the time. We all have a bit of a laugh. [Mandeep]Very, very funny, you know, because we’re recording this around the dentinal tubules. orthodontic month. Yeah. Which actually you’ve hijacked because you’ve thrown in a bit of an occlusion kind of day, and they just like, randomly and but the funny thing is right, you know, druce with our right, it’s got to be 45 minutes, you know, and I was thinking exactly like you’ve said, but not in the way you said it. I was thinking, you know, you tell orthodontists to do something for 45 minutes, that is going to each of them is going to deliver a two hour lecture. And that’s what it’s been like. Some of them have come back from work, I work late, late on Mondays, I’ve not been able to log on. So I go on about, you know, half nine and thank are God they let me watch the replay, it’s still ongoing. treatment, there’s like money. So in a way, Jaz, you’re not wrong with your analogy, which is why it’s funny, most things that are funny are true. So you know, I like that, you know that. [Jaz]But that’s not to be dismissive. It’s just something to laugh about itself is nothing in that way at all. But but that’s we’re coming to the end of our time. And thank you so much for sharing all those things can just because like people will listen to this. And I think I really enjoyed talking to you. And people will listen to this and watch this and think, wow, I like this ‘Gos’ guy. I like the way he sees the world. Tell us how they can find you. Tell us a bit about your course. Is it online? Is it in person? How’s it going with COVID? and What? Why not? [Mandeep]Yes. So I mean, I’ve had quite a few gdps reach out to me via social media. So if anyone wants any advice on anything, just reach out and I would share, you know, anything. I’m quite open. And I just think, you know, part of my gripe with orthodontics, in general, is there’s a real lack of leadership, especially with GDP-Orthodontics. Yeah, so I think, you know, specialists need to take a little bit more of the lead we have, but we’re all busy trying to live our own lives, and we’re having contract issues. And this that the other, you know, so it’s, sometimes it’s the priorities quite low. But I think, you know, connecting with your colleagues is important. Yeah, treating them as colleagues, not competitors is really important. So I have that kind of attitude. So just reach out to me on Facebook or Instagram. I’m not on any other sort of. [Jaz]I’ll put the links in the show notes on protrusive.co.uk and also on the Facebook group. So I’ll put all that there to contact you. But your course, are you doing another one next year? Or is it all fully booked? Or is it? How is it with COVID? It just I don’t get it? [Mandeep]Yeah, so it was tough, you know, because I wrote it, it was intended to be under normal circumstances, you know, a real face to face, you know, course. But we’ve adapted it to be a bit more blended. So it’s delivered, you know, over 18 months, there’s quite a few lectures given over webinar. There’s a lot of online videos, which are just constantly updating, so loads of clinical videos, treatment discussions. So we’ve structured it in that way. And then obviously, there’s the practical components where we meet, we do a lot of typodont treatments, and there’s a clinical element as well, where over four sessions, they could come to the practice. And if they feel confident, either treat patients or so. So yeah, so which is why it’s just very small groups. Yeah. So it’s just I only take two groups on a year of eight. So if I take eight on in April, so in April, you know, I’ve got eight spaces, four I’ve already gone. And then I take on a second group in September. So we just do April, September, keep it small, you know, I’m never going to be like what are these big academies or big kind of, you know, teaching Institute’s or whatever, because I think to teach orthodontics properly, I think you need a mentor. You need that close contact with someone. And then also for me, I need to be contactable to all my delegates, you know, they can contact me and then I can respond straight away and just guide them through the process and I hugely enjoy it. And the reason we’ve been so I run it with my wife who’s all she’s got an MSc in orthodontics, and she was the inspiration behind it actually because you know she I won’t tell you where she did her MSC, but the you know, the process and the teaching was just horrendous in a way that it was very scientifically driven. There wasn’t much in terms of mentoring or treatment planning or practical skills, and I thought you can go you can get an MSc and you could literally not have any of those skills and still get one. But it’s just, I was like, right, I need to do my own, we need to do a course. Awesome, great together. So she helps me in a way that, you know, she thinks differently to me. So she knows she’ll say something like a practical aspect, or you need to teach him how to do this, this and this. Because you forget when said things are second nature to you, you forget how it was like when you didn’t know any of those things? Yeah, so she called me, She is a bit more fresh in that way and says, Look, I struggled with learning how to do this. So if you teach them how to do it this way, and be descriptive about this, they’ll learn x, y, and z. [Jaz]That reminded me of the first time I put power chain on I’m like, Wait, am I doing it? You know, and like, you know, you guys think what the hell is easy, but first time doing that any simple thing that you can think of, right? And it’s so great that you have that input for you know, from your wife. And it’s great, because it’s so easy, once you become efficient and proficient something to forget the struggles of the learner. And the learner will struggle with so much more basic things than you ever thought. And it’s nice to be grounded in a way and think I can simplify something, but actually make it exponentially more valuable. [Mandeep]Yeah, I completely agree with you, Jaz. And you know, within that eight, you know, within eight people, I’ll have three who are hugely experienced, who actually done other courses already, you know, so this might be like the, you know, another diploma that they’re doing just because, you know, they want whatever we’re offering. And then I’ll have you know, another three, that I’ve done nothing. And then everyone else sits in the middle. So it’s sometimes hard if you had a bigger group to tailor to all those things, to all those sorts of types of knowledge. But I think if you pitch things to the people who know nothing, and simplify it, even the people who think they know loads will get loads out of it. Yeah, so it’s just another way of doing it. So they might say oh, I’ve never thought about doing it like that. So you know and I’m full of you know, breaking things down clinically like trying to make things easy, I’ve shed any kind of pearl you know, like how to do certain things whether it’s attachments, IPR, putting retractors on or using this type of retract for this patient you know, just making things easy, clinically. How to put fixed retainer on right? So touted all those things, but also you know, in the real world how to keep your cost down, how to be efficient, clinically efficient, how to have protocols in place, how to then present cases to patients after a good concern. You know how to put the patient for.. [Jaz]Your dream consent analogy is anything to go by that I’m sure you absolutely smashed that so nicely. I really enjoyed your teachings today, Gos, the way you explain things I really enjoyed it and I love the fact that you’re not afraid to become a little bit controversial because I think it’s gonna make for a really lovely I’m expecting loads of messages of ‘Oh my god, Gos just blew my mind’ because this is really fun chat. I mean, the wow an hour just flew right by. I really appreciate you coming on today. Gos, please send me the link for your course I can stick it on the protrusive show notes as well. So I don’t get bombarded by messages. I can just go on the website and click on find you as well. [Mandeep]Cheers, man. Thanks. There’s a few things here that you didn’t say. So you didn’t use the word, a myriad of uses. [Jaz]Really? I never knew said that. I say that? [Mandeep]You say that all the time. [Jaz]What? [Mandeep]You didn’t talk about people listening and cutting onions. [Jaz]Okay, yeah, yeah, fine. Yeah, that one I say a lot. I agree. [Mandeep]You say that a lot of gardening or cutting onions. I’m like, That’s such a Punjabi thing to say. One listener messaged me one time say I listened to you when I chopped my onions. I was like, this is a real thing. So that’s why I just I just imagined people just listening, chopping the onions all the time. That’s all you guys do. – Since you said that I now when I do chop onions. Hence the experience like you know, like justify your tears as you’re listening. You can justify your tears that you can justify, they’re crying because he was young. He wasn’t the movement of the inspiration of the podcast. [Jaz]Gos, thanks so much. Fun. No bust at the end as well. Thanks so much. And guys, check out Gosal on all the social platforms and I’ll stick the show notes on the website as well. Gos, thank you so much. Cheers, mate. Jaz’s Outro: There we have it guys. I hope you enjoy that really entertaining content with Mandeep Gosal. Gos, thanks so much for coming on to make such a fun episode. I think I really appreciate exactly where you’re coming from and I really respect you as a specialist in terms of how you work alongside and how you educate general dentists, is really awesome. So, more power to you my friend, guys, thanks so much and next episode will be about retention, all about your your niggling queries in retention. In fact, on the Protrusive Dental community Facebook group. Some months ago when I was recording this episode, I asked you what you wanted to ask Dr. Angela Auluck, and you guys had sent me some questions through. So your questions will be answered and the most important things about making sure that retention is on point. So I’ll see you. Same time. Same place. Next week.

We don’t refer all our extractions, root canals and crowns – then surely there is a role of GDPs to carry out Orthodontics? In the last 10 years we have seen a boom in GDP Orthodontics and much of this is ‘Alignment Only Orthodontics’. Protruserati, welcome to Straightpril! https://youtu.be/EuHTN4CXCxs Dr Nick Simon shares his journey and advice with Jaz Need to Read it? Check out the Full Episode Transcript below! In this episode we discuss: How GDPs can get involved in Orthodontics Which, according to Dr Nick Simon, is the best Orthodontic system for GDPs? His views on all the Dentists jumping on the Invisalign bandwagon How significant is the loss of anterior guidance in ‘STO’ (Short Term Ortho) cases The 2 most common mistakes GDPs make while carrying out Orthodontics Sponsor: Did you check out the Mini Smile Makeover course? You can attend again in the future at no additional cost – THAT’s awesome! Protrusive Dental Pearl: I use the Beauty and the Beast Mirror to ask patients what they hate most about their smile. It injects personality and humour – but you also find out exactly what the patient does not like about their smile! If you enjoyed this episode, you should also check out Are Class I Molars Important? With Dr Mo Almuzian Click below for full episode transcript: Opening Snippet: There aren't any systems that are better than each other. There may be an educational system and i do believe that the IAS from what i have experienced because it travels from simple to complex removable to fixed... Jaz’s Introduction: What’s the best thing about online courses like i mean i’ve done a lot of online courses and even more in-person courses and what i love about online courses is the ability to rewind and re-watch and skip forward and to go to that exact point which you need which sometimes in like an in-person course if you’re watching someone do a technique or if you’re in a lecture component you sometimes just relying on your notes thereafter and you lose that magic of revisiting that exact moment which you can with online courses. So i think the future of dentistry and dental education is very much online courses i mean i know in-person courses has its place but there is something magical about the revolution with online courses in dentistry, however and it’s a big however is because i want to tell you about the mini smile makeover course this is a sponsored episode by enlightened and mini smile makeover but i wanted to give you some context and perspective right? So online course is awesome because you get to revisit. Now what i loved about the mini smile makeover course where i went around about 18 months ago so and really enjoyed all the pearls that Dipesh Palmer shared and i relied on my notes and the little handouts they gave but the beautiful thing about the course is that they allow you once you go on the course and you become a delegate, they allow you to come again in the future and sit at the back so you’re not actually you don’t actually get to the hands-on bit again because obviously that’s for the paying delegates but because you’ve done their course you get to sit in the back and you can bring your laptop you know note making and sometimes the ability to re-watch that live presentation, the live lectures and the beauty of being able to network again with fellow dentists is just sensational. So i think that’s a wonderful model to carry out dental education i actually really wish and hope that this catches on and other course providers will also allow you to you know once you go on their course allow you to come again in the future and just sit in the back and absorb and that’s another reason why when someone asked me which composite core should i go on i’m very quick to recommend the mini smile makeover of course because of this ability to go again and i look forward to joining them this summer for my revisit. Hello Protruserati . I’m Jaz Gulati and welcome to another episode of the Protrusive Dental podcast and the very first episode of straightpril this month we’re focusing all about orthodontics but i guess i’m a general dentist you know i’m not a specialist therefore the sort of direction or the perspective of all the episodes is from the perspective of a general dentist like so many general dentists are doing or carrying out orthodontics. It’s actually amazing the the sort of growth it’s had in the last 5-10 years amongst gdps but i also have some specialists this month who will be sharing their perspectives on retention, on when to compromise and when to go comprehensive which i know you will love. That’s going to be really key up so but today I’ve actually got a GDP, Nick Simon, who’s very well known about as a GDP in the world of orthodontics. And I want to sort of pick his brain about which is the best GDP friendly system out there, which is a question so many of you ask, I just want to get some insight from him to inspire you all in terms of how he got involved with orthodontics as a GDP because back when Nick Simon got involved with GDP orthodontics, it was something that was a lot more frowned upon than it is now. I mean now, it’s so much more accepted that general dentists carry out orthodontics, and they do so at a good high level and we should champion that but to back when he was getting involved. There was still a lot of friction from the orthodontist that you know, you know, General Dentist should not be doing orthodontics kind of thing. So it’s great to have him on with his perspective. Essentially, what Nick Simon shares is that he saw many of his patients had lower incisor crowding. I mean, so many of our patients have that right. And quite often the patients would say to him, I want to get this sorted. So he refer the patient to an orthodontist. Now the patient would come back to Nick and say, Listen, I went to the orthodontist, and they want to remove my teeth and it’s gonna be two, two and a half year treatment. And this is not what I want, can’t you just straight in my lower teeth. And that’s what sort of sparked his interest in thinking Hang on a minute, should I be able to help these patients perhaps? So that was a real eye opening moment for him in terms of sparking his interest in orthodontics. Now for those of you not in the UK, and Nick does reference someone called Anoop and what he meant by Anoop Maini, who is a phenomenal dentist. Unfortunately he passed away Over a year ago, and it’s really sad because he was such a great pioneer in the UK and Europe of GDP orthodontic, so I want this episode to be almost like a tribute to him as well. He was a great guy. I spoke to him a good few times. He what he did to advance GDP orthodontics has been unrivaled by anyone I know. So that’s who you meant when he mentioned Anoop. And I think even though we should all take a moment to tribute, the wonderful platform that Anoop set up for general dentists doing orthodontics in you. The Protrusive Dental pearl I want to share with you is something I use in most of my orthodontic consultations. Here’s what I do, okay, is because what I want to find out from a patient is what is it that they want to change the most? What is their biggest hate? What is their biggest desire for their smile, because alongside all the objectives you want to achieve through orthodontics, you really need to make sure you nail the patient’s wishes and expectations. So the way I do that is I sort of inject some humor into a situation I inject some my personality into a situation, I was inspired to do this by Mohammed Al museun, who taught me orthodontics. And basically is this, you say to the patient? Do you remember the magic mirror from Beauty and the Beast? And of course, everyone remembers the magic mirror from Beauty and the Beast, right? So what I do is I have this sort of Disney versions, little handheld mirror. And I say, Well, here it is, here’s the mirror, okay, I want you to look at the mirror. And when you look at your teeth, you say to the patient, and I want you to tell me exactly every single little thing that you don’t like about your teeth, so that I can help you. And I think this is great because it gets, you know, the child or the adult laughing if they’re with a parent, they start laughing. It’s cool. It’s a quirky, fun little thing, but it also gets you that really important information you need, which is what is it that bothers them the most is the whole thought sort of, if I had a magic wand, what would you change kind of question, except just delivered in a different way. So I’ll put a link on the show notes about exact mirror that I have. I think it’s from the Disney Store. But you can use anything using imagination. I just want to share that with you two fold thing here. One is injecting some fun and personality into the question and two the importance of asking that question because you want to know exactly what they don’t like about their smile. I also want to share some cool news with you. I recently became an admin on the Facebook group for ripe global. Now, going back, I mean, you heard the Lincoln Harris episodes, which were phenomenal, as you know, and Lincoln started restorative implant practice excellence Facebook group some years ago. And the point of the group was to post full protocol photos. And I learned so much from watching these great clinicians around the world post up their full protocol cases, like who’s got time for before and afters, no one, you want to see that every single detail because inspires you, you’re gonna see a patient one day who has a similar presentation to what you saw on the forum, and you’ll get ideas and you’ll get inspiration. So I’ve been a huge fan of the group, huge fan of ripe global I’ve done videos for them, I keep adding content on their website, and was a great honor to receive the silver badge case, denoting the fact that I am now an admin for ripe global. So if you’re not already on the ripe global Facebook groups got over 80,000 of us dentists all over the world. please do join, it will be great to see you on there. I also want to give a shout out to Demetrius, who is a Cypriot dentist based in Germany. Okay, so Cypriot dentist based in Germany, Demetrius, thank you so much for reaching out. And I respect Demetrius because he reached out with positivity and with love, but also some very useful constructive feedback for me, which is this sometimes a lot of you when you’re listening to the podcast, you are driving. And sometimes I might say something like nti sci, or I’ll say something some acronym, right. And you guys, when you’re driving, you’re like, you want to know what it is, you don’t want to continue listening the episode because you want to find out what I just referred to, and you can’t because you’re driving, you can’t Google that thing. So I’m going to make it a aim to not use abbreviations so much or if I do to explain what they mean. So everyone benefits now because a lot of these episodes have been pre recorded like me my content calendar is for next three or four months. This change may not be immediately reflected, but I really really value Demetrius your feedback. Thank you so much. And then really appreciate you listening to the Protrusive Dental podcast my friend, guys enjoy this episode with Nick Simon all about GDP orthodontics, which is the best system how to get involved with orthodontics. What are the dangers pitfalls at the end, he shares with you The two biggest mistakes we make as gdps. Hope you enjoy guys. Main Interview: [Jaz]Nick Simon, welcome to the Protrusive Dental podcast. How are you? [Nick]Great. So thank you so much for having me, as you know, quite a keen avid listener to your podcast. I’ve enjoyed a lot of the previous episodes and it’s an honor just to be here today. So thanks. [Jaz]I really appreciate that and you know, I first personally I’ve known about you For many years, actually, I’ve probably known about you since I was a student in Sheffield, like maybe in 2011. Nine years ago, I’d heard about you, because the good work you’ve done, yeah, the good work you’ve done in the realm of GDP, orthodontics, right, and I’m a house level and now SoFo boy. So that’s in West London. And I knew this gentleman and his dentist in Ealing, doing really high quality work. And I sort of, I’ve sort of seen your name pop up everywhere. And then I got a message from you in the summer in the middle of pandemic, it was so nice to see the message from you. And you mentioned the podcast and the resin bonded bridge course and stuff like that. So it’s been so nice, another person like yourself, who I’ve been able to connect with from the podcast. So again, thank you so much for reaching out and eventually led to this. And I’m sort of I’m twisting around forcing you to come on here, because I think you think that you don’t have much summary for some reason, but I think you’ve got so much to share. So I’m really excited for today’s chat. But for those people who don’t know, who are Nick, just tell us a little about yourself, and what is your thing? Where do you practice a little bit of your background? [Nick]Background? Certainly. So well, I made my first appearance in the mid 60s. I was born at the London Hospital in Barts Health. And 18 years later, I made a return as an undergraduate. So that’s why I did my dentistry. And I have two wonderful parents, I could not have chosen better parents really, my dad was a dentist, he was one of the best dental communicators I’ve ever come across his way with patients was genius. And yet he has also skills, one of the early adopters of implants. He was a past president of the AGI. My mother was the business brain. I say that in in that my dad used to tell me that in the days when before computers, they had record cards, the nurse would transport the cards from the dental area dental clinic to my mom at reception, and she would add another zero on to the bill. And I think she said that no one complains, no one ever complains. And that’s how it was really so I grew up in northwest London suburbia in a very comfortable environment really. And at the age of 18. I went off to university had a great time there. And my first touch point, I suppose with orthodontics because as you say, I’m sort of known in a way for GDP orthodontics, although we’ll come on to what sort of type of GDP is the orthodontics? I don’t know if you because I think you went to London as well. Is that correct? [Jaz]I went to Sheffield. [Nick]Oh, you say Sheffield. Yeah. But after London, I come the final year where we had the orthodontic section. I do remember going off to a clinic maybe once a week or every two weeks, where we were looking at removable appliances. And my memory from that is that I actually can’t remember that anything moved. There were no teeth that moved. And a few years after qualifying, I heard that orthodontics was one of the best paid specialties that there was no in dentistry. And I really couldn’t compute it. I wonder what is going on here. I mean, at college, I thought it was a little bit like, you know, perio and ortho, maybe not real well. So max facts. I’m not that keen. I mean, Maxfact is serious stuff. I wasn’t keen enough on that stacks, although I really could understand what was going on. transitioners where I’ve been really. So that was my first touch points with ortho. My second was listening to Tif Qureshi. I think in the early 90s, when he came over and started talking at the VA CD, there’s a little section known as members pearls. And members were able to talk for about 20 minutes on their preferred subject. Tif was talking about what was to be the Inman aligner. And he was moved. And also doing some lower incisal bonding. And at that stage, I had no real ambition to move any teeth at all. But I do remember badgering him. Artists, let me talk on how he got his incisal composites to stay on because I couldn’t actually translate that my technique was very similar to him. But being at a clinic with sort of very low budgets, we were using very low budget materials, and they were falling off. So those are my two touch points with ortho. And it really got started when a friend of mine showed me a picture of some crooked lower incisors that he made straight and I thought my gosh, loads of clients come to me asking me Can I do this? And I say, No, I can’t. I’ll send you off to the orthodontist. They go to orthodontists they come back saying they’re not going ahead. They need these taken out. It’s going to take too long. They don’t want to go through that time and expense. So I took what was to be the first six months smart course with, this was before it came here, was in America with three other buddies from the UK. So we came over and we were [Jaz]So you flew to the States? [Nick]I flew to the States. [Jaz]And how many years qualified were you at this? [Nick]20 years qualified? This was 2008 2008. Yeah. So the course, for a little while, I think Ryan Sweeney tested it out dental town was where a lot of the adverts were placed. And the threads that Ryan did on, I’m going to open up a clinic, I’m going to do short term author, I’m not going to do anything else. And people said he was crazy. But I mean, you know, history shows what a going concern it was and how well he did out of it. And there were two proponents of that there was Ron swinging six months smiles, and Richter Paul with his power procs. So I did both. So I flew out and did both. And it was changing, it was mind changing, because this was a time when so called smart design was coming out. And we were all somewhere prepping teeth to make them straight. The so called portions of Boston Deficiency Syndrome, where you just place veneers from. So I came back thinking that this is going to be really good. I was really enthusiastic about it. And I started to ask a lot of questions on the forum, how to do this and how to do that. And in the matter of time, I was answering the questions. So I was helping too many other dentists. And then after that, I worked for another team on the Cfast. And then on IAS, I’ve heard sort of experience with three different types of forums, helping dentists worldwide with simple fix ortho. [Jaz]So one of the reasons I had you on is because when I learned that you’d actually work alongside and educated with multiple systems. One of the overarching questions I want to help answer today, which is extremely controversial, and I appreciate that is the age old question that you see all the time when people are initially getting into orthodontics. And they say, which is the best system, right? So people will say, Oh, is it QST? quick straight teeth? Or is it IAS? Or is it Cfast? Or people will say, Hey, I’m thinking of doing Damon braces, you know, so there’s so many different systems and whatnot. So that’s one thing that I think you’ll be in a good position, potentially, your answer might be biased, but I like the fact that you’ve really been with so many different camps. So I’m really looking forward to what you think about that. But is there anything else that you want to add in the in the background, just to add a bit of a sort of context, before we really dive into those questions? [Nick]I’m not being paid by any of the companies at the moment. So I guess I’m in a position where I can really be completely open about it. I think it is, as you say, it’s a very common question in the UK, certainly in the Facebook forums, people are asking that especially new dentists, and it’s a fair question to ask I mean, how do you decide what courses to go on? You put up a question and you start to take advice there. We both know that there’s no tooth as I said, on their come, I’m upset you put on a quick straight teeth bracket there and not an IAS one over what because you know teeth responds to force vectors, biomechanics, and not to logo. It’s human beings that respond to logos. [Jaz]Absolutely. All orthodontics is a prescription of a force. Yeah. And when you think of it that way, you know, whether even you know, we’re going to eventually build up to clear aligners, no matter what the cost or price, but we’re going to build up to that as well. Because nowadays, I mean, I think four years ago, people used to be like, which is the best fixed appliance system or which is the best system and that what they meant was, which is the best bracket system. But nowadays, more and more, it’s no longer which is the best system is like should I do Invisalign go or should I do Invisalign full? Pass the new question that you’re seeing more than the old question you’d get was like, which system so we can see this evolution. If you’d like of orthodontics in terms of preference of new dentist into aligners. [Nick]Yeah, I can understand that. Because fixed braces, I mean, think what happens is that teeth move along the wire, and they can be a little bit unpredictable. And this is the thing. I mean, when I was doing the Six Month Smiles, for example, we were told, and I wasn’t doing Invisalign, then from still actually, but we were told, how frustrating is it to finish off your Invisalign cases? So your clear aligner cases? How many refinements do you have to do? You know, you start saying to the patient, are you wearing your aligners, and there’s a kind of trust issue going on. So how it was sold is that the wire was acting all the time, and you’re gonna finish the cases better. Yeah, it’s an interesting thing. We will touch on that but before [Jaz]I ask you like I’ll just point like I asked you, which is the best system, fixed braces before I do that. You did touch on the type of GDP-Orthodontics that you do so what is it you know, that makes your What is your sort of philosophy or style of orthodontics, if you know what I mean by that my question because you sort of touched on it about You’re known for a certain type of orthodontics. And I’ve touched up on that. What do you mean by that? [Nick]Well, I’m also it develops and it evolves because I’m reading back while I’m doing in my braces. I’m doing less cases. I think when it came to GDP-Orthodontics, and suddenly working on the forums, one of the mistakes I could see was, someone would do a weekend course. And then on the Monday think they’re an orthodontist. You know, can I do this? Can I do that? Can I make space for this implant? And you know, there’s a reason why it takes years to get your em off. And as I do more fixed ortho, the more respect I have for orthodontists, and as I did more ortho, the more cases I was referring out to orthodontists. And you know, I have a good relationship with orthodontist too. But it does make you think now there was that advert? I don’t know Jaz, if you remember that advert that they’d be put out. It was some.. [Jaz]in the Daily Mail or something? [Nick]Yes, it might have. I can’t remember. I think the telegraph springs to mind that I remember exactly. But I remember that there was a double page spreads or big, big page adverts by the BLS saying that GDPs, no beware who you choose for your orthodontics. Should you even be going to a GDP? Maybe you should only be choosing your specialist ortho bearing in mind that a lot of gdps were subscribers to the BLS. It was a concern. And in a trust, the tragic loss actually is mainly because, you know, Anoop was GDP-Orthodontics, and no we actually met at a six month smile course that was taking place near Ealing, I went along to meet Ryan Swain because he was traveling to eat UK and he doesn’t travel over that often. Well, I met a newt, we just got chatting, where do you live? Where do you live? Turns out, we only live two minutes down the road, only two minutes. And that became the start of a great friendship. But once that POS advert came out, that was a springboard for Anoop, to really create the ESAO, the European Society of Aesthetic Orthodontics. And what that did, I think that was a really important era in orthodontics for gdps in this country, because it brought everyone together, regardless of the system. There aren’t any systems that are better than each other. There may be an educational system. And I do believe that the IAS from what I have experienced, because it travels from simple to complex, removable to fixed. And I’m and you’re now if I have a case where I have concerns or questions, I’ve got three specialist orthodontists who I can ask and get answers quick time. I think it’s just fantastic. And it evolves. But the ESAO was nondenominational. We did courses, talking about how to assess orthodontics, how to diagnose and how to treatment plan, because in my days, that’s not what we did. We didn’t have anything, you know, the assessment form is very much a form, and a call now, especially with an uptake of weight, especially since the GDC. And orthotics litigation. We all know that any GP providing orthodontic really has to do their assessment diagnosis, like a specialist like an orthodontist, there’s no real difference. So it did change marketly, then ones is that the company’s took notes, and the company’s raise standards so that we are now safer dentists across the board. And I think that was an important moment for the ESAO, once happens, there wasn’t really any word for the ESAO to go. So it just sort of stopped. [Jaz]But it achieved something quite significant for the like you said to the GDP movement and you know, Anoop Maini rest in peace really legendary person I was a student when I first saw him speak and you’re right. I mean, that activity I was seeing as a young dental student and you know, your, I think I believe you were involved and Tif. And all these great gdps in orthodontics we’re doing so much to facilitate us as GDP is to do more orthodontics. And I think you guys have revolutionized the situation and created a real boom in a way. But there are dangers of that as well, which we can we can touch on. But yeah, essentially the answer to highlight is there is no best system, but consider the fact that mentorship and guidance and a thorough assessment should be a foundation of any system that you choose. Absolutely. It’s the educational pathway, which is the key thing. So the next question I asked Nick is, I know you said you don’t do clear aligners, right. So why did you because you seem like someone who’s very passionate about orthodontics and you respect it and you know you have a good relationship especially So did you ever consider to Hey, I, you know, maybe the demand is there and patients are asking you, Hey, can I have clear aligners? Can I have Invisalign? And then perhaps you’re converting these patients into fixed appliance patients, or you are not treating them and referring them on but don’t you think that it’s time you provided clear aligners? [Nick]I do. So I am going to, in fact, I decided I don’t do any clear aligners. So the best way forward for me is actually taking the Diploma in clear aligners, so I’m booked on it for early next year. Brilliant. So I thought that’s gonna force me about clear aligners. Because I think there’s very, I mean, I’m not gonna say Invisalign is the best system, because I don’t know, I just think I need to try it. And to I think the market will be very interesting with other clear aligners, like 3M, and I think [brand] are coming into it. I think with more and more usage of digital scanning, I think that there’s going to be a lot of interesting clear aligners, [Jaz]I think I am waiting for a clear aligner company to be able to compete with Invisalign to continue, because they have such a huge market share. But to be fair, from my experience, Nick, having now used three clear line systems purely out of testing, and to see, hey, is there something better or is there something in a different approach to Invisalign and both the other alternative UK based clear alinger systems I used, one I used on my wife, and one I use on a patient, I was very disappointed converting to that, was upset, I was extremely disappointed, my wife was in agony. From from a clear aligner system, I’m not going to name because I don’t want to, you know, defame any system, but she was an agony, and none of my Invisalign patients that ever said their agony, and I know. So that’s one factor. And the other one, I use another laboratory based clear aligner system, the plan is sent me I was so upset with it, that when I actually also submitted Invisalign, there was a stark difference. So, Invisalign can achieve this in seven aligners or six aligners, or as it took this local company, 13 aligners, and it was just doing unnecessary movements. So, I do think that the amount of money that Invisalign invest into their technology, and their development is more than with all these other companies make. [Nick]It’s having more, and that’s the difference, isn’t it? Their real relevance is huge. So there are streets ahead. And you know, where we are. Westfields, for example, there’s a pop up shop that the public are well versed to knowing what’s out there on the market, and they asked for it by name, you know, fantastic for Invisalign. So, yeah, I’m going to start to get involved. I want to look into clear aligner systems. I didn’t really fully answer your other questions, I’m going to tell you why I’m starting to rain back on my fixed aligner. Fixed cases. And it’s to do with compromise results. Now term came up anterior aesthetic, anterior alignment orthodontics, in as, two comprehensive orthodontics. So either going to do the whole caboodle, well, we’re going to choose to do certain things. And the patient might choose only to look at their front scrounging. So a patient may be class two, have an they might have crowding at the front. And we may say, okay, we’re going to keep the premises at back as they are. But we’re going to align your front teeth only. And although Actually, I haven’t had any comeback, but at the same time, unlike CIF who has all these patients coming back for it seems like recalls, every few years at least, I don’t have that. But I do wonder about anterior guidance, because if we’re taking teeth, potentially out of anterior guidance or sharing less teeth on anterior guidance, how’s that gonna function over the course of a lifetime. And I’m just thinking that may be in a closed system where we can potentially actually predict the outcome a little bit more, I’m starting to think that maybe a class one crowding system is probably the safest system that there is, I can tell you that probably, I’m not really a dentist that goes for awards or anything like that. I don’t really give a monkey’s about that. But probably one of the things that warms my heart the most wasn’t a moment in a lecture that Professor Kevin O’Brien was giving. I just happen to be in that lecture. And he’s talking about and to a lot of GDPs, and maybe some not wonderful cases, and then he and then upflush one of my cases, and he said this is what we should be aiming for. I was really surprised that because, one I don’t know where you got this case from. But what it was it was case it was class one at the back class one canine relationship crowding other. And I think, you know, that’s why we should be Yes, I’ve done extraction cases, but I will always have that mentors. And is there a role for gdps in orthodontics? Absolutely. I mean, we’ve been doing it before, there’s a specialty. There’s been dentists attaching themselves to hospitals and doing clinics, we know about smile design and where to put teeth. But I think we do need to be careful, we shouldn’t take on too much there should be an educational pathway, because things don’t always go to plan. And I think as a GDP, it’s going to be more difficult. [Jaz]Well, I want to ask you, Nick, exactly some scenarios where you’ve seen because you’ve mentored gdps, in orthodontics, what kind of troubleshooting mistakes that gdps tend to make that you could just give some pearls on but before we get to that, just touching on a few points that you made, let’s discuss, for what it’s worth, if you don’t mind my opinion on these cases where you’ve got, let’s say, a class two, Division Two with very steep anterior guidance. And then you make you convert them essentially, to a class two a division one, because you’ve just done some anterior alignment orthodontics. So that is a concern, because you lost the anterior guidance. And you mentioned about the term How about their function throughout life. In my map of the world, you’ve got patients with AOBs, and you’ve got patients with incomplete overbites all over the place, right, whether they got plenty of space, and they don’t have much anterior guidance to begin with, and they’re fine. And then you convert this patient from very significant anterior guidance to no anterior guidance. So I worry not about how they all function. I worry about how they will parafunction, because I do believe I am in this camp that a lot of the issues are there, from the people who aren’t chewing for longer than 17 minutes a day, for people who are rubbing their teeth together when they shouldn’t be rubbing their teeth together. And that’s where I think the role of anterior guidance is more crucial. So when you’re doing a rehabilitation, you’re protecting, the reason why they needed a rehabilitation in the first place is because they destroyed their dentistry. So how can you create a minimal stress dentition. So that’s just my thinking of it. But certainly I do get happier. And I’m much happier as a GDP providing orthodontics, when I have a patient who’s already in class one canines a Class two molars, and I’m just relieving the crowding. I know that’s a home run case. And I totally share your sentiments that we should pick and choose our cases. And that’s really a beauty of being a GDP, right, you can do some cherry picking. So I just wanted to share that little point in there. And then the other thing that I want to talk about is you mentioned a great thing about a closed system right as you apply that aligners are closed system and what is interesting, because I agree with you in that respect. But sometimes when I have when I speak to orthodontists who perhaps only provide fixed appliances and I really admire you the fact that you know you’re such an experienced GDP with orthodontics, and I’ve seen your cases they’re phenomenal. And if Professor Kevin O’Brien in a podium will bring up your slides, and wow, kudos to you and to him as well to for highlighting and championing GDP orthodontics, I think, you know, well done to him as well for for sharing that. But the fact that you’re so experienced and already know so much about assessment and proper orthodontics, and you’re continuing to not just dabble, but you’re going for a diploma in that so amazing. You know, keep up that spirit. That’s fantastic. But when I speak to people who don’t have your mindset, and they stick to only what they know, fixed appliance, and they don’t even want to consider clear aligner therapy, what they say to me is they say Jaz, the problem is lack of control with Invisalign, they say that I as an orthodontist, don’t have the control, I like to put my you know, by wire bends my brackets in the right place to have the maximum control. But in my mind, that doesn’t make sense, because I think as soon as you put brackets and wires, everything is now moving. Yes, you can do a few things, you know, auxiliary things to reinforce anchors and whatnot. But essentially, if you don’t see the patient for a prolonged period, time is everything, the wires is taking effect, whereas with a clear aligner it can’t move beyond the parameters of that clear. aligner. So who’s right, who’s wrong? Are we? We both right? I mean, where do you stand on that? [Nick]In that conversation, orthodontists? Or are you talking about gdps providing fixed braces? [Jaz]I’m talking about anyone who provides orthodontics and who believes who stands in the camp that I have the most control with fixed appliances compared to someone with clear aligners. [Nick]Well, I think there’s definitely a difference between an orthodontist and the general dentist. [Jaz]Of course. [Nick]If I was a specialist orthodontist, I would go with my training. But let’s say that we’re GDP and we both talked about biomechanics briefly at the beginning, there’s different ways of doing it. And I’ve seen some amazing cases on forums that dentists do with Invisalign. So it’s down to the education and the skill set of the dental provider. That’s what it comes down to, and how much time you’re going to devote to it. But I do like the fact that teeth can’t move outside that clear aligner I also understand it could be frustrating sometimes, in delivering that care. I just haven’t done any Invisalign. So I thought the best way to go and deal with that is to take a diploma in clear aligners and force myself to do it. [Jaz]I mean, that’s amazing. That’s brilliant. I mean, from someone who’s done a fair cases, fair few cases in Invisalign, or clear aligners. The thing that we struggle with the most would be canines, you know, rotations of canines moving those canine, you know, similar to some degree with fixed appliances where they’re very anchorage demanding. You also class three cases where you got minimal overjet, you got crowding, and then you can just bring out those lower incisors. And what you end up with with clear aligners or any system is you get a posterior open bite because you haven’t retracted the lower incisors enough and you haven’t accounted for that. So it’s lack of planning, lack of diagnosis that you can run into trouble. So in your experience, this leads nicely to what kind of what couple of scenarios, few gems Can you share with gdps, about common errors or common mistakes that you have seen gdps make with orthodontics that you’d like to just share to avoid? [Nick]Okay, well, I’ll come obviously, from the fixed bracket, fixed camp. So the main one, but there’s two main ones, which are failure to assess, failure to diagnose and failure to plan. And the next big one is failure to communicate. So I know on the IAS websites, there’s now take an online course on how to do your assessment, diagnosis and treatment planning. I know Ross Hopson has done that. I think that’s invaluable. Really, I think the answer 100 quid to have that knowledge is just a fantastic. Communication, it’s part of consent, failure to tell people that theit teeth, they’re going to procline, failure to tell them that they’re going to end up with black triangles to anticipate, failures to tell them about retention, who’s responsible for the retainers? Are they going to the maintenance? Who’s going to pay for the maintenance? Problems with IPR? Not doing enough, maybe doing IPR when extraction is the best policy. Failure to refer from the very beginning is a concern over proclining, not looking at bio type, getting recession. Now, these are all big parameters that GDP got into trouble really over. [Jaz]Brilliant. So you get the communication one’s really big, but you also get a few clinical ones, black triangles, what is your best way to communicate to a patient a black triangle? You just show them a photo? Or have any analogies that use or any diagrams? I show other people’s cases. Obviously. [Nick]I do, though, I show I show patients because one of the things I do with fixed braces is I take a lot of photos. So I’m always on top of my cases, I’m taking photos from before we put the braces on, I’m taking photos of the bonds up, at the bonds up. And before the next treatment, I’m thinking what do I plan to happen? What am I planning to do at my next visit? And so it’s ongoing. So I keep tabs on it. You know, I say to myself, this morning, I put on the bracket and it was like a millimeter out in a vertical plane. You know that tooth is the intro to extrude. So I know about it, I’m measuring it, I’m looking at it, I’m looking at the shape of the wire. So I’m trying to keep tabs on what’s going on. I think that’s really important. [Nick]Brilliant. That’s a great job, take lots of photos and critique it. And that leads very nicely to one of my last questions is what percentage of your cases are you, once bond it up? Because I imagine are you doing freehand bonding or have your brackets or are using a template? [Nick]Yeah, so I’ve freehand bonded for the last, for almost all my cases, actually, it’s very rare for me to and so you know, companies would like you to use their labs because obviously it’s profitable for them. When I took the six month smile course. We were taught to do both. And so initially, to get me going, up and running, I would use a laboratory services for that. And as you become more experienced, I would then set my own brackets and using various companies, I’m not saying it could be any company. I can actually look at a bonding tray and see that the bracket is not in the right position. So I’ve missed that one out and and reinserted myself. But I’m not as fast as an orthodontist. I’m not an orthodontist. I’m a GDP. And you know, I know where I am. [Jaz]Having taken IAS courses, and advanced course, then we’re expected to bond up all the time. And so that’s what I do. Brilliant. And when you’ve done that, and you’d like you said, you’ve taken a photo. And by the way, that is a real pearl that we should highlight that you know, when you’re starting out to use these lab services, but eventually, but also to critique when you get back and really look at it, is that bracket really in the right place? What’s the action that will be happening? So that’s a great tip. And when you take the photos, like recently, you said, is a millimeter out in the vertical plane? In what percentage of cases will you be re bonding brackets at a later visit? to just get your bracket positioning perfect? Yeah. [Nick]So the two ways that I know of getting into things, the right shape is either to bend the wire, or to move the bracket, it’s a little bit tedious to keep moving the bracket. So it’s easy to bend the wire, which was our failure to bend stainless steel. So you need better brackets in order to do that. Is there a better bracket? Probably there is. Can you beat a metal bracket? I don’t know. I don’t think so. Also with a ceramic bracket, but if you’re going to use, you know, the composite brackets, or what are they poly carboxylated. [Jaz]Polycarbonate, I think. [Nick]Plastic, we’re calling a classical piece of plastic, then they can’t retake a stainless steel wire. So it all comes down to your bracket selection and your prescription as well. And your education. So do you want to chip in unless a bracket is obviously out. And that’s I’ve had, you know, really late night, which is rare on the night before, I’m not going to start and then there’s an obvious bracket out of position, I’m not going to change it until I’m into a 20-20 wire says probably on visit three or so. Because as things start to level, then I’ll start to pick and choose which ones. And yes, I will spend time placing, replacing my brackets as to what I want to achieve. Brilliant. [Jaz]Fantastic. And just as a last nitty gritty detail, which is your bracket system of choice, like for example, when I do do brackets, I’m using 3M’s MBT prescription brackets, I forget the exact name, but they’re by 3M. Which ones use parity. That’s the one. [Nick]Yeah, I think and also I like purity as well. They just come up. They’re very good as well, purity. And [Jaz]I do like the ones with the self adhesive bit. So you don’t even have to worry about putting the button and it’s already got the self adhesive. It just makes sense. But anyway, Nick, we’ve got we’ve had a few gems, he talks a little bit about the evolution of GDP, orthodontics, I pinned you and I asked you about which system is best. And you gave a very humble answer. And you gave us some really good gems overall and as your you know, previous history in advising other gdps and I’m so glad to hear that you will be going into the clear aligner space. And I admire the way that you’re going about it. So and I wish you all the best with that diploma. I’m sure you’re gonna Ace it and get distinction and all that sort of stuff. No pressure. Any closing comments from you, Nick, my friend for anyone listening who’s thinking about advancing themselves in orthodontics. [Nick]I think it’s an exciting journey to take, I wouldn’t not be scared about it. I think it’s a pathway like most things in life, start off small and start to grow. But I think it’s really enjoyable. It’s certainly something that our patients have been asking us for, you know, they’ve been growing up with teeth that they’re not proud of. And in the lockdown period, using zooms apparently is a growth in terms of people asking for orthodontic treatments because they’ve been seeing themselves on zoom and whatever. And seeking all that is aesthetic treatment. So I would say go for it. Choose a company, which has, I think a good educational pathway. And have fun. [Jaz]Amazing. Thanks so much, Nick once again for for coming on and sharing those pearls is really, really great having you on the podcast. [Nick]It’s my pleasure. Thanks very much for having me. I really enjoyed it. Just Jaz. Jaz’s Outro: Well, there we have it. Dr. Nick Simon. Thanks so much for guys for listening all the way to the end. I always appreciate it very much. Do follow us on Instagram. It’s @protrusivedental, DM us with your ideas and where you want me to go in the direction of the podcast. I’m really enjoying getting on these varied guests and the next one is a specialist orthodontist. What are we talking about? When is it okay to do a compromise plan and when should you not do a compromise orthodontic plan and you should be doing comprehensive plan. So what I mean by compromise plan is like you have someone with an increased overjet and crowding and to sort out the overjet and the crowding you may need to remove two teeth to allow you To resolve the overjet, but the patient for example, says that you know what, I don’t want any teeth removed. And I just want the crowding result and that’s it. I don’t care about my overjet. So is it okay to just resolve the crowding and leave the patient in a class two division one, ie a compromised result. So that’s all be tackling with Mandeep Gosal aka the ‘gos’ and he’s a specialist orthodontist. I know you’ll love it very much. And I’ll catch you next week, same time, same place.

Canine guidance is overrated. Read that again. Crazy, I know. In this episode, one of my mentors Dr Riaz Yar explains the rationale of a functional occlusion whereby the pillars are the central incisor and the first molar. https://youtu.be/aQRQ43R4Obg Dr Riaz Yar is SUCH a good Educator I found some similarities to the Posterior Guided Occlusion (click to listen to the episodes by Dr Andy Toy) in that we place too much emphasis on canine guidance. Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: There is no joy in mediocre Dentistry Dr John Kois I hope you find this episode stimulating – and if you are a true protruserati, you will be grateful for another point of view AND NOT be upset that we all can’t agree with each other, haha! Stay tuned for STRAIGHTPRIL! Did you miss out on SplintCourse enrollment? It will be relaunching in June – click here to register for the launch offer Check out Dr Riaz Yar’s courses here – his book will also be launching in Q4 2021 – watch this space! If you enjoyed this episode, check out Posterior Guided Occlusion with Andy Toy! Click below for full episode transcript: Opening Snippet: I just couldn't get it out of my head. It took, you know, years and years of reading and reading and reading. I just, it just never comfortably sat in my head. And so there was always this niggling doubt and it always hit me when someone asked me a question, you know, and the biggest question that always got me. If the canine tip's well, why would you give them canine guidance again?... Jaz’s Introduction: Hello, Protruserati. I’m jaz Gulati and welcome to Episode 66 of the Protrusive Dental podcast. Are you feeling a little bit less stressed off that phenomenal episode where Manuela Rodrigues which was Episode 65, which is all about how we can be more mindful in dentistry. So thank you again Manuela for that. This episode, I had to just squeeze in occlusion one more time before we came to the end of March because April is straightpril. Okay? Doesn’t quite have the same ring to it as splintember but, you know, give me some props here straightpril is not bad. So it’s all about orthodontics. Next month, we’re gonna talk about retention protocols, the do’s and don’ts of aligners elastic in aligner therapy, and the whole GDP vs specialist debates. So we have a GDP, and specialist on so you get both perspectives. So that’s all coming in a few weeks very soon. Before we dive into the meat and potatoes of the main episode, just want to share some news with you guys some really cool news, the splintcourse enrollment, which some of you, many of you took part in, has ended and oh my god, it was phenomenal. I’m so pumped to have delegates from all over the world from Taiwan, Singapore, UAE, India, Australia, New Zealand and Europe. It’s great to have a real community of people who just want to learn about splints. And already we’ve got this secret Facebook group, everyone’s posting cases. And it’s a really special group that’s really engaging, I just want to share with you the feedback I got from the very first delegate who finished splint course his name is Nasir Javaid. And this is what Nasir had to say about the splint course, “What a brilliantly put together online course. This course is bursting with educational gems, patient videos, detailed explanations and easy to follow and digest format, you can tell a lot of thought has gone into preparing and delivering this course. And it’s directly relevant to everyday practice makes it most engaging. One of the most value for money courses I’ve ever done. Thanks Jaz.” Well, that is just spectacular. For my first delegate who’s finished it, what can I am just absolutely made up after that feedback. Nasir, thanks for being the first delegate to finish and since now I’m recording this five people have finished a splint course entirely. And the feedback is just great. I’m going to share it with you in the future again. But I want to get to the main bit of the episode before I do. The other bits of news I have for you is that I have had two podcast features, which I think I’m pretty proud of and I’m going to share them with you. One is on Dr. James Martin’s podcast, which is on money, it’s Dentists Who Invest podcast and if you remember many episodes ago, I had James on my podcast. And then on the back of that he made his own podcast, Dentists Who Invest, and it’s fantastic. Delivers a great value. And I did my bit on the podcast about how as dentist we should be thinking about other ways, other ways to sort of spread our risk because I sort of say that in our profession, the most stressful thing is that it just takes one issue, one complaint, one GDC issue or your regulatory body issue wherever you are in the world. And that’s your livelihood gone, right. So how can we diversify our financial strategies to make sure that we are bulletproof? So that’s what we discuss. In fact, I’m just gonna play a little snippet from that podcast, [James] Whatever it is that you can you’re supposed to be financially free at some stage. And maybe having a tangible point is very, very, very helpful. So another good message there. Do you think you’ll continue to do dentistry, Jaz when you reach that point? [Jaz] Yes, absolutely. Because I you know, I feel as though I want to be able to do that. And I think everyone should I think every dentist should aim for this. Right? If you can make yourself in a financial position that you do dentistry, because you want to and not visit because you need to. Wow, I mean, can you just imagine that, that you can go into work and you want to do this dentistry and the occupation that you have in front of you, who doesn’t excite you, you can be like, you know, I’m not so interested. You don’t have to take that treatment plan on whatever. That’s the holy grail man. [James] It is. I love it, my friend. [Jaz] As well as Dentists Who Invest, I was also on the Dental Leaders podcast, one of my favorite dental podcast. And this is with Payman Langroudi & Prav Solanki. And I must play a short and sweet little snippet from the Dental Leaders podcast, which I think you should totally listen to is a great podcast. [snippet] So although I didn’t have enough knowledge to teach, I was always thinking how can I become a better educator? So once I’ve amassed enough knowledge once I’ve had enough failures once I’ve really given it my And I have something valuable to share, then I’ll be ready. So I was I was gearing myself up to it for many years, I was analyzing lecturers, which lecturers really engaged me, excited me the kind of traits they had, which ones although they had all the accolades and letters next name, which one just bored me, I never want to be someone who’s gonna be boring. I always want like engaging. Like, I always paid real attention to Raj Rattan lectures or stories, such an amazing storyteller. That becomes a very important part of me, you know, trying to make it through as an educator. So that was important. And funnily enough, I can go back his first year of dental school, where my buddy Eric, who was a dentist or a dental student from Korea, and he failed his first few exams. And he said to me, “Jaz, if you can help me pass my first few exams, I’ll take it to Korea all expenses paid, right?” So I stayed back within two weeks, I tutored him we got him to pass. But finally let’s bring it back now to this episode, Episode 66, which is on the philosophies of functional occlusion. This is with one of my mentors Riaz Yar I’m so excited to share this with you because Riaz inspired me eight years ago, to follow along this path of questioning about inclusion and including it was actually realized, I think, by pinpointed it, it was him to really set me on my path. He’s such a phenomenal educator. So I know you will love and really resonate with a concept Riaz has to share. The kinds of things we’re talking about today is that canine guidance is overrated. And actually what he suggests is about all about functional occlusion, which is really about the central incisors and first molar is which is going to just blow your mind. I know it is. Before we dive in though, the Protrusive Dental Pearl, how could I forget I would never do this do you, the Protrusive Dental Pearl I have for you is a quote. I want to share a quote with you from John Kois, who I’m sure we all know who listened to this podcast. But if you don’t know who John Kois is, he’s kind of a big deal in dentistry. He is this awesome dentists based in Seattle. They’ve got the Kois center, and the quote I want to leave you with is a beautiful quote. It is “There is no joy in mediocre dentistry.” There is no joy in mediocre dentistry like why do we do what we do? Why do we go the extra mile? Why are you listening to me right now? Right? What Why is this happening? Is because you want to go the extra mile. You don’t want to settle for mediocre? Because this is not fun. Right? When you are not, It’s sort of links back to last episode, we talked about mindfulness. And if when you’re doing your dentistry, if you’re doing back to back class two restorations, for example, and your mind is wandering, it’s not in the room, it’s not present in the room. You’re not giving the patient the best, and you’re not in a state of flow. And you’re not involved in the minutiae of the details, which if we can fall in love with those details, it just adds to our enjoyment and fulfillment as a dentist. So that quote by John Kois, there is no joy in mediocre dentistry. I think that is what it’s all about. That’s why you listen to this podcast because we don’t want to settle for mediocre right? So thanks for listening to my long introduction today. I do apologize. I want to rush right in now with Riaz Yar, one of the best educators I know. Enjoy. Main Interview: [Jaz] Riaz Yar, welcome to the Protrusive Dental podcast. How are you my friend? [Riaz]I’m fine. Thank you, buddy. I’m great. Just Yeah, thank you for the invite. Excited to do after you’ve had some really great people on here. So thank you for the invite. [Jaz]No, absolutely. I mean, you’re someone who really set me on the path for enjoyment of the topic of occlusion. You may not remember this, but it was 2013. And I think our first or second study club was with you in London. And I’ll never forget the first one minute of your lecture. I don’t know if you still do this. You have to tell me if you still do this. But do you remember what you did in the first minute of the lecture? [Riaz]No idea. I can’t remember. [Jaz]Okay, the first lecture, you just stood up in the middle. Okay, and you played a song, and you just got everyone to listen to a song for 60 seconds? Or there abouts? And then you say you sort of justified it saying that this song reminds you of university and it pumps you up? And it was some heavy metal song. Do you still do that? [Riaz]Yeah. I’m planning on it. With [inaudible] [Jaz]Is it Metallica? [Riaz]No, no, no, no, it’s freedom by It’s freedom anyway. [Jaz]It’s heavy rock,right? It’s a heavy metal. I remember I had to.. [Riaz]No, no, it’s actually not rocket fuel. It’s actually it’s very much, I’ll get it here. it’s rare. It was the album was Rage Against the Machine. [Jaz]Okay, fine, right. But I remember you playing the song. And I was like, Wow, that’s so unique and so different. So I’ll never forget that lecture for that reason, but also because of the impact you had in that lecture. I mean, that was I believe on the topic of TMD and occlusion at that time, and you made us realize how little we knew the anatomy of the temporomandibular joint that year in a strike fresh out of dental school, and no one was confident in the anatomy and you really brought that home, and then you really play with our minds, whereas you really, you know, made us think hard about occlusion so I never thought forgot you and I’ve been privileged to able to be in some of your lectures. So, it’s a testament to you as an educator. It’s fantastic to have you on for that reason. [Riaz]No, thank you. Do you want that you want to listen to rage against the machine again, don’t you think? [Jaz]Okay, I’m with you. Okay, fine. Perfect. Is that bond patrol, what’s the song name? Did you get it? [Riaz]Radio. Freedom. [Jaz]Freedom. Okay, freedom. Okay, there we are then so. So everyone you know, Riaz is sort of a treatment planning song. So that’s playing in the background as you’re treatmemt planning? [Riaz]Yes. So basically, that was with dental school. You know, literally, when we left dental school, it was that moment of freedom. You know, we literally were like, okay, shackles of dental school are done. You know, I don’t need to pick up a book again. You know, it was like, literally, I mean, I that’s how I felt I literally was like, I am not touching a book again. Now. It’s just to practice. And you realize very quickly, how little you knew. [Jaz]And you know, looking at you, you did a speciality program in prosthodontics. Right? So you did some special training in prosth? [Riaz]Yes. So did, I sort of, I was gonna do my maxfacts initially. So my plan was maxfacts, they were not qualified. And I was working as an anatomy demonstrator while I was working in practice as well, that was working in Sheffield doing nothing enough, or maxfacts, that’s it. And then I got married. And then that changed that idea could have like, literally, I’m looking to see if I do Maxfacts. And so therefore, you know, I’ll just do then I’ll just do general dentistry, which is fine. You know what? So bought a practice in 2003. NHS practice. One thing that frustrates my mother the most is, I can’t sit still, you know, literally, you know, I’ll buy a prac. I’ll do something and then I’m bored. And then she like, you just are you get bored so easily. Literally, I think I did it for two or three years, and I was bored or thinking I want to do next. And so what happened was I joined I did Paul Tipton course. [Jaz]Okay, cool. [Riaz]Yeah, In Paul Tipton. He doesn’t realize it. But he, you know, and this is not actually criticism of it. He made me realize that was not the way I wanted to learn. So I sort of I did is caught on that, you know, I thanked him for it. Because I thanked him for the fact that actually, that wasn’t the way I wanted to do my dentistry anymore. I’ve been learning why it’s not about his work or what he does. It just wasn’t the way I wanted to do. Learn doing courses here. So I wanted a structured pathway. So then I sort of worked my way to get onto a training program. And that was it really. [Jaz]And then it didn’t stop because you’re always doing extra things. And recently, I saw something pretty spectacular. You did Professor Zhu Kelly’s, like very coveted, very privileged, soft tissue program. Is that right? Unknown SpeakerYeah, masters. I saw the Kelly lecture at the EAD the European Academy of aesthetic dentistry. And he comes on. And just before him, there was a lecturer who talked about bone augmentation. And, you know, beyond all to do with implants. So this little Italian guy comes on, and he’s not tall, but he’s manly, the fiery and he comes on, and he is just like an angry man. Start giving this lecture. And then every sort of every sort of five or 10 minutes, he just stop and go. It’s not about the bone. It’s about the soft tissue volume. And I actually to crack me up, and I just thought that if you I want to learn from and literally his last slide was we decided to run a masters. And I said, so I took the detailed down emails straightaway, they said, you know, nothing’s happening for a till six months after so. But you have to go through quite a stringent sort of process because it’s in belong. Yeah. You want to submit all your qualifications and all these sort of things. And it takes a while. But anyway, I was the only prostho guy on there, because everyone else was, which was good. It was interesting. Because you know, I found the important [Jaz]A massive kudos to you. I mean, to me, as you I look up to you so much. And I look at you and I think Wow, man, you don’t have anything else left to learn you can start this soft tissue program that just shows your passion, dedication and your love to dentistry and how passionate you are about it. And definitely, it’s very infectious. But I think that’s what it shows. Right? You’re A) you can’t sit still, like your mother said and B) that you know, your passion and drive is so strong that you want to take on a whole not a completely different field because it’s irrelevant to what we do, but that’s really an admirable thing. [Riaz]Yeah, no, thank you. I think I’ve always learned that way. So I prefer to be tested and sort of stretched to learn a topic. And yeah, no, it was brilliant. One of the best thing that I did. It made me realize that probably would never do my training in the UK again, if I had to redo, if I was going back, you know, through my career? Yeah, I would go to Bognor Regis and do my training. No, I go states, I would go abroad and do my training abroad. Because if you’re going to commit to something, I think you should go to the best possible place to to learn. States, Zurich. So obviously, Swiss. You know, I mean, even need to be quite good at the moment. So you know, I wouldn’t do it here. Personally. [Jaz]I was very close to actually considering States, myself. And I got the same advice from Jason Smithson, around about four years ago, when I asked him and he said the same, you know, consider doing a Perio-Prostho program in the States or something like that. And a few people say that so, you know, I respect that. And it’s some good information for young dentists listening out there to consider. I do have an episode out there, I think it’s episode three about or two about moving to USA, we follow a young lady who has moved to USA to convert her BDS to a US one, and then you know, the world’s always different from there, so you can check that episode out. But today’s episode is all about functional occlusion. And Riaz, I want to start off by asking you, what do you mean by functional occlusion? And I’m just gonna drag out the question a little bit, because you’re the one who taught me that the role of sort of, the role of teeth is, or the relevant, you know, in general is mastication, in speech and in swallowing, okay? And then now you’re sort of the term functional occlusion. So what, how does that come into it? [Riaz]So it is a focus on those three roles. You know, when you think about what you do clinically, you know, you ask your patient to tuck the teeth together, you ask the patient to slide their teeth together. You know why? You know, the question always is, well, why are you doing that, you know, what’s the point of those steps? So when you ask them to tap the two together, that’s the swallowing position, absolute, that’s what’s done. And then when you’re looking at functional movements, you’re looking at mastication movements. So you’ve got to then understand how the mandible works, because that actually, is what teeth are designed to do. And then when you do get that wrong, then problems start to occur. [Jaz]Now, straightaway, as I want to start because you taught me that our teeth should only touch together for 17 and half minutes a day. And remember, you’re the one who the first person who taught me that and it was a Graf study in 1964, or 63. And you’re the one who sent me off on that track. And I started looking deep into it. So that my now my thinking is, please get now want to learn from me to correct me if I’m wrong. But now my thinking is those movements that we’re getting to do they are not functional, they are parafunctional. So how do, you probably go into this, but how do you then decide whether it is functional or parafunctional? [Riaz]So if it’s parafunctional, you’ll see signs those parafunctional. The functional movements, I think, you know, when I said that 70 and a half minutes, the follow on point from that was, what does that tell you about teeth? Well, that tells you that teeth are only really designed to touch for that length of time. Now, let’s even elongated say let’s say 20 minutes or 25 minutes, because that’s really, you know, that’s only one study that looked at in depth. So then when you look at that, you will find that but then parafunction is simply the extension of that. So function, low forces, less time. Parafunction, more forces, more time. So when you have those factors, we know teeth aren’t designed to handle that. So then you’re going to get problems with the teeth, it’s either going to be fracture, we’re mobility, migration, mastic, muscle issues if they’re parafunctioning, TMJ issues, you know, that they’re all the factors, sleep issues, you know, if you look at sleep apnea and parafunction, postural issues depending on try centric relation, if that’s, you know, philosophy you want to expand into. So the impact of teeth isn’t just this small little box that were designed to teach, it’s far greater on the overall health. So when you look at functional occlusion, we have to look at also what the impact is of functional occlusion because if you break your food down properly, you then digest your food better, your health is better, your sleep is better. If you are doing the thing that the teeth are designed to do which is related to the mouth is isolated to the overall health of the patient. [Jaz]How can you make that clinically applicable? I mean, is it just the same stuff we were taught at dental school well You know, that two hour lecture that we had on occlusion at dental school where, you know, we have our definitions, which are confusing enough. And then obviously, you want to try and get the concepts of anterior guidance or the minimal stress dentition. Is there anything that when you’re talking about function occlusion, is there anything that you think was was skipped or missed at dental school that you’d like to some key points I’d like to bring home during our short chat now. [Riaz]I think it’s teaching philosophies on occlusion is the biggest problem because we’re taught canine guidance, for example. So you know, you’re taught canine guidance at dental school and you’re told that that is physiologically correct occlusion. So when someone moves the jaw to the right, and the canines, take the guidance, and disclude, the posteriors, that is actually functionally and physiologically correct. And you have to then go back a step and you say, okay, you want to deliver canine guidance for your patients when you restore them? Why? Why would you do that? Number 1. Number 2, Who told you that? And what is it based upon? Because it’s like building a house, if you’re going to build the foundations on that house? If you’re using canine guidance as your house, what are the actual underlying pillars that support canine guidance? So if you then read D’Amico’s work, he published it in 1958. And then the other subsequent papers in 1962. And he said, you know, his rationale behind canine guidance was to refute the balanced articulation scope, which was what that was going on at that time. You know, everyone was given complete dental occlusion when they were rehabilitating the patients, and then there was numerous issues with it. So he said, No, that’s not true. It should be canine guidance. And he looked at Dr. Gregory’s work, Hector Jones work. Dr. Gregory he was the one who did his studies on Aborigines and they showed the wear of the canines. So it was like, Yes, you’ve lost a canine survival? No. First his. His understanding of the anthropological data was not quite right, because he only looked at certain number and not looked at a greater range. And canines are important teeth when it comes to function, but it’s not the establishing tooth of functional occlusion. The two teeth that established functional occlusion are your central incisors and your first molars. So if you think about it, then you go, Okay, well, why is that the case? Well, the reason that’s the case is they’re the two teeth that erupt first. So if you look at biology, and physiology tells you what which teeth are the most important teeth when it comes to function? It’s the incisors, and your first molars, you don’t see hypodontia first molars or central incisors are often, you do see a lot of palatally impacted canines. So if a function is designed, is dictated by the canine, then the poor child is not chewing properly from the age of six to 13. So functional occlusion is based around the principles of your first molar and your central incisor. And canines. .` [Jaz]That’s really facinating. [Riaz]Yeah, because canine guidance is part of your functional guidance, but when you go to canine guidance, you go beyond the envelope of function. So then what is the envelope of function while the envelope function is a three millimeter lateral movement in which you break your food down, you go beyond three millimeters, that’s then parafunction, that’s a habit based movement, not a functional movement. And that’s when you get wear of canines. And I used to always make me laugh when someone said, you know, when worn canines, give them canine guidance, because it switches the muscles off. No, you worn the canines, you’re going to worn when there’s a composite, you’re going to wear the [inaudible] [Jaz]It will happen again. [Riaz]It will happen again,because it’s not the canine guidance, you actually want group function in those patients because you want to share the loads and amongst all the restorations. So especially oblique because you know, materials are very good at compressive loads, swallowing loads, but not great at lateral oblique loads. [Jaz]One thing I just want to oppose the the areas and talk about a common error I see or people talk about is sometimes people message me and say for advice, they say hey, I’ve got this patient and they’ve lost canine guidance, and I’m thinking of adding some canine rises. But what’s happening is that they’re choosing these cases whereby if they add these canine rises, then as soon as the patient then goes into excursive again, there’s so much tensile load on that composite. It’s just going to break off and there’s no surprise when it fails. And you mention the great point which I want to highlight, because otherwise in passing, you could miss it is about those oblique. So in those cases, would you agree that perhaps if you were going to go down that path, you may then and there’s gonna be the rest of podcast, which is about raising the OVD but yeah, to me, you may have to consider raising the OVD or some orthodontics to be able to turn that load into compressive load. Am I going along the right path, you think? [Riaz]Yeah, OVD increases based on overbite and overjet. So your decision for OVD should always be analyzed as part of an overjet-overbite analysis. And I think that’s where the biggest problem is, because people think, yeah, I need the OVD to create space for the restorations. That is true. But when you increase the OVD, you reduce your overbite, so if you will reduce the overbite, you need to then make sure that you’re posterior disclude, the anterior certainly, but the incisors disclude the posterior. So if you then get the curve, then you have to make the curve of Spee flatter. If you reduce the overbite, so these are all things that we don’t realize we’re doing when we think about OVD, everyone just increase OVD. It’s easy as that. But when you increase the OVD, think of it like a clock. So you are at nine o’clock. And if you increase the OVD, meaning you go from nine to six, what happens to the line, the curve, you go from nine to six, you increase OVD but you also increase the overjet. That means you got to put material somewhere, it’s going to be either on the palatal aspect of the uppers and the labial aspect of the lower incisors. So yes, OVD is an option to give you bulk of material and change the angles and give but it still won’t protect against oblique forces, because of materials in bulk are still great with compressive. But oblique forces, they’re not great. [Jaz]But by oblique you also is it aka tensile stress, Is that good? Yeah. Okay, fine. [Riaz]Oblique means tension. So you basically put more tension on the restorations, therefore, they’re more likely to fracture or if they’re stronger than the underlying core, then the core will break. You know, that’s sort of the, it’s a balance. Someone has to win when it comes to force. So yeah, I think with OVD you increase to give you more material. So you bond onto depth of enamel. That’s the ideal. So you’re going, I’m gonna increase because I can bond to enamel therefore greater bonding strength, greater management of forces. But you it’s, the key decision factor is your overbite, overjet and your smile, because when you increase the OVD, they have the overbite is reduced, then you need to increase the length of the upper incisors so the patient shows more teeth. But if they’re already showing the right amount of tooth you’ve got and then take the gum. So, this is you know, OVD, you know, I give an advanced, two day advanced course on sort of looking at in detail OVD and how you analyze because the problem you have with occlusion is you use an articulator, that’s the problem. So it’s sort of whatever the reason why we do canine guidance, and we can’t do functional occlusion, is because the lateral movements on an articulator are nothing like lateral movements on the human. And the reason for that is if you just even go back to the basics of the articulator, if you just look at the ball and and joint of the articulator, first the ball is circular, and the fossa is Angular. When you look at a CBCT of your condyles they look like potatoes. They don’t look like balls. The glenoid fossa is not a perfect rectangle. So it you know, you can buy foster inserts, but you know the anatomy of the TMJ joint is variable. [Jaz]Riaz, you just reminded me of Episode 31 I did with someone called Dr. Andy Toy. I don’t know if you’ve come across the PGO, the posterior guided occlusion theory? [Riaz]Posterior guided occlusion theory meaning using the molars to guide the occlusion in? [Jaz]Yes, but also there’s an equation that Andy Toy and his team Ronald Presswood found whereby they did some anthropological studies and they found that Zola’s typical and the glenoid fossa and the angle that produces just like you said, that you know, the reason that can’t be produced into an articulator because too complex, but they found thatangle is the same angle as where the molars are at. So that was an interesting two episodes about how canine guidances is not The end goal shouldn’t be. And really, he talks about the PGO model. And if you haven’t checked out because I’d love to send you that to check out because I know you love this sort of stuff. But just wondering if you come across Andy Toy before and the posterior guided occlusion? [Riaz]I’ve heard of the theory, I’ve not heard of that terminology. I mean, we call it functional occlusion, because the dictating tooth is the first molar. So getting that, you know, distal buccal cusp of the upper molar, for example, right, and getting the curve of Spee right and getting your curve of Wilson right means you can design functionally indirect restorations, because one of the biggest challenges I think Dentists have are rebuilding first molar, because it’s the first two that is exposed, and therefore the first two that decays and first target needs endo and first, and it’s always that first tooth that needs the most work. And then, you know, most commonly people talk to me about, you know, the onlay looks really flat and don’t have the right shape. I don’t know if you’ve seen what we’ve done, do you know Nick Sethi? [Jaz]Yes, I know Nick very well, and I’ve seen some of the stuff you’ve done and the, I mean, do you want to talk about FIPO? Or is that for another time or? [Riaz]Absolutely another time. I think it just that was sort of the whole idea behind FIPo was that we do. We do a lot of our restorations, but we’re not looking at the true morphology and shape of teeth. And to try and design functionally driven restorations simply, you know, with a simple protocol, is what people really struggle with. And so we’ve been, that’s what the FIPO protocol is. But that’s just one of the principles that leads into, you know, you get the first molar, right, everything else is pretty straightforward. Once you have like guidance of the six, and then the five before the three cuspal inclination, and that’s what I thought modjaw helped. It’s helped me analyze more what I’m doing and, you know, see whether we are, you know, ultimately rehabilitating the patient, not just restoring them. [Jaz]Riaz, for those listeners who haven’t heard of modjaw, because younger does listen to this, and they may not have come across modjaw, I love your sort of postings that you do in your videos of showing people’s chewing patterns and whatnot. But can you just explain to those who haven’t had a modjaw before what it is and why it’s so awesome? [Riaz]So we’ll look at, this is the first, was not the first time not strictly true, but it’s probably the best technology we’ve had to date, where we actually use the human as the articulator. And how it works is it uses similar sensors that Pixar and animation use, you know, to replicate human movements in their cartoons. This is what we’re doing with that. So this is using a camera, infrared technology and using sensors on the patient. And what this is doing now is we’re actually looking at the data of the patient as the true articulator. And so this is using what’s called 4D technology. So we’ve gone from 2D 3D, we’re now into 4D, and it’s pretty amazing. [Jaz]And the data that gives you is just amazing. And it helps you to be a more functional dentist, I guess it actually can, you know, given the patient the best function. But the questions that are in my mind now is how can you make this actually tangible in terms? I mean, it’s very difficult, such a broad topic, but most people have been throughout dental school and they come out thinking that yes, canine guidance is what it’s all about. And it makes sense some degree is further away from the TMJ hinge. I remember you taught me the importance of canine guidance for those reasons, but also, mostly due to restorative convenience. And how easy is for technicians to build that in whatnot? But what are you saying now? You saying that you want the sixes to have some guidance? Can you just make it more tangible? The point about functional occlusion how it relates to sixes and ones and what is it that you’re actually looking for in terms of the dots in mind? [Riaz]So what you’re looking for is what are called your trajectory movements or your functional guidance. And so we call this cycle in and cycle out. So what that means is when the patient is coming in to the teeth to touch, that’s called cycle in, and that would be guided off the palatal inclines of the upper buccal cusps against the lower buccal cusps, the lower supporting cusps, so that’s what is guided in. Now the guiding in is what is the data for the brain, but it’s the guiding out there’s what’s called the cycle out, which is now the actual guidance against the palatal cusp of the upper is what breaks the food down. So this movements, and it looks like a pear, the classic description is a pear drop, and it’s not. I don’t think it’s sick strictly like that. It is certainly what I’m seeing Data Wise, is that we are getting a certain you know All shape. Now, what we’re looking at is two movements. We’re looking at the opening movement, and then the lateral movement, and then the closing movement in it. Now what I’m doing at the moment is I’m looking at patients before I restore them provisional restorations, and then my definitive restoration. So I’m looking at the chewing movements in three stages. And I’m answering the question whether I’m making things worse or better. Now, patients don’t recognize the restriction and cheering because they adapt. And if a patient has good adaptive capacity, they will say nothing to you, they’ll come in with your beautiful restorations and will tell you everything is okay. And that is right in their mind. Because functionally, they have adapted to what you’ve given them. But if you were to actually look at the chewing motion data, because remember, teeth are designed to break food down, you would probably find that the chewing cycle has narrowed and become more vertical, meaning that they’re still chewing but the lateral component to protect themselves from breaking your work, or because of the design of the teeth, that they’ve got themselves. So the movements of guarded, the functional movement is narrowed. And I can show you a picture of a case which we did. And when I did the pre treatment, I know people won’t see this book, I think it helps to sort of if those that do see it, then it consult [Jaz]Those who watch it on Facebook, Instagram, and YouTube and whatnot. So we can almost describe it. But what that mean, as you’re loading it up, and as you’re about to share your screen, I believe there is a Landin and Gibbs study whereby they had people in this or, you know, let’s call them cows, you know, like side chewers, for example. And then, after rehabilitation, they became vertical chewers. And I believe that was seen as a good thing. Are you suggesting that’s not a good thing? [Riaz]Yeah, definitely not. I think if you look at this sort of case here that we did, I mean, this is sort of, this is the starting position of the case. So just to give you an idea of where she was at, that’s the starting position. She’s got a bridge from the upper right, four to the upper right six, and the false failed, the three is in the position of the two. So that’s actually a three, canine and if you look at the sort of the design of the teeth before, just look at the shape of those cuspal inclinations they’re very flat. Yeah, that’s because we use an articulator. Okay, so that’s, that’s a type of design, depending on whether your average value set. So that’s just a modjaw. So what I did was, I did a preposition. So if you look, if you actually analyze the data on this, you’ll see that the width of the position is four millimeters width at the bottom. Okay? So each square is one millimeter. [Jaz]Okay. [Riaz]Okay? So if you look at the arrow four squares, so her width of lateral movement is four millimeters. If you look at what I did, and I put it into a provisional first, and her width increased on chewing on the right to seven millimeters, and then in a final, her width moved to round 10 millimeters. Now this is the bottom. So that’s actually when she opens the mouth laterally. So what does that tell us? Does that tell us now that her muscles are more relaxed? Does that tell us that actually, she’s more comfortable moving. But the next slide is what really sort of hits home this, because if you look at the cycle in, now the foot, the vertical movement when they’re coming into the teeth touching, okay, that’s where those lines also, this is now where teeth are touching. So when she started, she was two millimeter lateral movement when she comes into chewing her food, though. So the red is cycle in, green is cycle out. But look what happened in the provisionals. She actually had the same two millimeter width, but can you see the trajectory? It became steeper. So why was that? That was potentially her way of guarding she was going, actually I know my bridge is provisional. So I when I chew, I narrow my chewing cycle. So actually, don’t put too much force on an oblique angle. And then look what happened when we put her into a final? Look at the width and the trajectory totally changed. So she’s gone from a two millimeter functional movement and that’s because I’ve corrected the angles. If you look at the sort of the shape of the teeth, but that’s sort of, that’s where she’s at now. But if you look at the shape of the teeth on the right, Look at the way they’re positioned to be totally, you know, functional. And so, hey chewing has improved, you know that that is our role, our role is to improve the situation, improve the functionality. [Jaz]That’s very fascinating. Absolutely. [Riaz]if you look at this sort of cases where I mean this is, these are the angles of the cusps on a modjaw, you know, this is what functional teeth should look like, you know, they should have steeper angles, steeper. And that’s because teeth are designed to break down, your morphology is actually like this, you know, whereas, when I look at what we used to do this is before I had modjaw, so, these are cases that I did before modjaw if you look at this case, here, you know before.. [Jaz]On the right side is what you would do before modjaw? [Riaz]Now these are both modjaw left and right but if you looked at the next this case here what I did without, this is what I used to do look at the this is on another bridge value articulator you know, look, if you look at what I did, I also I did this with a case, I did a case where I made two sets of restorations on the posterior. So I did you know, if you look at that, if you look at the cuspal angles on the average value, and what I did here was I sent it to two different labs in two different countries. So the right modjaw is done in France. On the left side, the average value is done in the UK, or using my digital scan data, but one was done using motion data. And one was done using average value settings on the digital articulator. So look at the cusapal inclinations of functional data. Can you see how the palatal inclines and the buccal incline is the same when you have functional data. But when you don’t have functional data, look at the different angles. It’s sort of, you know, different shapes, there’s no force to functionality. Whereas when you do restorations or a functional look at the similarity in the shapes that are created, you know, this is a bridge. So this right one was made on modjaw, the left one was made from average values. These are all cycle in angulations, if you use an average value, the cycle in angulations are all obscure. But if you use motion data, you have very similar cycle in pathways, because that’s all teeth, designed to be functional and break in if you don’t. [Jaz]Riaz, I’m smiling, because you’re doing it again, you’re doing that thing they did to me in 2013, you’re making me think, you make me like rethink everything. [Riaz]You know, I thought, you know, when the penny dropped, gone, it was like an epiphany moment. And literally, it took me, It probably took me six months have to stop kicking myself, because for six months after the penny dropped, and the jigsaw everything just fit it together, I thought I was kicking myself solid, because six months, even now when I think about it, I get irritated with myself, because why I got irritated with myself is because I blindly believed what I was taught. And I never questioned it. And I should have questioned it from the very outset, you know, and someone’s had canine guidance to me, you know, and they gave me the rationale, I should have still gone Why, why why? or Why? Why? Why you know, and, you know, I want to use this opportunity to thank my mentor, because, for me, the guy who really planted the seed on functional occlusion was a French guy called [?]. And he passed away on the second of July. Very dear to me. And so, you know, it’s credit to him. But he sort of, you know, literally blew my mind, literally shattered everything that I read up until that date, and just, you know, made me think, you know, Ever since then, you know, I was like canine guidance, why? It’s crazy to even think that one tooth is gonna function and guide you. And it’s just, it doesn’t even make sense. Now that I say. [Jaz]I spot on I agree with you. And I definitely see the world and again, my world has been shaped by you as well in the past. So I definitely agree with you that canine guidance is not the be all and end all and most of our patients in the natural dentition don’t have it to begin with it. Would you agree with that statement? [Riaz]No, I think they have canine guidance. But if beyond and beyond the natural movement is the I have canine guidance on my right. But I have to go to an excursive movement that is not functional. It is a parafunctional movement or it’s a habit based movement. So when you do canine guidance, you don’t chew like that. You don’t have to have your canine to guide you in. [Jaz]Okay, brilliant. So yeah, I mean, one thing again, I’ll reference back to the the PGO episode is that one of the theories cuz now we’re just getting to philosophies and theories, which is quite interesting actually, is that if you were to observe canine guidance and you know we do this all the time your patients supine, Okay Mr. Smith can please grind your right half time they know what they’re doing, but when they do figure it out, you can see Ah, yes, the canines are touching and the posteriors are discluding. And you may say, okay, that’s canine guidance. But when you actually get them to do it with some force, you’ll suddenly see all the back teeth involved in that guidance movement as well. So the theories suggest that actually, how many people are really on canine guidance at full force, which is really what you’re doing in a parafunctional movement, or perhaps nocturnally. And what the PGO model suggests that actually, very few people are in canine guidance, because when you actually do the healthy clench, when you actually put some force into it, you compress the PDL, and you sit your condyle perhaps a little bit, and then suddenly, the sevens and the sixes and the premolar is coming. Oh, I’d love to hear your view, or the take on that. [Riaz]You know, forces in functional movement are low, unless your food is hard. So functional forces are low, you know, if you use [inaudible] paper, you know, you’re looking at 40 Newtons, which is 80 Snickers bars, you know, so the force of 80 Snickers bars the weight of 80 Snickers bars, it’s not actually that heavy. So you know, and that’s, if you’re gonna chew something a bit hard, you know, someone needs a bit more force. That’s why the incisors are so important, because of the number of periodontal mechanical receptors in the anterior teeth are more than the posterior teeth, because you grab the food, and that data to the brain tells you how much force you need to apply on your posterior teeth. It’s why you know, not to chew soup. No, you don’t think about it, you just you just put in your mouth, you know, it’s liquid, you don’t chew it, you swallow it. And if you have a bit of crouton in it, you know, straight away whether there’s a bit it’s hard crouton or soft, so this data is part of functional data. So functional forces are low, when they talk about clenching forces. And other Yes, you, when you apply force, you increase elevator muscle activity. And so the rest, the rationale behind canine guidance was because canine guidance separated the posterior tooth, and therefore switched off elevated muscle activity. But for functional occlusion, you want muscular elevator activity. You want it because you’re breaking your food down. You don’t want to be switching off your muscles, because.. [Jaz]That’s what they are. That’s what the PGO camp argues as well, actually one of the muscles on you don’t want them off, which is, which is in agreement with you. Absolutely. But I mean, there’s so many directions we can go in this episode. But really, this is an introduction for us to functional occlusion. One thing to ask to make it tangible is can we make functionally correct restorations without modjaw? That’s question A and the B part of that is, can we just achieve that if we’re conforming, by following the cuspal inclines of the adjacent teeth? Would that do the good job? [Riaz]Yes, if the adjacent teeth, looking at the mouth, is going to help make a lot of your decisions for you. So for example, using the FIPO protocol, for example, like a lower six you’re restoring, but the upper six is a natural tooth, it’s fine. So what I do is I just basically a bit of self etch primer on the tooth, and I put a small bit of composite on them and I get the patient to bite into that composite and light cure it. When they open. you then have the cuspal inclines of the palatal cusp in there, that is your data, you can adjust it a little bit to get the right inclination, but there straight away you have your anatomy of your restoration. So you don’t need modjaw to do functional restorations, you can do it quite quickly with a bit of self etch primer on a small amount of composite nuts if you’re doing single or two or three restorations. When you start to do a quadrant of dentistry, then you need to look at obviously functionally guided pathway techniques. So for example jaw, asking the patient to chew but not getting them to grind the teeth, but actually getting them to chew and get the data the other way around. You can then do it without modjaw but then the technician will struggle because he’s then putting the data on an articulator. So, the challenge is not you we can do it ourselves. But the challenge is when you then give it to the laboratory. Now if you’ve got digital you can potentially scan that and then they can use a digital software to then design the restorations using those inclinations. But even on digital, they using digital articulators set average value settings because with digital articulators you’re not populating it with a protrusive bite. You’re not populating it with [ ? ] function, for example, or [3D occlusion brand] or other devices, DNR cardiacs these are the digital tools that give you values to populate an articulator. So the modjaw, you know, it’s for me, because I got a lot of questions that I need to answer. And some of the questions I’m starting to answer in my own head, you know, am I rehabilitating the patient? Am I making their function better? And, you know, part of that assessment is obviously a muscle assessment, the TMJ assessment. And, and I think, to be able to do good quality dentistry, you don’t need expensive tools, you have to just first be able to understand the basics, well, that’s a good start. And then you realize that the tools will make you a better, will make you understand more and therefore perform better. And then, you know, you will end up investing because you invest in your career. And I think our modjaw, I think modjaw will be, I think that is potentially going to be one of the most essential tools we’re going to have if you’re doing rehabilitative dentistry in doing multiple. But if you’re doing general single arch, single tooth dentistry, then clearly no, you don’t need to even multiple units here in there. You could design the teeth, just looking at the morphology of the opposing arch and correcting it with composite, that’s well. [Jaz]Brilliant. I’m just very mindful of time, I’m going to throw some quickfire questions at the you Riaz, because it’s taking a very interesting, I’ve really enjoyed your almost philosophical debate. And there’s been some parallels to the PGO concept, which I’m definitely send your way because I’d love to have your input on that. But the kind of question that have now based on everything you said, is Frank spear said, in his sort of treatment plan sort of thing he EFSB. So aesthetics, function, structural, biology, that sort of famous sort of treatment planning sort of acronyms you like. And then and then Michael Melkers has always taught me that, in fact, it aesthetics, parafunction, structure, biology, because when we’re doing a rehab, and this is what the the canine guidance camp will tell you is that when you’re doing a rehab, you want to set the patient up for, to reduce the the forces in every way possible. And that’s what you sort of alluded to, as well that you know, it reduces elevated muscle activity. And of course, you want to get onto the anteriors as much as possible, whereas now you’re saying the Sixers have an important role. So now that you’re doing your rehab in a functional occlusion way, and you’re checking the occlusion at the end to make sure it’s set up for success, what percentage of the rehabs now have got pure traditional canine guidance? And what percentage have group function? Is that a fair question just to get an idea of what the end product actually looks like? [Riaz]Yeah, so I think in the last, since I bought the modjaw, everything has been shifting over to quick function. And prior to 18 months, it was, I was using FGS functionally generated pathways to try and get good function. But it was more difficult to do it was easy to just give them canine guidance. Because patients adapt. So I think, to date now, pretty much every case is a group function, it’s parafunction. Now I know, you know, what Michael said was, you know, aesthetics, parafunction, you want function first. And for me, if you get functio right, function and parafunction are not too different in their movements. You will have some that do more obscure movements, but you can’t prepare your restorations for that, you know, when they have a true habit based occlusion, you can’t prepare, you’re designed to protect against that. If they got, for example, they’re moving their jaw to get to that lateral incisor, or that canine, that’s a habit, you know, you they will just destroy that area, and you’re just going to be rehabilitating that area, you can’t switch off the parafunctional habits because parafunctional habits aren’t truly occlusion based. They are much more than that. They’re genetics, they’re hormones, you know, Hashimoto patients, Chlamydia patients, you know, you can have so far greater link to parafunction than just teeth. But that’s not to. I’m not, you know, I listened to Manfredini. I’m not that solid to the point where occlusion is zero? I think small, I think it’s a small amount in certain patients, but it’s definitely not all of it, you know, it’s not like occlusion. And then it’s that right? [Jaz]Absolutely. And you’re the one who taught me about micro trauma and macro trauma as I look to you in terms of my learnings with that. And just to wrap up a few more questions that I have I had a really good one. Now that you’re finishing these cases in group function, and perhaps the reason these patients ended up in your chairs, especially this is because they have done weird and wonderful things for dentition. There have been parafunction, they have been bruxing, they’ve worn their teeth away. And now you’re building the functional occlusion which involves group function. A) you’re not worried that they’re going to destroy with increased elevated muscle activity, all the lovely restorations that you put in? And B) does every rehab get a appliance for protection? [Riaz]If the underlying cause is also is parafunctional, then yes, for nighttime where they will get a protection or get there because that is something that we can’t control. So they do get a splint, if they’ve spent that sort of money. How, will they break my restorations? We’ll have to do the podcast in a couple of years time? And I’ll tell you, because at the moment they’re not. [Jaz]Yeah, of course. [Riaz]You may be absolutely right. In in two years time I, and I’ll be opening up, you know, I’ve learned this, you know, with people that have been through with me through my journey of will have seen me change my understanding and my teaching to reflect what I’m learning, and why I’m changing and why. And just to find it. [Kelly] was the one that taught me that with, you know, absolute passion, that his position five years ago is different to his position now. But that’s because what he’s learned and what he’s doing. So I’m, you know, recording these data’s and I’m doing the modjaw and I want to know, you know, do our patients I mean, that bridge may only last two years. Is that because of what I’ve done? Potentially. Could it be that she bit on something hard or, you know, a fellow but you know, it’s all these unknowns that we don’t have, but certainly, you know, we’ve got to be reflective critical of ourselves, when we’re looking at our work. So yes, I may come back to you in two, three years time ago. And story, Jaz, whatever told you in that. But I’m actually more comfortable in my skin now about occlusion than I’ve ever been. And that I’m now more solid on that. Now I’m happy to stand in front of thousand of people. And before, I believe I understood it, but I never really had 100% conviction, there was always this niggling doubt in my head. And I just couldn’t get it out of my head. It took, you know, years and years of reading and reading and reading. I just, it just never comfortably sat in my head. And so there was always this niggling doubt. And it always hit me when someone asked me a question, you know, and the biggest question that always got me. If the canine tips, Why would you give them canine on guidance again? I was always stumped by that question. Please deal with the material away rather than the tooth? That was my answer. And I remember even sort of saying it always felt I didn’t say hypocritical, but it just never felt, you know, yes, I did it. I was taught Robin Gray was one of my mentors who was you know, fantastic TMD, fantastic dentist. Steven Davis, one of my mentors, an amazing guy. And very knowledgeable. But I just have time with me. Until now. Now I’m comfortable in my skin. [Jaz]That is amazing. And I think that wraps it up, Riaz. Tell me, where can we learn more about your way of thinking now? Because there’s a lot of people who can have lots of questions in their head. And so I know you’ve always been a good educator, you’ve had your year long programs in the past, then if you start doing that, but where’s the for the hungry minds that we have. Which reminds me that I mean, we’re study club as well, where you people come and you feed them? That was great, by the way. Tell us where can we learn more, Riaz? [Riaz]Yeah, there will be some data coming out with our recent restriction of we were running a two day course in November, that is, again, tentative now I don’t know if that will happen. So I think just wait till next year, the year long course is starting again in February. It’s with, it’s going to be a diploma in Advanced Aesthetics. So that’s starting in February. It’s going to be me, Nick, and Sanjay, who are sort of running that program. So I think.. [Jaz]Is that London or? [Riaz]Yes, it will be in London and in up north. So Manchester and London. [Jaz]Brilliant, please do send me a website link. So I can stick that on for those who are interested. Because part of it is that I bring on lots of educators of various backgrounds, and some listeners will resonate more with just that, you know, some will resonate more with certain educators and other educators. So I want to give everyone the platform and it’d be great to have that. So check it out guys. Riaz has has blown me away once again and reset that sort of hunger to learn. So, thank you so much for giving up your time and Maybe I will take you up on that part two, because, honestly, I’m looking through my questions that I had. And we didn’t even get to when to just conform and and reorganize the staff, because it just went a little bit philosophical. And I really enjoy it for that reason, but one day what we might cover that. [Riaz]Definitely, my pleasure. Thank you, Jaz. And well done, by the way, I love what you’re doing. And this is, you know, it’s brilliant. And kudos to you. Because I think, you know, what you’re doing is giving everyone that opportunity to learn, you benefit, but actually you’re sharing it with everyone. So yeah well done. [Jaz]That’s very kind of you. Thanks so much for your inspiration we appreciate. Jaz’s Outro: Thank you so much for listening as always, all the way to the end. I really appreciate it always. Hoped you enjoyed and gained value from Riaz. I think what he’s done to advance studies in occlusion and helping us dentist understand over the years is just amazing and phenomenal. It’s one of the reasons that why on the splint course, one of the first few slides are having a splint course there’s a photo of him, as well as many other dentists who inspired me to learn more about occlusion and made me better at delivering splints, and maybe question the why, the how, the when of splints. So Riaz is definitely in that category of these inspiring dentists. That meant a lot to me in my journey. I’ll catch you in April which is straightpril, and we’re going to talk all about orthodontics over the next month. I hope you enjoy. Reach out to me on @protrusivedental and it’d be great to connect with you all. Enjoy Straightpril!

This is THE most common question I get – ‘Jaz, can you just tell me which camera to buy for dental photography, I am so confused!’ I’m no mug when it comes to Dental photography, but I wanted to get a real expert to help answer this important question. I present to you Alessandro Devigus from Switzerland who owns the @dentist.camera Instagram page (which I love). https://youtu.be/q3VkbMLhsn8 Need to Read it? Check out the Full Episode Transcript below! I was shocked that he recommended a Mirrorless set up – but I totally understand his rationale. Here are the links to the products he mentions: Budget Setup Nikon Z50 Mirrorless Camera Body – ensure the kit comes with a FTZ Nikon adaptor so it works with the lensNikon 85mm Macro Dx LensMieke Ring Flash for Nikon Budget setup for excellent Dental Photography The ‘Posh’ Setup A Canon or Nikon Full Frame camera, with a 100mm macro lens and 2 x flashes mounted on a bracket – pick your favourite brand eg Nikon or Canon. It’s all good! If you enjoyed this episode, you may also enjoy the IMPORTANCE of taking photos in your Dental Journey, check it out! Click below for full episode transcript: Opening Snippet: Hello Protruserati. I'm Jaz Gulati and welcome to another group function. Today’s mission is to help you figure out, which camera to buy? Like I am absolutely inundated with messages and one of the messages I get is, “Jaz can just tell me which camera I should buy?” Like people we don't want to do all the homework and the research and why should you right? Jaz’s Introduction: Nowadays there’s too much variety there’s Sonys, there’s Nikons, there’s Canons, there’s a lot of variety and it can get very confusing to know which setup is for you especially when some gurus will recommend a 60 millimeter lens and others will recommend a 110 millimeter lens or something and a different ring flash and a bracket system. It can get really confusing especially if you’re buying your first camera. So I got an expert Dr Alessandro Devigus who owns the instagram page dentist.camera which is just brilliant right? Because what he shares is every dentist who’s passionate about photography they share their setup, what are they using on that instagram page. So definitely check that one out. The question I’m answering for you today guys is if you’re on a budget, you’re a new grad and you’re going to buy your first camera, which camera does Alessandro think you should buy and then also he’s answering the question if you are an established dentist in the sense that you’ve got a bit more money and you’re maybe looking to upgrade your set which is the bells and whistles one that he would advocate. Now bear in mind that Alessandro is team Nikon and I’m team Canon, so obviously he’s going to recommend Nikon right? So it’s totally cool honestly. When you get a Nikon or a Canon, it’s not going to make a world of difference at all. I would probably go with the setup that he recommends which I’ll keep in as a suspense for you obviously. The thing that people will probably also want to know is what is my setup, what am I using. Well I’m using a very old model. I bought this like eight years ago right? I’m using a canon 60d if I was getting my setup all over again if I was a new grad and instead of getting the 60d which was pretty good back then I’d probably now get the canon 850d, I’d get the 100 millimeter macro lens which is still the same one I have today and I’d get a ring flash. Now I know you can get twin flashes and you get the sexy line angles and stuff but I think when you’re starting out in photography you want consistency and you want to be able to take effective occlusal shots and you don’t have to faff around too much. So I think start with the ring flash. It was designed for this kind of stuff, it’s brilliant and it’s going to get you a lot of good shots and you cannot, you can even be artistic with it. You can actually detach the ring flash part and sort of point it from different angles if you want to start taking sexier photographs but as a beginner I would definitely get a ring flash. So that’s my sort of pearl as what I’d get if I was a new grad. Now listen out to what Alessandro has to say, he actually recommends a mirrorless setup which he thinks is the future because it’s got this cool function whereby you can focus much more easily like it’s really clear to see with these mirrorless cameras. What is in focus and what is not in focus because one of the things that we struggle with when we’re starting out in dentistry is when we’re moving in and out and in and out to get that focus. Well with these mirrorless ones it can really make it easier especially if you’re still wearing loops and even a hood like I do I can see the advantages that Alessandro recommends and why he recommends the mirrorless version. So that’s my take on the 850d and listen up to what Alessandro has say on your first camera and perhaps a fancy camera if you have less of budgetary constraint but one more thing I want to say is if you are going to buy a camera consider going to websites like wex, W-E-X and looking at the refurbished section or go on gumtree or ebay and buy used like I bought all my stuff used from photographers so you know they looked after that equipment really well. So that’s a little hack to save you money and my camera’s still going eight years strong, my ring flash, my camera. I think I changed my ring flash once and the lens like it’s been eight years right? It’s such a great investment that’s tax deductible so I think if you’re not taking photos ready, keep listening and you’ll get a recommendation from Alessandro. Main Episode:Dr Alessandro Devigus from Switzerland, how are you today? [Alessandro]Oh I’m great seeing you and you did not shave this morning but you look still good. [Jaz]I haven’t shaved it many many mornings ago, never. So I like that. I’ve got you on as my expert today on dental photography because the most common question I get now if I’m getting this question then you must be getting this question like a million fold compared to me because you own the instagram dentist.camera and what I love about your page is that you get dentists who are passionate about dental photography of which are many of us. You get them to share their setup so if anyone wants to know what other dentists around the world are using, they need to visit your instagram page right now. It is phenomenal. But please Dr Devigus tell us a little bit about like one because you’re coming on the show in the future as well just give us a little flavor of why you know so much about dental cameras and then then we’ll ask answer that burning question which camera should you get as your first system like just how would you answer that? [Alessandro]Oh today that’s a very easy question to be answered. So my first answer or my first question back to this question is what is your budget? I might ask dentists about their budget, the budget for dental photography it’s always very low. [Jaz]Let’s do, if you don’t mind Dr Devigus, two scenarios, one is the new dentist who has a very limited budget and then the other one is maybe now you’ve been working a few years and now you can afford to buy a nicer system. I think that we’re going to really serve a lot of dentists by giving two suggestions from you, Dr Devigus. One on a budget and one not so much on budget but what you think is appropriate? [Alessandro]Okay. So the one on the budget suggestion I can give everybody out there today is going for a mirrorless camera and everybody out there knows that I’m a nikonian but you find the same or a similar setup also on the canon side. So I would go for a nikon z50 which is a dx format mirrorless camera offering all the advantages of mirrorless cameras like focus peaking helping dentists really a lot to get sharp pictures all the time. Attached an 85 millimeter dx macro lens and buy a mic mk t14 flash, you get a perfect system which creates great results in quality in handling. Easy handling, great quality at a low price and I think it’s below 1500 euros not pounds but we’re talking about 800 euros or even less for the camera for the for the lens and 100 for the flash. So you really get and this is the basic kit I’m also using in my office. So this is the basic stuff if you say oh no I want I’m an advanced photographer and my budget is unlimited then I would recommend going for a full-frame camera either a canon full frame or a nikon full-frame camera but also and attach a 100 millimeter macro lens go for a flash bracket attach two flashes to this flash bracket because the flash bracket is a tool that gives you the possibility to move the flashes in all possible positions you want you can imagine so it gives you the ring flash position and also the lateral flash position for let’s say more aesthetic shots. So but then we are talking about cameras around 2000 only the camera, 500 to 1000 for the lens then you have to buy the bracket for 300, you have to buy the flashes so this is three times the price of the basic kit and again I would I would recommend, I had doctors telling me yeah I’m lecturing and I want to do workshops I told them look the basics are always the same and you can start with this basic kit and I really tell you I love this basic kit I bought it. I put it together just to explore a little bit and I really love it and my girls my assistants, my dental assistants love it because it’s very light, no fuzzy setups, easy to use and consistent giving good and great results. [Jaz]Why did you suggest the 85 millimeter lens in the in the budget setup and not 100 millimeter? [Alessandro]Yeah because there’s no 100 millimeter dx lens, so the 85 dx corresponds to a 135 millimeter full frame lens. So everything above 100 millimeter from my point of view is considered a good lens for macro photography giving the working distance you need to avoid perspective distortions and give you a better light control, that’s it and I’m not discussing about a few millimeters more or less on focal length. [Jaz]If I was to twist your arm and also get you to suggest a canon budget camera, what do you think of the 850d I believe it is that seems to be recommended a lot as an entry-level canon as well I don’t think that one’s mirrorless though. [Alessandro]Yeah, I have to be honest I’m not the canon expert, I tested more on the Sony side. Some Sony cameras comparing them to the canon and Nikon setup and at the end for me I know that 50% out there are Nikonians and 50% are Canon users and from my point an important message it’s not the camera that is the most important part of your photography setup, it’s go for a good lens which has to be around 100 millimeter, go for a decent flash system and the camera attached to is it’s not really an issue but the issue is what can the camera do for you and that’s why I recommend using mirrorless cameras because they offer focus peaking and I want to repeat this focus peaking is highlighting the areas that are in focus when you are doing the manual focus. You have to do manual focus in dental photography and you can imagine even if, if you’re wearing glasses you can take the glasses off because you had you had your loops on you, take off the loops you take the camera you look through the camera even without putting on your glasses and you see the color where your picture is in focus so you don’t care if it’s sharp or not you see that the focus is on the canines on both sides so you have it helps you also in the orientation if you’re in the correct position in front of the patient and then you just click the button and it’s also easy to explain to anybody else. So it makes coaching it makes training much easier to tell people look through the camera and when you see that you see the red color on the spot where you want your focus to be set then just push the button and you’re 100% sure that you get a sharp image all the time. [Jaz]Amazing thank you so much for that and just such a humble man. You didn’t even like give us, give your own introduction I mean just tell us a little bit about that we have a few dates lined up in I believe May and June to really go much deeper into photography so we’re going to cover the basics of getting started into dental photography because you’re so experienced and so knowledgeable about this and then we’re going to talk about advanced techniques in the future but tell us a little bit about your practice and how many cameras do you own? [Alessandro]I tested more than 100 cameras in the last 15 years, so I can consider myself to be or to have some experience in that field and give you some advice and my advices are never to go for the most expensive stuff. To go for the most sophisticated things. For me it’s important that everybody out there can get a camera can set up the camera and can take great pictures every day and we are not professional photographers, we are dentists and we have to use photography as the second tool, the second imaging tool we have, we have the x-ray to look inside our patients and we have the photography to look on the outside of our patients. And this should be something that is easy to use reliable and predictable and repeatable and with the standard and we will talk about the standards in dental photography in these two episodes for sure. [Jaz]Amazing, Dr Devigus or Alessandro. I can call you Alessandro now. Thank you so much for helping me with this group function because it’s a question I’m getting so much and I just wanted you dentist.camera on instagram to answer it and guys do check out the instagram page, wet your appetite and send in your questions ahead of the episodes in May and June which we’re going to really make it the most like complete resource that we can do in a podcast where it comes to photography. We’ll make it some enjoyable learning and so you can learn about how to improve your current setup or how to take more standardized photos which is the toughest thing when you have those whitening cases and how to keep that standardized to taking a photo three years later and how to keep that standardized and any sort of questions you have for Alessandro please send them in, I’m sure he will do his best to answer them. [Alessandro]Cool looking really forward to that and hope to see many of you on all the social medias and especially to have many of you joining the discussion with Jaz in a very short time. Jaz’s Outro:Amazing. Thank you so much.

You place some veneers and your patient leaves in tears of joy. Imagine getting a letter a few weeks later to tell you that the patient now HATES her veneers and would like a full refund. That is soul destroying stuff, and it’s NOT about the money! https://youtu.be/LCAhjm9ymy8 Dr Rhode to the Rescue! Need to Read it? Check out the Full Episode Transcript below! Within the context of this specific scenario where 6 veneers were placed, we discuss: A. How this could have been prevented B. How to handle the veneers that are ‘bulky at the gumline’ C. How to handle this refund request…! I want to thank Dr Manrina Rhode for yet again adding so much value for the Protruserati You can check out her course on Designing Smiles website If you liked her episode and want a full hour of Veneers from preps to Temps, check out Everything Veneers with Manrina Rhode Click below for full episode transcript: Opening Snippet: You pour your heart and soul into a treatment. You like study extra, you go on extra courses, you want to give your patient the best they can get so when it comes to like cosmetic dentistry, veneers remember your first couple of veneer cases like you really think about it. You really go that extra mile to make sure your patient is ecstatic at the end and then you get a letter saying that I would like a refund for my veneers like that crushes you right? Jaz’s Introduction: So this my friends is something that was experienced by one of the Protruserati. She’s going to remain anonymous and I really wanted to help her. So I’m recording here on Sunday as in like an emergency episode I message Manrina Rhode, veneer queen who else right? About how to tackle this scenario. So the scenario is basically you do some, you place six veneers for a patient and she’s really happy, she approves the try-in, she approves a mock-up even, she signs your consent form, she leaves really pleased on the day that you fit the veneers and then you get a letter and you think this letter is going to be a thank you letter but actually it’s letter say that I have gone and got a second opinion from so-and-so dentist pg, dip aesthetic dentistry and implant density blah blah and we both agree that the veneers are too bulky. So the main complaint was actually I think by the gum line they’re too bulky and I don’t like them anymore without actually telling the dentist. They just wrote in like out of the blue right? And I would like a full refund of all the treatment. So this dentist wrote to me to say that she’s really upset that this has happened and she followed the whole protocol and she worked so hard and she’s a really awesome progressive forward-thinking dentist who has put a lot of time and money into her education so I felt really crushed for her because of one sentence she said that she’s really lost confidence in herself. And we will all lose confidence in ourselves in some procedures throughout our career. It happens it’s inevitable and I want to make this episode to help her out and so that we all as a group can learn because we all have patients, veneers patients in particular right because I’m happy to say that patients who come seeking veneers they’re all a little bit crazy let’s face it. They’re a little bit crazy I think and we have to be wary of body dysmorphia. So I pitch this scenario to Manrina Rhode, how would she advise handling a scenario A) had to prevent this from happening in the first place that you don’t have an unhappy patient. B) now that a patient has complained of bulk veneers, is it okay to prep them down? How do you manage that? and C) should this dentist give the money back to the patient? What does Manrina think? I actually felt bad about asking Manrina this last question because very tough question to ask. I really twisted her arm at the end so anyway I hope you enjoyed this group function and I hope you gained value from it thank you so much. Main Episode:Veneer queen, Manrina Rhode, welcome back again to The Protrusive Dental podcast, how are you? [Manrina]I’m good, Jaz. How are you? [Jaz]I’m amazing thank you so much for coming at short notice to really help this dentist but I thought this would make a really great group function to help all dentists because we either have all been in some kind of a similar scenario where a patient is unhappy and or wants a refund or it’s something that we can find similarities and or avoid certain the situation for the future for any dentist who can learn from this. So if you don’t mind, I’m just going to go straight in to the main question but for those of you who haven’t listened to Manrina’s episode on veneers yet, it is one of the most listened to podcast episodes on my podcast. It was episode I think it was 19 or 21 so I think around about that sort of that time and it’s on YouTube and it’s got like over a thousand views and I’ve always get great feedback from people actually listen like on the way to work when they’re placing veneers just because they want to learn for those last few nuggets from Manrina. So that was, if you like the ones with them lots of value in them you should definitely check that out. So Manrina, the scenario is there’s a young dentist, a really really caring sweet dedicated young dentist who really cares about what she’s doing she took on a veneer case and she’s always asking for advice stuff, always happy to help people like her who are so interested and keen and what happened is that the patient has now told this young dentist that I don’t like the veneers anymore because they’re too bulky at the cervical region and I want a full refund so that’s the long and short of it. In what we don’t see in the background is the fact that she had fantastic consent form that was personalized to the patient. She did a smile trial, she didn’t take any shortcuts. She did everything step by step by step and the sad thing is that she said in her message to me that she feels like she’s lost a lot of confidence and she feels really like broken which is really sad so Manrina, I think if you break it up into three components, number one how to prevent your nuggets to, how to prevent being in that scenario? So should we tackle that one first. [Manrina]Yes, let’s do that. So there’s got to be a lot of stages that you go through before you get to your final veneers and it sounds like this lady did go through a lot of them. So the first one that I use is photoshop that I use initially to show the patient what they should expect they’re going to achieve. I think in this case she was closing a diastema. So particularly in diastema closure it’s really important to use photoshop because you want to use it to decide how many teeth you need to involve in the process to create your plan. So also I guess she would have given orthodontic options that’s really important in diastema closure depending on whether you want to make the teeth bigger when whether the teeth are already quite small and you want to make them bigger and so maybe orthodontic options aren’t as relevant or they are relevant but you don’t want to close the space fully so you want to be familiar with smile design so you’re making sure that you’re keeping golden proportion, you’re keeping the right 1 to 0.8 ratio for that central incisor. It all starts with the central incisor and then it all goes back from there with smile design so and also to check that they’re happy with diastema closure whether they would want full diastema closure, whether they don’t. I know in this case that wasn’t the issue. Well she says it wasn’t the issue but maybe part of this is the fact that we were closing a diastema and so maybe things look a little bit more bulky than they would otherwise depending on how much the dentist prepped the patient. So there’s so many things going on in my head right now regarding this case but so basically I would start at the very beginning with some sort of imaging software and there’s lots of imaging software at the moment out there I use photoshop and there’s dsd and I’ve started playing with ivory smile recently from ivaclar and that’s been that’s really good as well. Actually I’m definitely going to be talking more about that on my instagram page and on my veneer course. And then once you’ve kind of had a play with that and shown the patient okay if we just close the diastema we just veneer the front two teeth then this is the result that you’re going to get but the front two teeth are going to look a bit bulky and so that can be shown on photoshop, that can be shown with just a composite mock-up in the mouth and then you start getting and then when it when you do that if you do for example a composite mock-up in the mouth, you would then take a photo of what you mocked up and show it to the patient and they can take it away with them so they can start getting their head around the fact that maybe two veneers isn’t enough and maybe they need to, if they’re looking at veneers and they don’t want ortho then maybe they’re looking at four veneers. Also at that stage you need to have the conversation that if you are looking at four veneers to redistribute the space then that can’t be done with a very minimal prep or no prep type veneer because you need to remove from the distal of the ones to mesialize the veneer to make the centrals not look too wide and redistribute the space to those laterals and even then sometimes you can end up looking, it can end up looking a bit bulky at the front if the rest of the teeth are small. And so sometimes unfortunately in these cases you need to do even more. So you then need to involve canines and premolars and do an eight unit case to really get a nice space distribution and you need to be aware of that because patients are always going to want the minimum number of ceramics and us as clinicians we want to do the minimum number of ceramics as well because it’s better for the patient, treat your patient as you would treat your own mouth or the daughter test as you would treat your own child if you have one. But also you don’t want the patient to get stuck like you don’t want to be so trying to be this really great dentist and doing the minimum number and then only doing two ceramics and then they’re not happy and then you end up in in a situation perhaps similar to this although this is not exactly what happened there. So first thing is before you do anything is really consenting and not only with a great consent form but having that conversation, giving the patient visual aids either using computer generated images or in their mouth so that they can really understand. You can also do a trial smile and I think you said that she did that so you could have an additive wax up made from the lab. [Jaz]So she did the trial smile and she took a photo of it. So at that point do you maybe it’s just a thought cut to my head at that point you get the patient to sign off something that you know what I like this trial smile. At any point is that something that you advocate to your students? [Manrina]Yeah I think the more you get patients to sign off at every stage the better it is. I definitely think you need to get a sign off at the temporary stage so not quite at the trial smile. So the problem with the trial smile and I don’t do them as often now as I used to do and the reason for that is because if they’re not additive if they’re made exactly how the smile is going to be then the patient will have shine through of their own teeth because you’re not necessarily always adding and then it’s difficult for a patient to understand what it is that you’re trying to show them because they don’t understand that the teeth are shining through oh I’ve got yellow patches shining through is that what you’re trying to do here. And if you get the lab to make an additive wax up just for the purpose of this trial smile so it’s all being stuck on then the trial smile is going to look really bulky and then you need to explain to them oh it looks bulky but the real thing won’t be this bulky and so there’s limited benefits to a trial smile. Definitely I think that that stage is better achieved using some sort of digital imaging software. But moving on from that say you use your digital imaging software and then you decide you’re going to do however many you’re going to do four veneers for example which I think is what this. [Jaz]Let’s go with six because she did six so let’s use the example of six as we move forward. [Manrina]Oh she did six okay fine I didn’t know okay fine. So six immediately in smile design we’re taught to always be wary of doing six veneers and the reason for that is the way that a veneer even with the most the top ceramics that that I work with and they’re amazing. Inevitably, the way that a veneer reflects light is slightly different from the way a tooth will reflect light. It’s porcelain as opposed to enamel and when you do six you only go as far as the corner of the mouth and then you have a different reflection of light from the front of your smile to the back or to the side and sometimes that can make the premolar region look less obvious or look different from so these just look more obvious or bulkier even if they aren’t necessarily because you’ve gone to the corner of the smile. So I advocate or I was taught that you really want to do two, four, eight or ten. Not to say I haven’t done six veneers in my career. I have done six but it’s again the more information you’ve got the more these sort of nuggets take today, keep them in your head. Come on my course. Come and learn them. And the less problems you’ll have because I think it is harder to get a natural result with six than it is with four or eight because immediately they’re going to look different from the bit bulky at the front of the smile. So okay she did six, so if you go on to okay you’ve done your digital design, you’ve done your preps and you’ve used a stent and put the new smile on in temporaries so the patient can try out and you smile. It’s that stage that’s really super important and I will never move a patient from that stage until they’re 100% happy. If they’re even arming and eyeing slightly about I don’t know they kind of look bulky okay maybe they’re okay I’m not moving from that stage because of this very reason I don’t want to refund anyone’s treatment at the end of it and I’m not, it’s not even about the money it’s about the stress of it. You want to keep your life stress free, you don’t ever want to feel like you don’t want to do a smile makeover again because you’ve got all this stress at work this is supposed to be a treatment that gives you a lot of pleasure because it’s really enjoyable transforming someone’s appearance and giving them that joy and so let’s not involve any stress in it. So once they’re in temporaries that’s when you want them to sign off and so really you need to have that conversation and I assume that she did have that conversation and I assume that at that stage the patient didn’t feel like they were bulky that she was happy with the way that the temporaries were so that’s that. Then you go on to your finals, it depends what lab you’re working with. If you’re not able to charge the prices that maybe I charge or other some other dentist charge then maybe you also can’t work with the labs that charge what my labs charge because obviously it’s all relative and maybe if you’re working with having to work with a less expensive lab maybe they haven’t got the skill set to not create bulky veneers. They’re definitely ceramics have a style and they have a shape that they like teeth to be. So one of my favorite ceramics Nikki from precision dental. She’s a master ceramist I’ve worked with her for 18, 19 years now and she’s wonderful and if you look at my instagram page there’s such a variety of cases that she’s done for me from very natural to very Hollywood to blocky to very minimal and according to the patients you know she’s diverse but she still has a style. She still has a style that she likes to go to that I know like that I can recognize her work and it’s very subtle but having done over 12,000 veneers with her I get it I can see it and I also I know about different labs and the different pros and cons that I have from each one of those people having their individual style. So and the problem sometimes with the less expensive labs is that they make these bulky veneers they because they don’t have the skill set to make them very thin at the cervical margin but still put the correct anatomy on and potentially the dentist doesn’t have the skill set to remove enough at the gingival third and I’m not saying this about this dentist at all because I don’t know but sometimes dentists don’t remove enough there and then for it’s not the lab’s fault, it’s the dentist fault that they don’t have the space to make a thin veneer in that area and then they end up looking more bulky because dentists can be a bit scared of they’ve prepped the margin it’s starting to look like a bit of a heavier prep, they’re scared that they’re getting too deep into things and so they kind of leave it but then you end up with it with a bulkier, a bulky veneer. [Jaz]Well I’m just going to say because in the interest of time and I really want to squeeze as much out of you in this valuable but small amount of time I have with you so I think the take home message really for that first bit is temporaries. Make sure you absolutely nail it in the temporary and I remember in the episode you talked about you’re happy to keep them on temporaries for as long as it needs to be until the patient is absolutely ecstatic and I remember that so I think that is one main takeaway from part one. Let’s just tackle part two now which is- [Manrina]Even if you have to give up the case, if can’t get them happy in temporaries and you need to give up the case at that stage, much better to give up the case at that stage than go on to finals because once you’ve got that lab bill associated and you’ve got that final thing stuck in their mouth you know you’ve gone too far so this is this is really a very important appointment. [Jaz]Brilliant and now let’s tackle the bit where let’s imagine to help purely to help this because I really want to serve this dentist. She has the complaint of the cervical area by the gum line is too thick and too bulky and that’s the main complaint the patient saying. What is the best way to manage that? Is it a matter of just starting again? Is it a matter of just prepping away some of the ceramic? How to handle that in just a couple of minutes because I want to ask you one more thing after that. [Manrina]Yeah so you’re breaking up a little bit, Jaz but I think I got what you’re saying that how we’re going to manage this now. Now we’re at this situation she’s cemented it. So first of all at the cementation stage just really be very be wary of that try in. So before I at the cementation appointment I always say to my patients nine out of ten times I’ll go ahead and cement your veneers today but one out of ten times I won’t and that’s because they’re not perfect for me and if they’re not perfect for me they’re not good enough for you so just to let you know if they’re not perfect I’m not going to cement them. So you also need to be aware as a dentist and look at that stage. That’s another stage where you could get the patient to sign off so sometimes I’ll put them in with a try and paste and I’ll still get them to sign off saying that they’ve seen their veneers that they’re happy for me to cement. So that’s another stage that you can put in there and sometimes they’re not. Sometimes even I’m happy with them but the patient will look at them be like no the laterals look like they’re slightly different length so I really don’t want that and so much better at that stage to catch that than later on. So I’m not sure if this dentist did that but good to show them and at that stage if she thought they were bulky the lab could have adjusted that for her. Okay but anyway we get to where we are, we’ve cemented them and then the patient feels like they’re too bulky. For sure prep your veneers like you would prep enamel. I do it often. I’ll go and recontour a veneer and sometimes patients come to me who have had veneers done by someone else and they don’t like them and I can see why they don’t like them, I can see what needs to change and I’ll just be like you want me just to contour them for you rather than changing them and they’re like yeah go for it and I’ll just prep their veneers. Obviously you have to be a little bit careful it’s easier when you’re changing it incisally but when you’re prepping the labial aspect you don’t want to if you start getting shine through and it gets very thin and you’ve got the tooth shining through you’ve got a real problem. So just very gently, very carefully contour the porcelain. Obviously it’s not ideal to do that I’d rather the lab did it because when you do that you remove your glaze and so you remove some of the shine from the ceramic and that’s what I think happened with this lady. So then you can polish it. So there’s lots of polishing kits available out there porcelain polishing paste and porcelain polishing burs that go on the slow handpiece and they’re full kits that vary in color and you start with the darkest color and you move your way through from gray down to pink or whatever the shading is for the brand that you’re using and so go to any brand that you’re familiar with I think I was talking to her about Kerr. She messaged me on me on instagram as well to ask about how to polish this porcelain and yeah I sent her a link to a Kerr polishing kit and also feel free to call the reps at Kerr and say I want to polish this porcelain and they can advise you how to best use their kit like whether it should be used with water whether it shouldn’t you know and all the little tips that they have to get the best result and really you can get quite a nice shine from polishing that way. [Manrina]Amazing. Very good and it’s great to learn that because yeah a dentist myself included would be would be not so confident in prepping the ceramic but I think when you have the good kits that you use and the experience that you have then it becomes easier and easier but it’s something that naturally I think a lot of dentists are worried about prepping especially someone else’s work and the whole show through issue that could happen if the veneers are thin in any one area but I think you raised a fantastic point. The last question now is what should she do? The patient wants a full refund, I don’t know. This is such a tough one but I know I realize it’s probably one of the toughest questions I’ve ever asked a guest on my show but what do you advise? [Manrina]No not at all. So again it was breaking up I think the question is that if now what do they do? The patient sent a letter she’s asking for a refund and what should a dentist do at that stage? So my immediate thought is don’t take the stress if she wants a refund you just contact your indemnity people you let them know what happened, she’s done everything correctly, she’s given the consent form the patient’s consented along the way she’s got all her notes and then the indemnity people will advise you. I’m sure that if they advise that you should give a refund in this situation then actually that’s what indemnity is for and your indemnity people will pay for it so they’ll probably cover the refund and I don’t think you’re going to be out of pocket from it and even if you are out of pocket say you need to refund it and you know you’ve paid the lab bill and you’re going to lose that money then I would just take it and treat it as a learning experience. I know that these cases can be scary when you’re starting out and I don’t want this patient to lose confidence and I don’t want them to think that this is going to happen all the time. It probably won’t happen very much and the more she does them the less it will happen I can’t remember anyone asking for a refund for at least the last 15 years with me and so and I do 10 or 20 units a week. So it’s not something that happens often but it is something that maybe happens at the beginning of your career because you haven’t got all these stages in place to make sure that that doesn’t happen. [Jaz]So Manrina I think you’ve answered it will be unfair to because you’ve really done a good job of answering that question that’s very helpful. I want to say is where can, tell us about your course I mean is it happening now there’s covid and stuff? Is your course happening and also tell us about your clubhouse room so we can start joining them as well. [Manrina]Yes great so I started an aesthetic dentistry club on clubhouse so check that out and please join it as a member and I do a regular room on it every Tuesday at seven o’clock. I choose different topics and different speakers to come and talk with me every week and we talk about various topics around aesthetic dentistry. Really, really interesting ones I know Jaz we had you last week and we were talking about TMJ issues and occlusion which you would think would be not that interesting a topic but I don’t know I really enjoyed it and learned a lot actually and I think what’s interesting about these rooms is getting all these different speakers in and hearing all these insights also letting people come up from the audience and hearing their insight that’s how we learn and that’s how we grow and none of us know everything. So it’s a real really great opportunity to just like kind of work together and learn from each other. [Jaz]And your course is it happening on the covid dates and stuff? People keep messaging me saying is Manrina doing a course again? I don’t know, ask Manrina right? But now is an opportunity to just tell everyone who’s keen. [Manrina]Thank you yeah so I’ve got my four-day veneer course. I suggest everyone does it who’s not doing a lot of ceramics even if you are doing a lot of ceramics I’m sure you’ll pick up a lot from it. Obviously I’ve done more veneers than I’d say 99 dentists in the world it’s all I’ve done throughout my career of veneers every day and so that’s I’ve got a massive amount of experience in it. So even if you know the basic process there’s so much to be picked up from my experience and a lot of people that come on it that don’t know the basic process because you never taught how to do a smile makeover with post and veneers at university and the plan is that once you’ve gone through the four days that you can go ahead and do them with confidence so even for this lady if she’s feeling like she’s lacking that come learn you have a little support network with the people who do the course with you. You can bounce ideas of each other, it’s called designing smiles and it’s on my website drmanrinarhode.com yeah and it’s running yeah we did one last month and we’ve got another one in June. So yeah thanks, Jaz. Jaz’s Outro: Brilliant. Manrina thank you so much for giving up your time today and I think it’s going to serve this young lady but serve a lot of dentists who are about to have such an issue and that can avoid it or have suffered with similar issues in the past and can now really reflect together. So thank you so much for sharing your expertise today have a lovely week.

I gave Manuela Rodrigues one task: to reduce the stress levels of Dentists and the Dental team who listen to this episode. https://youtu.be/cNY_2QLWTuI With Mindful.Dentistry Manuela I know what you’re thinking…the whole positive mental attitude thing goes straight out of the window when a file has separated or the palatal root of the upper molar has been swallowed by the sinus. This is why I wanted Manuela to make this a highly relevant to the daily stressful scenarios we face. How can we make our profession less stressful, Manuela?! I pitched to her 3 different scenarios: When things are just not going right at work – think of TOUGH treatments/patients Litigation. Having a case over your head is one of the most stressful, gut-wrenching, confidence-destroying experiences a Dentist can have. Running late. I am SOOOO guilty of this and is the number 1 daily cause of stress for me! As Manuela promised, you can get 25% off her Mindfulness in Dentistry training by using the code ‘protrusive’ Do follow Manuela @mindful.dentistry on Instagram If you enjoyed this episode, you will like 10 Habits of Highly Successful Dentists Click below for full episode transcript: Jaz's Introduction: Dentistry is a highly stressful profession, so you have to be able also to balance it with investing on your mental health, investing on your mental well being with things that better prepare you for the highly stressful days. Jaz’s Introduction:Hello Protruserati, I’m Jaz Gulati, and welcome to another episode of the Protrusive Dental Podcast. Today is going to be really monumental, we’re talking about stress. This is an episode I hope will change your life. Let’s face it guys, we’re part of a really stressful profession. The thing that really brings it home to me is that actually, every profession can be difficult. Like, even ask the guy who works at McDonald’s. He will tell you his job is stressful. Right? Or ask the hairdresser when she’s got a long queue of customers and she’s got a really picky client who she’s cutting hair for. Then she will tell you that, oh my goodness, this is a lot of stress. My profession is the most stressful. So everyone has a case and an argument for their profession being the most stressful. So, in dentistry are we really such a stressful profession? Well, I think so. Let me tell you why, right? I listened to a podcast episode who my good friend, Payman Langroudi and Prav Solanki run, Dental Leaders Podcast, which by the way, I was on recently, so if you haven’t checked that one out, do check it out. And he had someone called Tom Youngs, who was a dentist not even just a dentist, a phenomenal dentist, like a really amazing clinician who posted lots of YouTube videos lots of great clinical cases, and you’d think, wow, what a great dentist, but then he left our profession. He started to work for a, I believe it was a, a startup, like a tech startup. And then he had a few years with them and he’s, I believe he’s moved on perhaps from there. I’m trying to remember that podcast episode I listened to, but the long and short of it is that he has been a dentist and he’s experienced lots of other sort of professions as well. And then on the podcast, he says that. Dentistry is by far the most stressful profession. So that’s one example I can give you about but you don’t need to know that, right? You don’t need me to convince you that our job is super stressful. Let’s face it, right? As Lincoln Harris said in many episodes ago on the podcast that we’re a surgical specialty and really it should take about 11 or 12 years to train us like in the medical fields. But we only get 4, 5, 6 years of dental school and we come out of dental school with not so much confidence and not so much experience. So we’re kind of learning on the job as we go along. It’s the truth and it can lead to very stressful moments in our career. So that’s why I’ve got Dr Manuela Rodrigues, who is known as the mindful dentist or mindful dot dentistry. And she will be answering some very real world tangible questions because. I’m kind of a really impatient person. I didn’t want to do the whole, because I’m the worst person to do like the headspace and the mindfulness and stuff. Like, ask my wife. We’ve tried it and I’m like, okay, I’m bored. I want to do, I want something more exciting. Right? So I really, really, really twisted Manuela’s arm. And I said, okay, can we make this extremely clinically valuable as best as she can? Rather than, and I mean no offense to her or anyone in that space, like, I don’t want wishy washy, right? So I think what she managed to do on this episode is absolutely phenomenal. So Manuela, thanks so much for what you did, and guys, I’m so excited for you to listen. We basically cover three main areas. Area number one is day to day clinical struggles, clinical failure and struggling with your dentistry or having difficult patients or difficult cases and how that can bring on stress and how we can manage that. The second one is, is a darker one, is litigation, right? Some of us, many of us have had complaints against us and that can be such a dark and stressful period of our lives. It leads to sleepless nights and it’s a really nasty thing to experience. I wouldn’t wish it upon even my greatest enemy. To be honest with you. So therefore, I want to really get her insights into how she can help you if you’re struggling with a complaint or a near miss and you’re losing sleep because of it, what can we learn? What can she teach us about being mindful that could help us to to better cope with our emotions and actually have a more fulfilling, less stressful life. And number three is one that really bothers me a lot, which is running late. Okay. I’m guilty of being that dentist that does kind of run late time to time. So I just wanted to ask her at the end about, okay, what advice can she give me as someone who can have the tendency to run late so that I can better control my emotions and not be so stressed when it happens. So I hope I gained a lot from this episode. So I hope you do as well. If you listen all the way to the end, Manuela has got a discount code for you. This is not like a sponsored episode or anything, but she was very kind afterwards to email me and say, you know what, Jaz, for the Protruserati she has an offering, like a journey she can take you through to through mindful dentistry. And she wants to pass on a discount to you. I was like, that’s very kind of you. So I can pass it on to you at the end. So you have to listen all the way to the end for that. Protrusive Dental Pearl:But before we get there, I have my Protrusive Dental Pearl for you. This is a really great pearl. I actually really love this one. It’s going to go in my like top five pearls, right? Get this, okay? In dentistry, one of the most stressful things, which is like the theme of this podcast episode, is how every sort of collision, every mental you experience, or every course you go on, they all have differing and sometimes annoyingly, opposing schools of thought. Like, one person will say vertical preparations are terrible, vertipreps are dirty preps, don’t do them, they’re going to invade the biological width, whereas other dentists would be like, vertipreps are the most conservative way to treat a tooth, etc, etc. I don’t know if that was a good example or not. Or, some people will say, this is the correct way to do this implant technique, or the others will say, no, that’s completely wrong and none more so. Then in the world of occlusion and splints and that kind of stuff. So especially in splints and occlusion actually. So it can get really annoying as someone who just wants to learn and do the best for their patient. So I came across a comment on Facebook that I just had to pause and reflect on how powerful this comment was. It’s by my friend, Alan Matthews, who’s based in Scotland. And he had this to say, right? It was like some argument. Everyone was like giving their different viewpoints. And this is the way he summarized it. He said, listen to everyone, listen to all the schools of thoughts, right? So listen to everyone, but do what feels right to you. Now, this is such a simple one, but such a powerful one. I thought, felt like a massive load lifted off my shoulders when I read that. I’m going to just accept that it’s the beauty of dentistry, that there are so many different opinions, and I will listen to you. I will listen to everyone, no matter how wacky or how boring it is. I will listen to all the schools of thoughts, but I will always do what feels right to me. And that’s why I condone for you, the Protruserati as well. I think it’s such a great way to live your professional career. Listen to everyone, respect everyone, but do what feels right to you. So I hope you enjoyed that pearl. I love that pearl. Alan, thanks so much for inspiring me with that. So let’s join in hopefully what will be a career changing episode for you guys. Enjoy. Main Episode:Manuela Rodrigues, welcome to Protrusive Dental Podcast. How are you? [Manuela] Thank you. Thank you, Jaz. It’s a pleasure to be here. I’m doing well. [Jaz] Amazing. And you are known as the mindful, I guess the mindful dentist in a way, your Instagram handle mindful.dentistry. It’s great what you’re doing and the messages you’re putting out and really mindfulness has become a bit of a buzzword, right? It’s become over the last probably about six years ago, I came across it. So I want, let’s speak to the listeners and tell them what was your journey with mindfulness? What is mindfulness for about the three or four people who are listening and don’t know what it is? I don’t know how you could possibly avoid it, but for those that don’t know, tell us what it is and then how did you get involved? [Manuela] So my journey with mindfulness started more or less 10, 12 years ago. Because 12 years ago, I had a health problem. I had the Cushing syndrome, so I had one adrenal removed, and so my body was producing 10 times more cortisol than needed. So after the surgery, after the treatment, I thought to myself, okay, maybe I need to change something in my life. Also, so I discover mindfulness, I discover meditation also, and I started to use it as a way to reduce stress in my own life. So this, the mindfulness is this presence that you bring to not only to your life, but actually to everything that you are doing, right? So you become aware and present moment to moment and I started to apply it also in my dentistry practice. So I graduated from dental school in 2001. So and I realized that I was, during work, I was overthinking a lot. So instead of being totally there with my patient working, my mind was running around and sometimes worrying about less good outcomes of the treatment that I was performing. And I realized also that led me to work from a place of insecurity. So I starting to bring this conscience present to my daily work. But what actually was decisive for me was that in 2014, I started working in Belgium and and I attended the workshop that they have that is specific. It’s like mindfulness in the difficult practice. So it’s one day workshop. And it teaches you how to apply it. And that really- [Jaz] That was specific to dentistry? [Manuela] Yeah. That was specific to Dentistry. And it’s something that dentists here in Belgium it’s part of their on ongoing education. So if you want to take that, you can have that. [Jaz] Wow. So even like as part of the recognized part of the sort of learning for dentists. That’s pretty spectacular. That’s pretty cool. [Manuela] Yeah. And in the end, because I already had my mindfulness practice, I talked to the person that was giving the course. And I said, this is so interesting because I already started to apply mindfulness, but I now realize that I could go even further. And we continued to talk and and I realized, yeah, maybe I can really start going deeper on this and I started to apply it. And then in 2016, I started my teacher’s training as a mindfulness based stress reduction instructor teacher. And it took me about two years. To get the certification and even during my certification, I started to working with colleagues and I started to explain this to colleagues and I had amazing feedback and that’s a certain, and when I finished my certification, I started to organizing the mindfulness based stress reduction courses for dentists. Because I could apply all the programs due to my experience as a dentist. I could bring to every session, the dentistry practice into it with practical examples of course. And I have very good, very good feedback and very good results. And at a certain point in the end of in 2018, I decided, okay, this is, I’m dividing my attention and my time between these two things. What am I going to do? And I decided to pause my clinical practice and to dedicate myself full time to do this project that it’s mindful dentistry. [Jaz] Well, congratulations for making such a monumentous decision and something that obviously sounds like a bit of a passion, how you got involved sounds good. And really nowadays, there’s mindfulness from what I’ve read in my experience in every facet of life. Like, for example, there’s mindful eating, right? I’ve come across that before. And now we’re talking about mindfulness in dentistry. So I’m hoping it’s going to open a lot of people’s eyes. Cause when I started speaking to you on Instagram, I thought, how can we make this for the Protruserati listening a valuable episode, but really clinically relevant day to day. So how could we make it? I mean, clinical is maybe a strong word, but the real life scenarios that we face as dentists. And if you can give us from all the courses and the teaching that you do, I’m sure you can share with us how to manage the following three scenarios. So I’m going to share those scenarios with you all. So people can, can follow along with the three things we can talk about. We’re going to talk about one, technical failure. So, as dentists or perfectionists we beat ourselves up. Like, for example, I beat myself up when I’m doing a restoration class two and I have an open contact at the end, right? Honestly I hate that the worst I’ve probably ever felt is when something’s gone wrong, like a perforation. I’ve never extracted the wrong tooth, but I can imagine something like that happens like errors in practice or even technical difficulties that can really stress me out. So I want to know what Manuela, what you think about how we can better manage that using mindfulness. That’s scenario number one. I mean, the example I wrote is that I once got a splint stuck in someone’s mouth. I was making a direct chair side splint and I got it stuck in a mouth. I can tell you later how I handled it. I’m proud of myself the way I handled it, but I want to know what to do. When you’re actually in that very stressful situation. So that’s a scenario number one. Scenario number two is a very dark one, right? And something that, especially in the UK with the litigation, I’m assuming the US as well, litigation rates are high. So what if you have a patient complaint and you’re battling that? I know dentists who have sleepless nights. I myself have had sleepless nights in my career, and I know I will do in the future. Hopefully not after today, but this is a real reality of dentists. So a litigation scenario. And the third one, last one is thing. I hate the most thing I experienced with you today. I do apologize. I was running late, but today’s show, right? I am stressed when I run late. I hate, absolutely hate running late because then the next patient can sense it. And then you’re trying to not rush dentistry. Cause good dentistry happens slowly. I do believe that. So these are three scenarios we’ll talk about today. Before we get on to that. I want to just check with you something, if I was to boil down the definition of mindfulness as me, okay, what I’ve come across is savoring the moment, what do you think, is that a good way to explain mindfulness? [Manuela] Speaking in the dentistry context, because that’s what I teach and that’s what we are talking here specifically. It made me made that definition that you just said a little bit more complete. For me, mindfulness, I talk about presence. I talk about not only savoring the moment, but I talk about experiencing the moment with presence. With awareness, I talk about awareness and that’s very, and that’s what we are going to talk about later. But dentistry is actually if you look at it, if you have disappointments with challenging work, sometimes with anxious patients it’s hard, it’s hard work. It’s hard to keep your focus. So it’s not easy and you are under mental strain, you are under fatigue sometimes, and you have challenges that might come up that we are going to talk about later. So when I talk about Mindfulness, a mindful dentist. I talk about presence. I talk about awareness in the moment to be able to maintain that present and to be able to work from that place of presence. So to illustrate this a little bit more with the practical example is if you are working with your patient right seated on your chair working and you are done, you are doing this feeling that you already did like a million times. And your heads might want to space out because you have other things a lot of the things in on your mind. Okay. [Jaz] So usually what’s for lunch. [Manuela] Yeah. Food is in my mind a lot. So I know what you mean, but if we do that and if that becomes a habit, then you are missing on the big details on your work. You are missing on the subtle messages that your patient might be giving you that he’s starting to feel uncomfortable. You are missing the microanatomy that might make all the difference. And who knows what else might you be missing? Okay, so there, it’s very easy to do that. So when I talk about mindfulness and dentistry, I talk more than just savoring the moment, I talk about presence and bringing this awareness to your daily work and to into what you are doing. [Jaz] Right. Well, I like the way you explained that. And sometimes I enter a state of flow you know Mihaly Csikszentmihalyi, the chap who came up with a theory of flow. And would you say that is similar? Am I down the right avenue? ‘Cause sometimes I’m doing three hours with one patient. And it feels like five minutes. And I feel good and I feel like I’ve enjoyed myself. How can you relate that the theory of flow to mindfulness and dentistry? Cause what I’m there is I’m in love with every small details. Is that something that you can relate to? [Manuela] Yeah, that’s exactly it. When you are in the moment, when you are aware of what you’re doing, when you’re grounding, which are grounded with yourself, when you have this mind body connection then you enter in the state of flow and that allows you also to enjoy and savor the moment. So that’s exactly, that’s- [Jaz] Awesome. Well, I like that very much. Amazing. Well, let’s tackle that first scenario then. So, technical failure. Okay. Let’s say we’re struggling. Let’s make it really tangible. Let’s say I am a dentist who on a given day is struggling with an extraction. This lower molar is taking so much time. I raised a flap. I’ve sectioned it. I’m now still trying to use some cry or something, trying to lift this root up. It’s just not budging. The patient is breathing heavier is obviously annoyed. Your nurse is looking stressed. You are getting stressed. What lessons can you teach us to handle this scenario in an optimum way? [Manuela] Let me just do a small disclaimer before we start just to say that it’s not realistic or even desirable, the concept of a stress free dentistry work practice, I mean, or a stress free dentist. Stress is always going to be a natural part of dentistry work, and it’s going to happen. What we’re going to talk about here is practical ways, of course, of dealing with that stress. So going back to the practical scenario that you just proposed when we find ourselves when a situation where the procedure is not going has we planned and we start to struggle normally we react. So we were trying to solve the situation. We are going to be trying to solve the problems because we need to move forward. So what happens is that when we work and stress, we disconnect. We disconnect from our body and we are just inside of our heads trying to solve the problem and our vision narrows. So our vision narrows, our critical thinking narrows, our creativity disappears completely. And that’s why sometimes instead of solving the problem, we can even make the situation worse because what we are doing, it’s not solving the problem and we are not paying attention to the details. We’re not paying attention to the big picture also. So the first step- [Jaz] Is that because of the state of panic? [Manuela] Yes. It’s because we take our brain, take us as a threat. So we have to, we are being threatened and we have to react to find solutions. So the first step here, it’s not action, but awareness. We go back to awareness. So awareness of what’s going on. And we actually need to pause for a few seconds or a few seconds to one minute. You don’t need much more time than that. We need to recognize the situation. We need to recognize our body tension. We need to look up. We need to take four or five big inhales and long exhales, and we need to ground ourselves again in our body again. [Jaz] How can you explain that to a patient? Because I want to make it really tangible. I can imagine myself and I’m really trying to imagine myself in a situation and the advice seems sound. You’re right. Our creativity is gone. You can’t think on the spot. You’ll panic. You’re not thinking right. But then if I suddenly say, okay, let me pause. Deep breaths is, I don’t want the patient to think that, oh my gosh, the dentist is now having a breakdown or something. So, so how can we, is it just okay to say to the patient, what I like to practice mindfulness. I’m just going to regroup myself. Would that be appropriate thing to do? [Manuela] If you, it depends with the person that you have seated and in in front of you. Of course, if you feel comfortable, you can say that, but this is not something that you’re going to be even needed to explain what I mean is you just need from a few seconds to one minute. So, if you don’t want to explain it, you don’t have to explain it, okay? You just need this pause to look up, do an intentional relaxation of some key points. Put your shoulders down, relaxing your belly, your face, your jaw. So bring this intentional releasing and do two or three deep breaths and continue working from this place of groundness, from this place of opening, because this immediate, this gentle awareness that you bring to your body, it immediately releases your critical thinking, your creativity, your flow. Okay. So if you don’t want to explain, you don’t have to, if you think, okay, this is going to be weird, especially when you are not used to do it, when you’re not used to do it, but when you start being used to do it, you see that you don’t have to explain and the patient doesn’t find it weird because you’re not actually doing not anything weird. But in the beginning, if you feel that need, then yeah, you can say, okay, I just need a few seconds to, cause I’m tired. I mean, this is a long appointments. This are appointments with stress, with fatigue, like I just said. So it’s normal if you need to just a few seconds to just look up. Okay. Let’s get back to it. It’s simple as that. [Jaz] So, that I can make that makes sense to regrain your creativity. Would you say that’s the thing that we sometimes skip because when we’re panicking with a situation, we’re just digging, digging, digging to actually pause to do almost like a power pose or relaxation and get your sort of a regroup. [Manuela] Yeah. [Jaz] That’s what you’re saying? [Manuela] Yeah. Because this allows you to return to that presence that I was talking about. So, and this allows you to continue working from that place of presence instead from a place of mindless reaction. Okay. So and when this natural releasing happens, this opens this open, not only your body, but also your mind, your critical thinking, your creativity, your ability to collaborate and to problem solving. Okay. So learning to release your tensions through this intentional relaxation is an important skill that can be learned. It can be developed and it brings your full intelligence and creativity back in the game. [Jaz] I definitely think that would be more useful to be able to plan because in that situation, you need to have a plan. Okay, now I’m going to do this, this and this and communicate that to your nurse and be like, okay, we’re now going to try this. If that doesn’t work, we’ll have the plan B and then we have plan C and then hopefully you execute your suture in that specific type of scenario. So definitely to be able to think clearly and to show the patient that you can communicate clearly as well, not just gibberish when you’re panicking, you’re flustered, you’re sweating. So totally, that’s good. Before we move to the next scenario, did you have any more gems with that? [Manuela] Just to make the technique practical, that it’s actually, you have to be able to recognize that you need to pause. You have to be able to pause because this is sometimes the part that I find it’s most difficult for dentists to do because they’re trying to solve the problem and they think that the pause is not going, just going to lead them to wasting time. And it’s actually the other way around. So you recognize, you become aware of the situation, you pause, you bring this. It’s conscious relaxation into your body. You ground yourself again. You take a deep breath and you continue working from this place of groundness. So this is the actual technique. And just to take things a little bit further because dentistry is a profession that creates many triggers. Just so what happens after that extraction that didn’t go according to plan, right? So you had the scenario that you just talked about. And of course, after that you are late, right? You are running late because it didn’t go according to plan. And maybe after you have an anxious patient and maybe after you have your assistant entering your room saying, oh, the lab would just call saying that important work that you have for tomorrow, they are not going to be able to deliver it in time. So we have to cancel the patient. So we- [Jaz] This is everyday, this is everyday stuff. This is real world stuff. [Manuela] That’s it. So we spend our day in fight flight mode. It’s like tense, right? And it’s one trigger after another trigger, right? So and there’s this quote from David Allen. Your ability to generate power is directly proportional to your ability to relax. So we have to be able to be aware of all this triggers of all this stresses. Otherwise we spend our life or day just reacting to whatever is happening. And sometimes in automatic pilot and I’m sure you already worked or you know someone that’s clearly carries a lot of tension in the shoulders and the face and we notice how this tension is holding this person from expressing all his creativity, from enjoying his work. So when we spend our days with this overstimulation, there will be this constant flow of cortisol in our bloodstream. There will be a constant muscle tension. And of course, if this becomes chronic, then you have the physical problems. It starts to have the physical stress symptoms. So high blood pressure, insomnias, heart diseases or gastric problems, and sometimes even emotional burnout. We all have different ways, of course, of coping with stress. And to being able to recognize the stress triggers and how to manage all of this and how to bring this relaxation can balance the stress physiology. So what I wanted to distinguish here is the first part is how to deal in the face of stress in a situation like we just said. So to be able to pause, to be able to recognize and to be able to bring the presence again and to work from a place of groundness. And then you have the second level of coping with stress because dentistry is a highly stressful profession. So you have to be able also to balance it. With investing on your mental health, investing on your mental well being with things that better prepare you for the highly stressful days. So if you develop hobbies that bring you joy, if you learn to play an instrument, if you learn breathing exercises or start a meditation practice or whatever, or exercise practice, whatever works for you, but to be able to compensate. Otherwise, if you develop maladaptive coping behaviors, for example, addictions or compensations or emotion can develop, can lead to emotional burnout. What you’re actually doing is that you are even adding more stress to your already stressful day due to your job. So this is very, very, very important to be able to bring relaxation not only in the face of stress but also then to your life to be able to compensate, bring balance to that part. So there’s two different levels that are important. [Jaz] So we talked about in the moment, to practice those awareness and relaxation techniques, whether your crown’s missing from the lab, whether your, the root has fractured, whether the tuberosity has come away or whatever’s happened, but to manage that, but then also outside your life. And that reminds me very much of my old principal used to tell me that we spend so much money on equipment. We spend so much money on softwares for the practice, but we actually need to invest in ourselves. So like you said, whether being mental health, physical health, and that’s because we are like equipment ourselves in a way that we need to keep us keep ourselves well oiled. So, and I also read once that for every clinical course you do to a non clinical course, that could be communication or something that you offer, for example, mindfulness, which I think is great that you’re doing that, but you mentioned a key point about the toll it takes on your body. And that leads nicely about if the situation becomes chronic, right? Because the second scenario is litigation. So this is very much not in the dental chair, but this is something that you take home to your husband, to your wife, to your family to bed. You take it to bed with you and you lose sleep over it. Yeah. What can you share with? Unfortunately. Hundreds and thousands of dentists who may be experiencing sleepless nights at any one point because of a burden that they carry probably related to litigation or a complaint or unmet expectations or just negative emotions, staff issues at work, whatever it could be. What do we do then when it becomes chronic? [Manuela] First, it’s important to understand the difference between what we just talked about, which is something that our brain perceives as a threat. So like a fear, so like an immediate danger. So when we are in our daily situations and to worrying, so worrying it usually means anxiety. So it usually it’s the state that arise when we are anticipating a threat, right? So the perception that things might go wrong. So the first scenario that we just talked about relates to the immediate danger and the second scenario worry relate with anxiety and comes from a possibility of a future threat. So they are not the same but they have the same physiological response. And this response can cause emotional and physical damage, just like you said, it can cause the physical parts like insonious, like not being able to sleep at night. And of course the emotional part, it can lead to emotional burnout. And sometimes this anxiety becomes chronic, so it’s a chronic problem. And there’s actually studies that show that anxiety, sometimes anxiety patients can even become addicted to their anxiety thoughts, even without realizing. So it’s like the mind body looping system. So you are worrying about something that’s happening or something that might happening that it’s not good in the future. And of course that brings anxiety and not just thoughts about what can go wrong, but anxiety on your body as well. And the more this happens, I mean, the physical feelings can generate more anxiety thoughts. And our brain again, takes this as a danger and it reacts in a physical way. So the key point in what the practical thing is here, can we relief or how can we stop this anxiety? And it comes down to developing also three skills that you might think as a three steps process. So first to become mindful of the thoughts of the anxious thoughts. The second one to be able to drop into our body and become mindful of the physical sensations of our experience. Because usually anxiety thoughts have a physical reflection or this not in your stomach or it is constriction in your throat, whatever it is. [Jaz] Sweating or- [Manuela] It has a physical expression. Always. And the third step is to actually to offer yourself some words of comfort or of care and that has the ability to calm down your inner critic. So but we can take this with a little bit further with your example and in the practical way. Okay. So imagine that in this case of litigation so usually of course, our mind starts racing with worries, fear, and the possibility of all the scenarios that can happen. So the familiar not in the stomach starts to appear or either that is all the constriction in the throat or are there is the sweating palms. But you have the physical part now, where do you go from here? So you have two options. The first one is to go on the habitual road of your mind running free, not aware that that will lead you to even more spiral downward of thoughts and of physical sensations. And of course. Your brain takes your physical sensations as threat, so it reacts on that and it’s like a circle. And the other approach is to actually apply mindfulness and which allows you to interrupt this sequence much sooner before it gets a hold on you. And you can break the cycle, okay? So, how do you do this? Again, with awareness. Okay, so you develop awareness of thoughts. Actually, when your mind is running free to that path, you become aware this is a skill and it can be developed, but you become aware that you are having all this awareness. Thoughts that are making you anxious and that’s your it’s reflecting on on your body. Okay, so when the body holds to stressful thoughts it tension immediately increases due to cortisol and hormones like we already talked about and that’s why we cannot sleep at night. And that’s why we are in this circle that we cannot, so if we become aware that we have these thoughts, we can interrupt them. And by doing that we can, after becoming aware and after interrupting them, we can offer ourselves the word of, okay, everything is okay. You don’t have to deal with this. Now you can calm and this is not something that you need to be worrying about now. And this has also, it can be developed with the second technique, which is, you have the situation, you have the practical situation, right? So you are worrying about a patient that might sue you. So my question is- [Jaz] That might sue you or an ongoing complaint. Yeah, absolutely. [Manuela] So, but that ongoing complaint or that might, that a litigation problem has a cause. So what is the actual cause? Imagine that is like I don’t know an endo treatment that failed and that you need to extract the tooth and the patient doesn’t accept or doesn’t understand that. Okay. So that is the primary event, and that is the primary situation, okay? And then you have a secondary situation, which is your mind racing with thoughts. Okay, he’s going to sue me. Do I need a lawyer? Should I get a lawyer? Am I going to have money to pay for the lawyer? How am I going to do this? I know I should not have done this. So do you understand? So, and actually yeah, and actually a practical exercise is to distinguish from the primary situation. So what actually is going on from the secondary situation that is your mind bringing all the extra suffering to the situation. Okay. So, and my advice is to focus on the primary situation to see the situation as it is, and not as you wish it to be. Okay. So it’s like this Mark Twain phrase, I’ve had a lot of worries in my life. Most of which never happened. [Jaz] It’s the same way as saying worrying achieves nothing but steals the happiness of today. I don’t know who said that as well, but that’s one of my quotes as well. [Manuela] Yeah, but attention, I mean anxiety and worries actually serves us because it has a purpose, right? It’s intelligence and it’s what differentiates us from other animals, for example, right? The ability to what we are doing when we are worrying is bringing this ability to anticipate now what’s ahead. So the problem is that when we get hooked on worrying thoughts, right? And they take over us. So when we let this thoughts get a strong hold on us, then that’s the problem, right? But so by reducing our anxiety by reducing our anxiety thoughts, this does not prevent us, of course, from using our intelligence and from anticipating and looking to the future in order to be able to anticipate things to better deal with things. But the fact that you are being mindful to what is happening in your heads, the fact that you are being mindful of this worry thoughts will help you to distinguish which of these thoughts are actually useful for you and which ones are just bringing noise to your mind and that are totally unnecessary. Okay. So this will also ease your self doubt. And the last part is to bring this word of comfort to yourself. And this is just recognizing also the good. I mean it’s not about positive thinking. That’s not what I’m talking about. Of course, recognizing what’s happening and if what’s happening is not good. It’s we have to be able to do it, to find solutions of course, and to be able also to learn from failure because when we fail, we have to learn something from it. [Jaz] But this is what we grow as clinicians. I find the more I fail, the more I learn, the less failures I have. And so failures inevitable in clinical dentistry. So you’re totally right there. And it’s just how you take it on the chin and grow from it. Really? [Manuela] Yeah. And if we also bring this this intention of recognizing the positive, because we all have a positive and negative things on our everyday dentistry practice. And we, as humans have negativity bias. So if something goes wrong in that day, that’s what you will remember in the end of the day, and that’s what you keep on overthinking. So to be able to bring this recognition also to the positive is it helps to balance the inner critic. So if you start overthinking and start worrying about specific things and to be able to bring balance and to say, yeah, but then I had many patients today that actually are satisfied. All the materials worked well today. Everything ran smooth. I didn’t run late. So to be able to also acknowledge the positive brings balance to our inner critic and calms our inner critic. [Jaz] That’s that’s brilliant. And my favorite takeaway, I mean, it was all lovely things to say. My favorite takeaway of what you said was separating the event from your feelings and thoughts. I found that very powerful. So I’m now imagining myself to last time I had a phase of sleepless nights and worrying and whatnot, which often is, ends up being for no reason, usually and I’m thinking, hey, it was you know, let’s make it up. Let’s say it was a perforation incident and then me thinking, oh, my goodness. The patient must hate me. What’s going to happen next? We’ll have to prepare for the GDC getting sued and stuff. Whereas actually if I saw it as an event and then focus on the positive and negative and the learning and reflection. So that would have definitely have helped me. So if anyone out there is. Unfortunately, going through this tough phase, you have to separate the actual event that I like the beautiful way you put it, the primary event to your thoughts on. So that’s a real gem from I found actually. And actually, it’s not funny, but it’s in a way like every time a nurse or receptionist has me paperwork. The rule is that they have to say, don’t worry. You’re not being sued. Then they have to hand me the paperwork. So it’s a little thing that we have actually, and I’m comfortable with that. So it’s one of those things. Right. Well, the last question, I think you covered it a little bit already is I hate running late. Like for me, I had a great day at work today. I had an awesome day because everything was on time and that’s me in a happy place. And no matter what you do, we will always run late in clinical dentistry is inevitable. So what advice can you give for situations like this where you’re we were running late, not in terms of, hey, you know, you should do an audit and figure out why you’re running late. Cause that’s of course, that’s a given. How can we manage our, the way we talk to ourselves, the way that our emotions are running and those of our team in the day-to-day struggles of running late. [Manuela] I’m going to actually tell you, start by telling you a story of a colleague that attended my stress reduction course not so long ago. So he had already contacted me last year in beginning of 2019. But due to time he could not find the time to do the course. So now due to the pandemic context and he found the time and he did the course, but it was interesting because he did the course after the lockdown. So he was already going back to work and, during the middle of the course, he just said to me, look Manuela, the big part of stress in my daily practice is gone. It’s gone because due to the COVID protocol, I now have longer appointments and less patience. [Jaz] This is me. This, I totally feel less stress now because every, all these fallow times I catch up with my notes and I have a coffee. This is me. You’ve just described me and I didn’t even think about it that way. You’re right. [Manuela] That’s exactly what he said. He said, I don’t run around anymore. Like a fool trying to do everything. I don’t multitask anymore. So a big, big, 90 percent of my stress is gone. And so I asked him okay, so if everything goes back to normal, if the before protocol is installed again, and he didn’t even let me finish, he said, no, no way you don’t get me there anymore. So and and then I asked, but okay, so before who? What was the problem? It said, yeah, but I really didn’t thought that I could do less patients. I really thought I need to have this number of patients. And now that I do it, I see that things run smoothly and the income is doesn’t make the difference for the quality that I have in my day of work. So, of course, the first advice, and we’re not going through that, but the first advice is actually to, you have to be able to look really objectively in the way that you are running your agenda. And you have to, of course, weigh in the everything, because if you, of course, if you have appointments every half an hour. You are going to be late. You are not going to have time to talk to your patient or to listen to your patient the proper way. So, and you are going to have chronical stress due to being late. Okay. And that can be handled. But of course, even if you are managing your agenda and in the right way, and you have the perfect flow of patients, situations might happen and you see yourself running late. So what to do? You have to be able to first accept the situation. You use the word that I hate. I hate it. When you hate you usually what you do is that I don’t want this. This is happening. And you start reacting and working from this place of, okay, I have to solve this, or maybe you start working faster again. If you do that, you miss the details, not only of your own cues of your body, but also from the patient. Also from the attention that you might be paying that attention to your work to the detail. You’re not going to have it. So the first is okay. Okay. I’m late. This is what it is. So again, see the situation as it is and not as you wish it to be. That’s an important, an important one. From that moment and if we go back again, and if you ground yourself again, again, pausing, bringing the awareness to the situation, trying to relax your body and continue working from this place again of groundness and continue to do your work completely focus in what you’re doing in order to deliver your best to what you are doing, okay? Once you finish that patient, then you deal with the next situation. So, dentists are not good in multitasking. That’s not a good thing. So, perform one activity. From the beginning through the middle and to the end before you beginning another. Okay. And truly engage with how you are spending your energy. So this is the most important thing. Okay. Because if you are late and if you are working from that reactive place and your mind is already thinking, okay, I’m going to be late. I have already the other one waiting today. I had to be home at seven and I still have to go to the supermarket and I’m not, that’s not going to, you are not going to be able to deliver your best. [Jaz] Yeah, absolutely, absolutely. You’re right, I wish I wasn’t, I wouldn’t be in that situation. But you are. So you have to do everything to the best of your ability and accept it. Absolutely. [Manuela] You have to be able to bring the distinguish. It’s a very clear perspective of what you can change and what you cannot change. What can you change? If your latest chronic, maybe you should take a look at your agenda and the way that you are managing it. Okay. If it’s acute, I mean, if your agenda, everything is okay, but sometimes you get late. Then you have to accept that you cannot change it. Right. And you have to be able if you want to deliver your best to your patient, you have to be able to ground yourself to work from that place of presence and to deal with and to respond to the situation. So to bring an accurate response, a response that serves you better, that serves your patient better that serves your work better instead of working from this place of reactivity that can actually lead you to make more mistakes. [Jaz] I think that’s great. And the story that you said about that gentleman who has his quality of work has improved since the COVID is exactly, you described me and I know loads of associates who usually will be there one hour after their clinical day has ended. Doing what? Guess what? Doing their notes. Making sure the notes are correct and litigation proof and whatnot. But now that we’re able to just have a bit more time to get the notes right, leaving on time, it’s been great. And I liked the point you raised about actually just being in the moment with your patient, because we owe it to that patient. Even though we’re running late, we owe it to that patient to give them our best. And I guess one thing I’ve always managed the way of running late is. Some people speed up, which I think is dangerous, and you lose being in the moment. I actually then purposely slow down so that patient doesn’t sense that, hey, I’m rushing anything. And you know what? It actually works well for me. And I always say to patients that, look, one day it might be for you. I’ll run late and I’ll always do my best. And patients can be understanding when you frame it like that, when you actually invite them in calmly. Even though you’re running late, then it’s infectious. They then also become calm. So I love all those points. Please, can you tell us if anyone wants to, cause those are the three scenarios we covered really well, but if anyone wants to learn more, how can we find out more about your the courses that you offer, your Instagram page your blogs, that sort of stuff. Cause I’m sure there are lots of colleagues. Who need more than just this 45 minute episode. They want to delve deeper cause they really see the benefit this can have to their quality of life and work. [Manuela] So you can find me at Instagram @mindful.Dentistry and you can find my mindfulness based stress reduction courses at my website, which is mindfuldentistrytraining.Com. And what I basically do is it’s eight weeks mindfulness based stress reduction courses. Only with dentists either in group or one to one. But we cover all this aspects of bringing awareness to actually your triggers, the way that you are reacting. How you can bring a more accurate response. And so it’s a eight weeks process, but you need that time to be able to, first, again, to be able to bring the awareness to what you are doing, right? Because sometimes you’re not even aware because I sometimes talk to colleagues that complain about stress. But when I ask, okay, but what is your actually stress? What’s causing your stress? What are your triggers? How do you react to them? And they have no idea. So there’s this lack of awareness the same way as when I ask. At it’s in the second session of the course, for example, I asked tell me one good thing that happened in the clinic the last week. You know I think that brought you joy, I think, that make you smile. And I have colleagues like, oh, oh yeah. I mean, if you ask me the negative, I can say, but the positive. So there’s lack of awareness of what you actually is going on in your daily work. So during those eight weeks, we go through all that and believe me, it’s a big change of perspective and it works. So my offer is this mindfulness based stress reduction, dentistry due to my background. And you can find it at mindfuldentistrytraining.Com. [Jaz] Amazing. And I hope some people are able to reach out to you to gain some advice if they need and again, we’re very active on Instagram. So that’s great. Thank you for giving your time because one of the listeners Anisha, if you’re listening, I know you are, buddy, you wanted something about stress reduction at work as well. So it’s great that you’re able to offer that because my podcast is very clinical, but I wanted to bring someone onto it. Actually, clinical dentistry is stressful. And I think the three scenarios you tackled today are golden, are really things that dentists can really benefit from. So I really appreciate you giving up your time to share those managing techniques with us. But one thing I’m going to leave everyone with as well is it’s one thing to listen to an episode like this and have some information. And it’s a totally other thing to apply it because what’s going to happen the next time you’re in a stressful situation is you might just forget this conversation. This what you heard, you actually have to be aware of it and actually implement it. So you know, for those listening, please do implement this, actually make it part of your regime. And I think that way you will gain so much more. What do you think about that? [Manuela] Yeah, absolutely true. And you actually I mean, you can start applying this. You don’t have to engage in a mindfulness course. You just have to give yourself the chance to pause. Whenever you feel that you’re about to react and whenever you feel they’re about to getting into this autopilot modes, just reacting. So just take a deep breath and take a step back and give yourself the opportunity to respond. So that’s what you can start applying. [Jaz] Amazing. Manuela, thank you so much for coming on the podcast. [Manuela] Thank you. Thank you, Jaz. Thank you for the opportunity. It was lovely to talk to you. Jaz’s Outro:Thank you so much for listening all the way to the end. I told you she’d make it really powerful and impactful. And listen, if you gain from that, follow Manuelaismindful. dentistry on Instagram. And please do, if you’re listening on Apple, leave a review. I love reading the reviews and they mean so much to me. So if you found value from this, hit that subscribe button to get all the updates for future episodes and do leave a review where you can. And reach out to me on Instagram on the Protrusive Dental Instagram page and tell me what kind of content you want next. I’m always happy to serve. I also promised you a discount code. So Manela is running a program, Mindful Dentistry. I’m just going to find the details for you. So her website is mindful dentistry training.com and she’s offering any of the Protruserati already a 25% discount with the code Protrusive. And it’s basically mindful dentistry training course. So if you resonated with what Manuela had to say today, if you found a lot of value from it, and hopefully you feel uplifted after today. But if you just need a little bit more support, if you’re in a bit of a tough situation, and you think Manuela is the person to guide you through it, then check her course out. And like I said, this is not an affiliate program or anything. I just love that she’s going to be able to help so many dentists. So check out Manuela’s content. I’ll put it on the Protrusive website, protrusive.co.uk/stress. And on that page, you’ll be able to find Manuela’s link and the reminder of the discount deal. So I’ll catch you in the next episode, guys. Thank you so much again for listening all the way to the end.

‘What on earth is Clubhouse?’ I hear you ask. Well, it’s kind of like being in a Whatsapp room with Richard Branson…and instead of typing you’re all just leaving live voicenotes. It’s like a Live Podcast and you get to contribute (sometimes). It’s also like a cult – it’s super addictive and invitation-only (at the time of publishing this). https://www.youtube.com/watch?v=s9POp8N9-Os Kevin Rose – who helps Dentists ‘Think’ Need to Read it? Check out the Full Episode Transcript below! My favourite thing about Clubhouse is that sometimes you’re not in the right state or environment to be on video – this audio-only platform has gained a lot of popularity! I have seem some great Rooms (like a Whatsapp group) within Dentistry where a lot of knowledge bombs have been dropped. There is something beautiful about Live content that is difficult to get a replay for – the FOMO factor is real! In this Interference Cast I am joined by Kevin Rose who helps drive better conversations in Dentistry. TLDR: I think Dentistry has a home in Clubhouse – we can learn and share great content (live podcast, right?) – we can also use it to change public perceptions of Dentistry. It’s probably not going to land you many patients in your chair, if that’s why you’re on it. You need to see a bigger picture! Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome to this interference cast on something very topical, it's clubhouse. Jaz’s Introduction: You were thinking what the hell’s clubhouse, don’t worry we’ll cover what clubhouse is but before you continue it’s basically a new app it’s like a new form of social media where you’re just listening and you’re speaking there’s no video involved so imagine like the way I described in this episode is it’s like a WhatsApp group except everyone’s constantly like talking and interacting in that way rather than by video so that’s what clubhouse is. Is there a place for dentistry in clubhouse? I think there is and hopefully you’ll be able to see that there is a role that all dentists can have in clubhouse. So if you are already on clubhouse join the room, the clinical dentistry and communication room. I’m calling it teach preach and leech and I nicked it from a group I am part of in Singapore and this is going to be a room to just discuss clinical dentistry, your clinical issues I think in the next episode we’re discussing composite veneers versus ceramic veneers, the do’s and don’ts. The sort of things on case selection for each of those and why one may be superior than the other that kind of stuff so it’s like a live podcast if you like. So join me on Wednesday evenings at 8 p.m. I’ll put the link on protrusive.co.uk and every time I go on clubhouse at the moment I’m putting on the Protrusive dental community Facebook group. Joining me in this episode is Kevin Rose, I’ll let him introduce himself in the episode so I hope you enjoy and brings you value about clubhouse in dentistry. Main Episode:Kevin Rose, welcome to the podcast how are you? [Kevin]Very, very, well indeed thank you good morning. How are you? [Jaz]Very good, thank you. It’s my son’s first day at nursery today so I am actually super anxious, excited like he’s had like these little settling sessions but today’s like first whack so yeah I’m kind of scared. [Kevin]How old is that these days? When they go to nursery is it four, three? [Jaz]It depends. He’s 19 months so it really depends like some kids I know been you know in nursery since who are six months old or young so he’s 19 months and we thought this is the best time now for him to start picking learning a few extra things plus we’re moving out soon so at the moment I don’t know if you know, Kevin I live with my parents so since I came back from Singapore 2017, been living my parents. Finally fleeing the nest because it’s just the way it worked out. It’s somewhere closer to work so a can cut out the commute and then so this is a big chapter coming up in my life. [Kevin]So you need to delegate parenting for a few hours a day definitely that makes a lot of sense now yeah I get it mine are much older. [Jaz]How old are yours? [Kevin]Oh crikey 21, 23 and 18 nearly yes there you go. [Jaz]Well the first thing for some reason the first thing I want to ask Kevin about your, of course you can’t really call them children but your offspring is are they on clubhouse? [Kevin]They’re not. I don’t think so but then there’s been a bit of a social media blackout between myself and my children for many years. I think it’s just mutual respect we don’t touch on each other’s social media worlds. So I don’t know, we do Strava actually quite a bit with my kids I was interested yesterday my one of my daughters actually strava mowing the lawn which I thought was quite impressive actually that’s keen isn’t it? That’s keen to get the miles in but no I don’t know and clubhouse for me is literally this is day 15 and I find it fascinating for no doubt reasons we will discuss. So what about you? [Jaz]Absolutely I’m on day 10 of clubhouse and to fair I was I got my invite like ages ago but thing is I’m on android so then I was just thinking okay I need to get on clubhouse, it would complement the podcast like a live version really well and it sounded really intriguing and then I said to my dad ‘Dad I think I’m thinking I’m getting like a second-hand iPad, iPhone.’ He’s like, ‘Son what are you doing we have 5, 15 iPhone in the cupboard!’ So I open the cupboard and literally I’ve got like so many old iPhone and the newest one was an iPhone 7 which blew my mind. [Kevin]Wow. [Jaz]I know right? What is your one sentence pitch? What do you do for dentists? [Kevin]I get them to think I get dentists and that’s it I really do and I believe that that experience within and outside of dentistry, yes okay I can at 12 years I could probably talk, I could probably talk my way around the dental surgery right? I kind of get the lingo and I get bp lingos and I get I know what a flat plastic is now by the way. Who knew right? I was like made of plastic turns out it isn’t but yeah so I get that bit which means you can hold a conversation and I’ve got all of the stuff if you like, the things you would expect from a coach or a consultant or a trainer to bring with them into any business. What I really believe, Jaz is that the difference between those that defined success is probably another conversation but I really believe that the difference between those that really succeed and don’t is actually it’s a small percentage of difference and that difference I think comes down to the conversations that you have with yourself as a business owner, that internal dialogue and the conversations that you have with others and in a dental practice those conversations are with patients and members of your team and if you think about it the day-to-day challenges of running a business tend to be more about people and customers that’s where the difference is. So I think yeah, what do I do? I get dentists to think why is that really important because that’s the extra 20% is the difference between a good day and a bad day and I do that because I ask lots of questions and I’m curious and I give a damn that’s my philosophy on it. [Jaz]Brilliant. Well we’re going to talk today about clubhouse so for those listening right now I mean I’ve done it already where we’ve been on the big dental groups and I said hey you know we’re hosting a clubhouse room and you know what the number one question is right when we say ‘hey join our clubhouse room’, can you guess Kevin? What’s the number one question that dentists ask about clubhouse? [Kevin]Oh let me guess is it how to use it to attract patients by any chance? [Jaz]No it’s very much more fundamental than that, it’s what the hell’s clubhouse right? So literally we’ve been absorbed into this because I’m really addicted to it now and I’m sure you’ve been in loads of rooms and getting a lot of value and stuff and then there’s a good and the bad and we’re going to get to that in a moment but most people are still that phase because we’re pretty much early adopters because it’s in my early. 60% of the world uses android and it’s on iOS at the moment I think only about 6-7% in the world use iOS in the first place. So it’s a small offering at the moment, it’s a small community, it’s an interesting community but essentially for those listening you don’t know what clubhouse is imagine a radio show on your phone on demand but with your mates. It’s like a WhatsApp group but you talk except you’re not typing but except on this WhatsApp group you got like you know the most successful billionaires in the world potentially sat in this WhatsApp group of yours. What’s your take on clubhouse? How do you explain what clubhouse is to someone? [Kevin]Well I’m going to steal your definition there actually because I struggle to explain it and I’m a bit of a, I am an ambassador for it. I keep bragging on about it to people. I mean my take on clubhouse is that number one actually, it’s not obvious. It’s not obvious how it works or what to do with it. The first time I was asked to speak, it caught me off guard and I didn’t even have the microphone settings, the privacy settings on my phone correct. So I went I was pressing all the buttons trying to unmute myself and inevitably with clubhouse probably doing something else at the same time and I guess that’s also the beauty of it. I think I was it was quite early on I was having a cup of tea or something making breakfast and there are some I was asked to speak on clubhouse. In terms of where we go with it and what opportunities it provides I want to put that into context because my job is to get us thinking right and I say that’s what I do I ask the big questions that perhaps other people don’t think or scared or don’t want to face up to and the bigger question it’s always been my thing for 12 years now is how the hell, how the heck don’t we get more, can we get more people to go to the dentist? Why doesn’t everybody go to the dentist? And you know where I’m going with this there is something, some hang-ups people have about dentists and dentistry and yet everyone that goes to dentists raves about their dentist they talk about their own dentist and their dentist is special and yet you get these massive percentages of the population and these numbers are replicated globally I’ve got clients in other parts of the world there’s big sways of the population who just don’t get it and that’s not all to do with NHS and affordability there is I think a bit of antipathy towards the profession and by the public and they’re misunderstood and they assume that every all the phrases ‘I’ve never met a poor dentist.’ Well I’ve met some dancers that are struggling right now but you won’t get that much, you probably won’t get that much sympathy from the public if you were to go and say that. So that’s the issue that I think we’re struggling to fight with as a profession and I think it’s more of a PR issue than a marketing issue in many ways and I mentioned that because that’s how I think we use clubhouse to our best advantage. [Jaz]I’ve been using clubhouse in a completely different way I come from very much as an extension of my podcast how can I serve the community of dentists because so far you’re right, Kevin I go on clubhouse and the majority of the room so they call rooms in clubhouse where you join in and there’s people on the stage just call the stage with people at the top and they’re like hosting and moderating and then I’m just explaining for those who don’t know what it is you raise your hand virtually and then you call up to the stage if you get your turn you can put your contribution in and so the kind of themes I’m coming up with is helping dentists which is the main one I’m getting involved with clinical stuff which is not happening that much moment but I’m hoping to change that but it’s more about marketing, how to get Invisalign number one. How to attract more patients? How to use social media in Dentistry? Those are the kind of rooms I’m seeing, how to acquire your practice and that kind of stuff. So everything that you see on all the other extensions social media we’re seeing it turn up on clubhouse. Now what I love about clubhouse is you vote with your ears right? If because I’ve been to a few rooms now, Kevin and all I’m seeing is one host or moderator is just completely just, ah this moderate is awesome follow them this is amazing and everyone’s just sort of digging each other up but no one’s actually giving any value. So you vote with your ears you just leave if you don’t want to be in that, you just leave. So that’s why I’m enjoying the most about clubhouse. [Kevin]Yeah and that’s you’ve I think there’s a meeting of mines it’s yes because that’s my I’m going to say concern with a very small c it’s not a problem, it’s not that it’s wrong. I think at the moment almost inevitably with this being a new technology and you’re right those rooms largely seem to be about how to get more as if we’re chasing something and that’s fine. [Jaz]I mean that’s our place, it’s got a place and people want to learn that and that’s got a place that seems to be the majority at the moment. [Kevin]Yeah absolutely and of course you have to have that in business okay and that’s part of what I do you know part of what I do is help people get busier practices. No one’s trying to go backwards generally in life or business and I support that. The trick I think we’re possibly missing is if all we use clubhouse for is just another platform to say exactly the same things in a slightly different way then I think it would be A) it’s a shame because I think we’re missing an opportunity. Going back to my point about the PR problem of dentistry. So yeah if you are a member of the public and let’s just take the obvious one at the moment and you’re looking for some kind of removable clear aligner teeth straightening system there’s plenty of choice out there. And there’s plenty of dentists on clubhouse talking how to give patients choice and to be their choice, there’s a lot of that going on that’s what you’re alluding to and that’s great if you’re already in the market as a member of the public for have for looking for that but what about the millions, millions what are we now 60 million people in a small island most of whom are born with the teeth in their mouths that they’re going to have for the rest of their lives and what half of them regularly attend the dentist there’s enough out there, Jaz right? There’s enough people out there for us all. What I think we’re missing is this hump that people have to get over to at least to even pick up the phone to a dental practice so this is where I think clubhouse has its biggest opportunity. Now I wrote a blog about this last week when I google.. and it’s not my greatest work because I think I’m still finding my feet with this myself but when I googled clubhouse last Wednesday or Thursday I got to the end of the internet right? I finished the internet. There were only 22 pages 22 pages about clubhouse now there’s a caveat there google then said we’ve removed certain things to avoid duplication right but in essence what I’m saying is its new. Now if you can’t google the answers to something heaven forbid what have we got to do, Jaz we’ve got to start talking to each other. We’ve got to start asking questions, we’ve got to start thinking, we’re going to start doing our own research and I think that’s to me it just got me really thinking hang on a minute if clubhouse is that new that we run out of internet at the moment in terms of what to do with it then it’s finding its own feet the internet is not giving us the answers to what we do with clubhouse okay? We’ve had to work it out for ourselves and that’s what we’re doing that’s what this conversation’s about but that then got me thinking well what if you’re a member of the public who isn’t getting the answers you want from the internet as well okay? So there are questions that you would want to ask as a patient which I don’t think you’re going to get the answer to until you look somebody in the eye and to express their feelings, their emotions the internet doesn’t really serve the limbic system well the inner chimp, the fight or flight it doesn’t it delivers facts. It delivers facts in a bit of opinion and opinion it’s harder for the internet to connect emotionally and yet if you think about it you know if you businesses crave to have what we have which is the ability to emotionally connect with other human beings you guys do it all day long you know big companies try and do it with cars and with cans of fizzy drinks and with inanimate objects to get that emotional connection and yet you guys have got that emotional connection so I’m bringing bring this right back into clubhouse in a second I promise you. So here we have I think, if you want to attract more people into your dental practice and most people would say that they do okay? And by the way when you say attract I’m talking about attracting and retaining loyal and motivated patients and it not just to be about the numbers to be a there to be a quantity but also a qualitative outcome the things that we really need to measure and it gets hard because it gets subjective okay but I mean I was thinking about this the other day I mean what I would measure if I was a dental practice and I was also doing clear aligners I’d also be measuring how many of my customers bring those aligners back for recycling that’s just as important and yet it’s not the obvious thing so we have an opportunity here to use, to think about the where the internet lets us down as a member of the public because it doesn’t answer the real personal questions that you have to pick up the phone for, you have to get on a messenger for and guess what in the last 12 months you actually can occasionally speak to a dentist on a video at home on an evening and of course it’s absolutely transformed how we interact with people with patients because they do get to look you in the eye that’s why video consoles are so successful. So there you have it what where do we go with this well the internet isn’t the answer, the internet isn’t the answer to all of this. Engaging with people eye to eye if you like it is the answer. We’ve proved it with video consoles and I think even though clubhouse is just an audio format that’s where I think there’s still a massive opportunity which is yet as yet untapped from what i’ve seen yes we can talk about using it to attract patients who are probably already in the business of looking for a dentist I get that but what about those that aren’t? That those that don’t get it yet? So we can use clubhouse I think to and again this is a working title but to bring people almost behind the scenes you know how when businesses have a bit of a PR issue they take the cameras, they bring the reporters behind the scenes and they show them what and all and actually and it’s not all pretty but it does change people’s perceptions I didn’t realize it was like that if you look at over the years businesses that have used that easyjet for example who’d have thought that people shouting at the check-in desk at easyjet would actually build the brand and yet that’s what you had. We’ve seen it with restaurants and right now and again a bit of google research there’s only 22 pages to look at I know them all the company that owns burger king and it’s a big restaurant chain i’ve never heard of actually. They’ve got clubhouse, they’ve got something called open kitchen. So what they’re doing is as a member of the public you can actually go behind the scenes and talk to the chef of a restaurant chain, who in turn owns burger king or the chefs. So you can actually so what can you see, where we’re going with this is that going to sell more burgers tomorrow because of that directly? Well you’ve got to forget that you’ve got to be detached from that you’ve got to look at that bigger picture. So I could be cynical and say it’s junk food, it’s pollution, it’s packaging, it’s making kids fat and all the rest of it but you’ve got to admire being brave enough to bring the public and bring them so they can see something from the inside out. Now that’s a very long answer to how do you use clubhouse well you use it in exactly the same way. So you use clubhouse to bring skeptical people okay not just the fans not just the ones with the aligners and the white teeth and the veneers okay? Skeptical people who are on that scale of complete fear and anxiety through to just having read a tabloid newspaper once okay and everything in between. Bring skeptical people to see what it’s really like. Okay I mean look you know this conversation now okay but don’t pay the patients don’t know that dentists are bending over backwards to try and help the public. Patients think it’s hard to get a dentist and yes I know it’s hard at the moment relatively because of covid all the rest of it but all these myths and memes and prejudices that the public have let’s debunk them but you won’t debunk them by just saying ‘I’m a dentist. Here’s my opening hours. Here’s a special offer we do straightening, whitening, implants and all the rest of it. That’s what you do okay and I’m trying to avoid stealing Simon Sinek’s quote but it’s almost inevitable you have to anyway yeah people don’t buy that they buy why you do it so what’s that why and what a better way to communicate something that can be quite ineffable because it’s a feeling than a conversation to really get that passion across. [Jaz]Kevin, I’m just going to object because I’m going to sort of debate with you a little bit all in good nature. So firstly I was listening very carefully there’s a few points you said. Firstly I love the whole burger thing okay is the fact that they got the open kitchen on clubhouse. Is that going to sell more burgers tomorrow? Who cares. That’s not what it’s about okay so I love that firstly okay? So from that I can extrapolate that as dentists we can serve our patients not just our direct patients but humans. Let’s serve humans, let’s improve their perceptions of dentistry because we can do wonders with that so that’s I definitely agree we can do that and I think we should because I think it’s very altruistic because when i’ve hosted a room about clinical dentistry, once you geek out with other dentists you know how sad am. I there was someone from Harvard, there was someone from UAE, there’s some from Spain, all dentists were just learning each other pitching different scenarios. Love that. Now here is the skeptic who wants to attract more patients to our practice maybe clubhouse is not the best place for them because when they host a room all about how to overcome your dental fears ,well you’ll have a patient from San Diego you’ll have a patient from Nice, you’ll have a patient from Shanghai I don’t know I’m making these up right? Maybe one person, one patient is 30 miles away from that may come see you. So maybe it’s not the best reason to attract patients your practice at the moment with the small scale it is maybe in the future it could be used in that way to sort of help people overcome their fear and then eventually come to your practice but at the moment it’s not about that. At the moment it’s about raising the profile of dentists, helping the humans the greater good of dentistry so I think that’s where I’m seeing it go at the moment. So that’s my only objection because you said about emotional connection I think you can get that emotional connection through YouTube like so many dentists I know have made wonderful YouTube videos where look at the camera in the eye and say you know what my practice is in Reading, here’s where I work, here’s how. Here’s what we do, this is what we’re about. Where do you see the role of that versus clubhouse and how can clubhouse compete with that? [Kevin]Well it’s an audio format only so but YouTube tends to be static doesn’t it? I know billions of things get uploaded every day but it’s not quite, it’s not a dialogue. It’s a recording I guess? That’s the fundamental difference. and you’re right going back to those things I was expecting you to like beat me up then as when you said I want to challenge you and I’m happy to be challenged on this there’s nothing to challenge. It’s just an idea about something that hasn’t yet been done. So is there a right or wrong? Is it limited? Yeah if you’re hoping to go on clubhouse and fill tomorrow’s white space forget it. Absolutely, forget it you know or catch up on some UDAs that’s not what it’s about and if you’re looking to you know do more dentistry tomorrow because of it no way, you’re kind of missing the point there’s a principle which I’ve always believed in and in the end it cost me a career I left a profession because of this. To be detached from if you like the outcome the end result whatever you want to call it that’s a good thing in life and certainly in business because people will see through it otherwise and I do believe it’s actually effectively GDC 1.1 right? So not of a vested interest. So it’s a good thing from a regulatory point of view so it was always a good thing. So go on clubhouse to sell some dentistry, no bring a patient in your surgery to sell some dentistry and make some money good luck with that. In the short term fine maybe you’ll get away with it but if you want to change perceptions and it is a bit ultra I mean I’m an idealist right? I get that and I just think that I don’t know if this is a phrase or not whether I’ve made this up but something about you know all the boats sail into the harbor better on a rising tide I don’t know I’ve heard that somewhere but you get the gist of that we, if we all and that’s the other thing about clubs by the way I think it’s got a huge collaborative even this conversation came from a half past seven in the morning, clubhouse message or something when you’ve got so many millions of people who are missing out on basic dental care but for the lack yet of having a good conversation with a front-line dental health care provider well if we’re all having better conversations we all benefit if everybody’s having better conversations with the public generally then everybody more people go to the dentist so why make it a one-man crusade to get more patients in within your immediate postcode don’t see it like that. [Jaz]Brilliant and because I just want to clarify that those thinking they’re going to jump on clubhouse and get those patients and you’ve nailed it there so. [Kevin]Please don’t try and do that get off clubhouse if that’s what you’re trying to do because it’s not going to work, it’s not going to work. It’ll ruin it. It’s not Facebook, let’s not spoil it. [Jaz]Exactly and I know you’ve got a meeting so I’m going to wrap it up by say to summarize a and advocate what Kevin said there. Have conversations have better conversations and have or create emotional connections and you can do that through many mediums. Clubhouse just offers you another way where you can be doing anything you’ve been washing the dishes you can be doing any anything you can imagine but there’s no video involved so there’s a beauty of clubhouse which I’m really enjoying as well it’s on the go you can learn a lot, you can just be a fly in the room because sometimes you say hey I wish I was a fly and on the wall when these billionaires are having conversations and those rooms exist and they’re fantastic all right so I know you got to go but is there anything you want to wrap up with my friend? And thanks so much for coming on. [Kevin]Well thank you i’ve enjoyed it and it was all a bit on the hoof. We didn’t talk or prepare for this it was just let’s just talk about clubhouse those are my thoughts and you’re right that fly on the wall thing there. It is that’s a bit like what clubhouse is you’ve got a chance to change the perception of going to the dentist in a conversational way and that’s what clubhouse I think it’s one of the biggest opportunities and to sign this off the internet isn’t personal okay? It’s a library of things and like any like a real tangible library you’re not allowed to talk, you’re not allowed to interact right? I mean I’m old enough to remember libraries I used to go there to go and tell it to go to get books out after school and look at teletexts like it was the internet of the day right I mean rubbish by comparison but you weren’t, you’re not the whole point of the library it’s almost a a stereotype situation just take it all in, it’s one way. So the internet is just an online library. So who do you talk to directly when you’re searching for stuff on your computer you can’t and what are we missing what are we missing more of in dentistry? Conversations with people not just those that have already bought the idea of going to the dentist those that might just need a bit more encouragement and reassurance so I think any platform that allows us to talk directly with our customers or patients in this case and including from this perspective of I would say just recall it from the inside out wow that that’s how you change people’s attitudes and perceptions towards something and that’s a wonderful opportunity so that wasn’t a very brief answer I can’t give you brief answers on this stuff because- [Jaz]We’ve stuffed that one out Kevin but we enjoy your rambling that’s fine thanks so much I know you got a meeting to go to as well I’ll be taking my credit tonight soon. So thank you so much and yeah I’ll put this up very soon because this is very current so I’m not going to delay on this one we’ll get out very soon buddy. [Kevin]I’ll see you on clubhouse no doubt okay. Jaz’s Outro:See you clubhouse. Bye Kevin.