Protrusive Dental Podcast

Two ‘TMJ Queens’ in Two Days – another tribute to International Women’s Day last week and what better than having Dr Priya Mistry from USA who has limited her practice to the treatment of Temporo-Mandibular Disorders. https://youtu.be/FGVSbFjFrlw Step by Step Examination Protocol Need to Read it? Check out the Full Episode Transcript below! I first discovered Dr Priya Mistry’s fantastic content on YouTube – I really enjoyed her style of content presentation. I quickly saw her grow on this platform and help so many of the public with their TMD concerns. I realised that a lot of what she has to share is not just helpful for patients, but is really useful and helpful for Dentists, especially as many of us find the TMJ to be a mystical joint! I probe Dr Mistry about her full examination protocol for a typical TMD patient so we can gain insight in to how Dentists limited to TMD get to a diagnosis – arguably the trickiest part! Some parts of her specialised exam is already familiar to us – the usual palpation and range of motion measuring. Other parts are very different, such as measuring leg-length and really analysing the postural chain. Also, there are a lot of pre-appointment questionnaires that patients need to fill in advance of the appointment. The main take-home from this episode is to figure out when to treat TMD patients yourself in practice, and when to refer to someone like Dr Mistry. I enjoyed her ‘4 levels of TMD’ which was very easy to follow. If you enjoyed this episode, do check out the episode with Dr Gurs Sehmi where I probe him for the full protocol examination for his Smile Makeover treatments! Enrollment for SplintCourse ends on Friday (thanks for all of you who joined from around the world!) I look forward to catching you on the Monthly Live Webinars: Click here for Full Episode Transcription: Episode Teaser: Yeah what really, excuse my French but what really pisses me off right is when Dental Professionals right like we have this like closed mind and we don't accept that there are other ways there are unknown unknowns and they go by the very poor quality evidence that exists right? So I hope when I commented on your video I hope you didn't feel like I was like disagreeing with you I was just coming at a different angle I kept a very open mind. Jaz’s Introduction: Hello, Protruserati! It’s Jaz Gulati and welcome to today’s episode all about the perfect TMJ exam. I’m joined today by someone really cool. Her name is Dr Priya Mistry. She’s based in Oregon, USA and I found her on YouTube. And honestly she is such a cool girl she makes brilliant content for patients actually but I think as dentists we can learn so much. In this episode we cover about what a TMJ examination entails for her. Now, remember a lot of these things we won’t be able to implement in our practices especially for GDPs because she is limited to TMJ. She’s limited to treatment of people with temporomandibular disorders so what she does is way above and beyond what we do including like CBCT scans, a full body examination while they’re laying down so you get to hear her workflow. So what we can learn from this episode is what do these people do that are limited or specialized in the practice of just TMD. We also answer towards the end of the podcast about what is her approach to someone with disc displacement without reduction these are people who used to have clicks and suddenly they’re locked and they cannot open very much. So how does she treat this very difficult condition to treat? You see, I’ve been reading the evidence I’ve been checking out and the evidence is very varied. There’s many different ways to approach it so I’d like to listen to her schools of thought and I want you all to keep a very open mind, keep an open mind because a lot of what she teaches is not evidence-base, it’s not taught in dent schools but that doesn’t mean it’s wrong. I’ll tell you why it’s likely not wrong because the three arms of evidence-based dentistry, don’t forget we talked about this in the Lincoln Harris episode that the two other arms of evidence-based dentistry aside from the literature is the patient values and the clinician’s expertise, okay? These are two other arms and the evidence that’s out there in the field, in the entire field of TMD it’s very varied, it’s very biased, it’s very poor quality as a whole. So there are so many unknown unknowns. So just have an open mind when we listen to this yes we talk about posture, yes we talk about the neck and stuff but I think there’s so much we can learn. I’m hoping it’s going to open your eyes if not anything then to at least the importance of the airway in your diagnosis and trying to get grips with patients who may have sleep disorder breathing, I know I always bang on about this but I’m hoping you’ll gain a lot of value from this. The Protrusive Dental Pearl I have you is when you’re doing the TMJ examination I want to make it obviously relevant, use your pinky fingers to feel inside their ear, by doing so you’re doing an intra-auricular examination of the TMJ which will give you more information. Why? Because you’re going to get closer to the back of the joint and that’s when you can hear a lot of closing clicks and you’ll see Dr Priya discussing that as well. And the other reason is when we’re feeling the lateral pole of the TMJ which is basically when they open up and you can feel their condyle that’s we’re touching the lateral pole the condyle that when we’re doing that. That’s not very well innervated doesn’t have a great blood supply there. Therefore by touching behind joint i.e. from the intra-auricular within the ear approach you obviously have to tell your patients you’re doing this beforehand otherwise I think what the hell is this dentist doing. You get to feel a much more innovative and vascular portion of the anatomy and you do gain some more information i.e. is there inflammation, is there pain that kind of stuff. So there we are that’s my Protrusive Dental Pearl for you and now let’s join Dr Priya Mistry aka the TMJ doc. Dr Priya Mistry, welcome to the Protrusive Dental podcast, how are you? [Priya]I’m well and thank you for having me how are you doing? [Jaz]I’m great and honestly I’m so excited to speak to you today. And for those people in the UK maybe around the world who don’t know yet who you are. I’m going to give my sort of version of an intro and then I want you to do a proper intro. Priya, look I came across your content on YouTube I was searching about Aqualizer splints something I’ve been using on and off but then sometimes I deliver it I’m thinking is it supposed to be this flimsy and then y’all. I came across one of your videos and then I saw more videos and I see that on a regular basis nowadays you’ve been creating some wonderful content. So I was in awe of your content and just so everyone knows the content you make is primarily for patients and I have seen you in the last two months grow and grow and grow and it’s been an absolute pleasure to see. So, Priya, tell us a little bit about yourself, what you’re practicing, what got you into this crazy field of TMJ, TMD. [Priya]Yes, so I’m over here in Portland Oregon and I’m working with my mentor Dr Arthur Parker, who has been doing TMJ work for (gosh) well over 40 years now and he’s just wonderful. And he’s really just meeting him sort of changed the course of my life. And so I’ve been practicing general dentistry for 13 years and about two years ago I very randomly walked into my mentor’s wife’s jewelry store to get a clasp on a necklace fixed. So my mother-in-law gave me this beautiful necklace but I just want to I felt like the clasp was a little bit flimsy so I just wanted to change the clasp and I walked in there and luckily my mentor’s wife her name is Debbie. Debbie and I are both pretty chatty and so we got to talking and she told me about the work that her husband does she told me he stopped practicing general dentistry 35 years ago and he opened up his tmj only practice sort of as a hobby but also it’s his passion. And so I thought, huh, tmj only? That’s pretty rare because even if you refer to a tmj specialist. They’re doing a lot of other things and they’re typically doing a lot of restorative dentistry which we don’t do at all. So I thought huh? And I remember walking out of that store and I called my husband right away he’s a dentist as well. And we had been living in this area for about two years at that point but I have had babies each year so I didn’t really know the dentist in this area. So I called my husband I said do you know Dr Arthur Parker he said yes that’s a huge name he’s the tmj guy like he’s a big deal I refer all my tmj patients to him. And I said well you know I kind of want to reach out to him and maybe shadow him he said definitely like go back in that jewelry store talk to his wife get his contact info. [Jaz]Buy some jewelry. He probably didn’t say that he said talk to her but don’t buy some jewelry. [Priya]Don’t look at anything just talk to her. So I went back in there and you know the rest is history I started shadowing him and I was just fascinated to see what he was doing. And so I was shadowing him maybe half a day three times a week and every single time I came in the patients would say are you taking over? Because Dr Parker saved my life. And I had one patient say they were about to commit suicide they were in so much pain and Dr Parker saved them. And I thought is he arranging for all these patients to come in when I’m here. I thought gosh I’m hearing this time and again what is he doing and so it turned into a mentorship and then I just actually bought the practice last week and he’s still working, I’m still learning from him. He’s amazing. [Jaz]Congratulations that’s so so so good well done. [Priya]Thank you. Thank you so much. [Jaz]I can’t believe you’ve been practicing for 13 years though you don’t look like it. [Priya]Oh yes it’s the haircut. [Jaz]Fantastic Wonderful. Brilliant. But what struck you about the fact that you know his wife when you met her she told you that her husband has an interest in tmj but did you already have an interest? What was that connection that you felt that you needed to reach out to him? [Priya]Yes, so I had taken a course in 2011 about sleep apnea in children. And I just remember thinking children with sleep apnea? Like you know we’re taught in school or at least I was that it’s associated with like very obese older people. I didn’t think about children I thought huh? So when his wife spoke to me she said that Dr Parker is doing tmj work and he also works with the kids with small airways to help guide their growth and development. So there is another aspect to our practice too and so that kind of hooked me but then also the tmj part there’s so many patients I’ve seen in 13 years that came into the office and they could barely open their mouths and I honestly had no clue what to do for them. I mean they couldn’t even open enough for me to get impressions even if I wanted to do something so I would put them on muscle relaxants, anti-inflammatories and say come back in a week if you’re feeling a little better then that means we know it’s your tmj and then I would just make a regular flat plain splint and hope. [Jaz]So Priya at that stage I think what you’re describing is a very typical situation for a lot of dentists we don’t see these issues so often when they come we try and think back to our anatomy from dent school we’re like what’s going on? So we failed to make a diagnosis maybe you went through that, right? Is that what you felt at the stage that you experienced? [Priya]Yes definitely. And so when she said that he’s been doing tmj work for so long I thought oh my gosh I can finally learn how to do something beyond this. Because I felt like I would just give them a split and hope for the best and I thought that’s just not good enough for our patients so I need to learn more. So then I thought maybe you know I didn’t know where it was going to go but I knew I definitely wanted to learn if he was open to it and it just developed. [Jaz] SplintcoureHey it’s Jaz I’m just interfering into this episode to tell you the following if you’re listening to this podcast when it’s released then we’re probably just a few days away from the splintcourse enrollment coming to an end. So I only wanted to open the course for two weeks because I want to limit the number of students because I want to focus on monthly mentorship. I’m going to do monthly coaching webinars for all your splint queries for all your patients because I realized when I did a resin bonded bridge course that actually people need opinions, people need mentorship so I’m so excited for those who have joined me on the splint course if you want to learn more about how to treat patients in general dental practice with splints and how you can improve myofascial pain and protect your precious veneers, how to find centric relation better, easier with clever appliances then please do the split course. I’ve worked really hard over the years to make lots of clinical videos. One thing I didn’t have in the resin bonded bridge course by putting in the splint course is so many clinical videos, testimonials from patients, showing you step by step every single technique from tmj diagnosis from muscle examination to the final delivery and adjustment to splint. So I really hope you join me just a few days left. If you haven’t already check out splitcourse.com and enroll today. [Jaz] Back to EpisodeI love that story. I love how it started with the necklace, the jewelry about the clasp this is wonderful amazing. Well let’s get into the meat and potatoes of the episode talk ’ve seen your content your wonderful way you make content and the your patient mannerism and your education style is brilliant. So I can see because one part of treating patients with tmd is the ability to educate our patients, is the ability to take an empathetic approach with our patients and you definitely have all those fine qualities. So tell us what is your protocol for a tmj exam. Let’s say a patient comes in and she’s been referred and tell us what percentage are referred and what percentages come to you directly. And to be honest with you one thing I did want to explore with you is now with the YouTube you messaged me saying ‘hey you have a patient in the UK [exeter] and that kind of stuff and we’ve been emailing I’m sure is blown up how many patients and I’m sure patients want to drive from everywhere because Priya even though I make my content for dentists people have been watching my videos about ipr techniques with an orthodontist and about splints which I make for dentists and they are finding me and they’re driving hundreds of miles to come and see me. I bet that’s happening to you as well so give us a flavor of that. [Priya]Yes, yeah so people are trying to come from far I mean with Covid there’s a lot of limitations and the tricky part is I really don’t encourage people with actual intracapsular problems to come see me because that can be a four to six month resolution and so I need them nearby, I do jaw manipulation. I can’t do that on somebody that’s coming from a different state or they have to travel far so the people that I have encouraged it’s just been a few that have come from far but it’s mostly muscle, myofascial problems. And those patients I think a few of them have come one has had great success the other is still struggling but that’s tmj there’s often other parts of the body involved. And so we’re trying to figure it out I wish you, I wish it was closer because I think we could have probably nailed it by now but it’s very hard to work with people that are far away. So I really prefer people close by but it’s been- [Jaz]But it’s the impact of social media. It’s the impact of creating content and it’s just amazing how and I’ve joined these and maybe you should join us as well. I’ve joined this group on Facebook with people who are suffering from tmd and you should totally go and share your content there’s like thousands of people. I just want to understand their journey and understand their issues and these people are really desperate and I know you’re going to go into this so tell us about these patients that seek you out or refer to you. What is the typical exact first appointment? [Priya]Yeah so typical first appointment takes about an hour and that includes our examination and talking with our office administrator and getting an appointment set up. So it’s not super long but it is very thorough so when these patients get referred to us the first thing we do is we have a really comprehensive patient intake form. So it’s a lot of paperwork but it’s for a good reason because the paperwork has very specific questions as to pain. So are they having headaches? Are they having neck pain? Are they having ear pain? Is it sharp? Is it dull? Is it constant? Is it coming and going fleeting? Stuffy ears? It covers so many things along with limited range of motion, noises in the joints blocking incidents there’s a lot in that intake paperwork along with a sleep apnea questionnaire because sleep apnea and tmjd are very much related. And then also a history on any accidents any car accidents, anything that could have caused whiplash and so sometimes people come in and they say oh my gosh this is a lot of paperwork. But then when they sit down for the exam they say I didn’t even think that you know my accident two years ago yeah like I did have a really bad whiplash I wouldn’t have put that on there. So there’s a good reason for all the questions but it starts with that intake paperwork and then once I get that in my hands I read it very thoroughly like I know everything before I go in there. And so there’s that that’s a big aspect to it and then of course when we go in the first thing I do is I just sit down I say I read through your paperwork it sounds like your condition started I don’t know two months ago whatever it is. And I say tell me your story because people want to tell their story people want to feel as though you’re empathizing with them which I do very much so these people are typically in a lot of pain and so they tell their story I listen I take really detailed notes I want to know everything. And I ask questions every now and then I try my best not to interrupt them and then at the end the two questions I always ask if they haven’t covered it in their history is what is your prior orthodontic treatment? Did have you had any did you have braces? Did you have invisalign and when you had braces? Did you have any permanent teeth extracted? Tell me and so they tell me about their orthodontic history and then I also ask history of injury to the head, neck or jaw think back even if it happened in your childhood let me know if there was any sort of injury. Because even though our paperwork covers it they don’t necessarily think to tell us about a really bad accident when they were 12 or 13. So I go through that and so once that part is done then we can really get it started with actually physically examining the patients. [Jaz]So that all is part of a very comprehensive history taking which starts with the forms continues on to their story and how much time do you think of that appointment is actually them telling you the story you reading their paperwork just so we get an idea? [Priya]Depending on how chatty they are maybe 10, 15 minutes I mean you know I kind of guide them because sometimes it’s easy to get lost in explaining your story so I’ll sort of nicely interrupt and sort of guide them back on track if they’re getting a little off. But yeah usually about 10-15 minutes and also an important part of this is I observe them as they’re talking to me I observe their head posture, I observe if one shoulder’s higher than the other and then right after this exam they actually have to get up from the chair they’re sitting in and then sit down on our exam table so I even observe the way that they walk. So this is all I’m getting an idea of their overall body posture because that definitely plays into the mandible and it’s positioning. [Jaz]So what are you then examining for? [Priya]Yeah so I’m looking for a lot of these people have cervical misalignment so the cervical spine if they are rotated or these vertebrae if they’re rotated or if they’re tilted at all it’ll show in their head posture like they’re looking off one way and they don’t even realize it right? And then discrepancies and shoulder height and then even in [gate] if someone’s walking really straight great but if one leg’s swinging out one way it shows me that there may be some instability in the hips as well. Ao I try but be discreet about it- [Jaz]Do you have like a diagram of the body and you’re sort of making notes about any postural issues or is this something that you just on the side just make a note of? [Priya]No we noted in our exam form too. So there is a point during the exam where we actually lay the patient out on a table so we don’t have a dental chair in that room we actually have a massage therapy table. So at that point then I make more notes about it but these are just simple observations at the beginning and then I comment on it later on in the exam. [Jaz]Sure. Tell us what’s next. [Priya]Yes so what’s next is I have the patient take a seat just sitting facing me on the exam table and the next part is a range of motion exam. So I use my little range of motion scale and I ask them to open and I basically just say do what you can don’t hurt yourself. And so I just kind of see what their range of motion is ask them to move side to side and we write that down so there’s an assistant in the room taking all the notes writing it all down on the exam form. After the range of motion exam then we- [Jaz]Just tell the dentists out there because you want to make as educational as possible some young dentist students might be listening. What are the figures that are normal and then which figures are you thinking or there’s a red flag, there’s something going on that we need to investigate further? [Priya]So 45 to 50 millimeters is normal opening and then 10 to 12 side to side is normal lateral excursions. 25 millimeters opening and below can be indicative is usually indicative of the jaw being locked closed meaning the articular disc is displaced without reduction so the jaw is locked. Somewhere in the 30s can be kind of tricky because there could be an intracapsular problem or it could be all myofascially driven like the muscles are so angry that the patient isn’t able to open more so further evaluation is needed for that. So those are sort of the numbers involved there. [Jaz]That’s really helpful. Thank you. [Priya]Good yeah so after the range of motion exam then we do a muscle palpation exam. So for the muscle palpation exam I always say I’m going to be feeling muscles around your head, neck and jaws and when I do so I use about this much pressure and so I put about three pounds of pressure on their like arm or shoulder just to give them an idea of how much pressure I’ll be using and I say if that gives you- [Jaz]I personally I put my finger on there on their forehead and I say this is how much pressure I’m pulling because they need something to compare to because if when I didn’t used to do that and I just felt the muscle they were like yeah they don’t have a reference to compare against. So it’s so important to give them a sensation they can compare to. I’m really glad you mentioned it. [Priya]It’s so important right? And so I say it once I’m feeling muscles around your head, neck and jaw if you feel more than pressure I want you to stop and grade it on scale of 1 to 3. 1 is a little tender, 3 is painful. 2 in between and I say if you just feel pressure we’ll keep going to the next spot but if you feel more interrupt me. Grade it on that scale and let me know if it’s your right side your left side or both and so they’re usually good with that and we start at the temples and we just go through the whole muscle exam. So I have a video on my YouTube called muscle palpation exam and there’s even a I think there’s a form that you can download afterwards if you want to incorporate that into your paperwork . – [Jaz]Amazing I’ll link that on so my producer will put that on so everyone can access that I’ll also put it on the blog on protrusive.co.uk so people can find easy access to this video because I think it’s so important to be able to do that correctly as part of your record taking. [Priya]Yes, it is important to do that correctly and the muscles can give us so much information as to what’s going on with the patient and sometimes what’s interesting is when I palpate the lateral pterygoid at the end of the exam I do that. Right after the muscle palpation exam I then put my fingers over the joints and asked the patient to open and close and I’m feeling for pops and clicks but what I often see is patients who are limited in range of motion. Not locked but limited in range of motion. They can open more after I’ve palpated and released that lateral pterygoid it’s so interesting but I see it time and again they’re able to open a little bit more so if you see that if you observe that. That’s telling you that this might be more muscular driven than an intracapsular issue so I see that a lot so the next step I guess which leads me into is I check- [Jaz]I just want to ask on that point actually just want to because a great point you mentioned there now. This is a very controversial area whether you can or cannot palpate lateral pterygoid. A lot of people think you can’t, I mean I appreciate your expertise in this as well because you’ve you know got a mentor and you’ve limited your practice so but we need to appreciate that there’s both sides so some people from cadaver studies say that okay it’s not possible whereas what you have experienced and what you feel is like a myofacial release these patients are able to open more. So you know we have to be open-minded and consider that actually we don’t know exactly if it’s possible but I love hearing your experience I love getting different viewpoints on the podcast. So that’s it so we’ve got one point for yes we can palpate it and i’ve also seen the video of you doing the release on yourself in that live video you did which is fantastic so that’s good to know. [Priya]Right so next what I do is I tell the patients that I’m going to place my fingers over their jaw joints and I’ll watch and feel as they open and close a few times. So here I’m looking to see if their range of motion increased I’m also feeling for any pops or clicks or crepitus and you can feel for that pretty easily and I’m watching for any deviation off to one side or an s pattern deviation even on the way back up I’m just watching for all of that so watching feeling and letting my assistant know what to write down. And so that’s sort of the next part then I ask the patient to lie down and say ‘are you comfortable being on your back?’ So then they actually lie down on their back and I tell them we do a little bit of a postural exam here and I say I’m going to start by checking leg length and then I’ll place my hands on your head and finish up my exam so I do I just go to the end of the table I check their leg length and most people have some discrepancy and so I make note of that because if there’s a discrepancy in the leg length that usually correlates with the discrepancy in the hip height and so once there’s discrepancies along the postural chain it’ll feed up and back down and with the mandible being suspended in a sling of muscle it’s very responsive to those changes in the postural chain. So when I say postural chain I mean the mandible I mean the spine itself the shoulders, the hips and the feet so looking at all of that- [Jaz]This is really fascinating because we don’t get taught any of this at dental school I don’t know what your experience was about the extent they went into this. Did you get taught any of this at dental school? [Priya]No I got taught none of this at dental school no and I would never have even thought to look at leg lengths when I’m doing a tmj exam right? Like when I first started shadowing my mentor here I could not figure out why he was checking leg length. And Dr Parker is amazing but he is a man of few words and so I always poke him and ask him a lot of questions. And so after the first couple observational sessions that I had with him I just said I don’t get it let’s sit down and talk and that’s when he explained the postural chain the same way I just did. And I said that makes sense and so that’s another indication as to whether I know we’re going to touch on this later whether to get a body worker, a physical therapist, a chiropractor involved at a later stage so it’s just sort of giving me more pieces of the puzzle. [Jaz]Brilliant. Fantastic. You explain that really well. Fantastic. So you’ve laid them down you’ve done the leg length what happens next? [Priya]Yes so then I do leg length and then I actually sit down and I say I’m going to put my fingers in your ears I know that sounds funny but when I do that I can feel inside your jaw joints so I just use my little pinkies and I place them in the ears and I put just a little bit of pressure going anteriorly. And I ask them to open and close and this is the part of the exam where you can actually feel closing clicks really well. Opening clicks are often like you can feel them from here but the closing clicks you can’t always they’re just softer they’re just quieter so here you can feel that you can feel crepitus really well and so that’s just sort of gives you confirmation as to what you felt from here and it gives you more information oftentimes too. So I do that- [Jaz]That area is much better innovated than the lateral poles and that’s why another reason gives you so much information so if you felt the lateral poles and then sometimes they’re not feeling any pain sometimes I’m sure you found intraorically that actually reveals the might be some inflammation, some pain is that what you found? [Priya]Yes, I have I found the exact same thing. And so that part of the exam is pretty quick and then the last part I say I’m just going to take a look inside your mouth now so when I look inside their mouth I’m looking for a lot of things really. I’m looking for scalloping on the lateral borders of the tongue that scalloping on those lateral borders is telling me that there’s probably not enough room in their mouth for their tongue or they’re using their tongue as sort of a soft night guard or it’s just it shouldn’t be there essentially. And so when I see that scalloping I know that tongue isn’t always in the proper position up against the roof of the mouth with the light suction. It’s doing a little bit more than it should so I look for that scalloping on the lateral borders of the tongue. I look for tori, palatal tori, mandibular tori, a narrow arched palate I’m looking at that I’m looking at molar classification, looking for deep bites, I’m looking for cross bites, looking for signs of clenching and grinding clear signs like wear on the teeth, recession, abfraction, craze line so like vertical fractures in the enamel gives us lots of clues I’m looking at how much space the tongue takes up in their mouth so we call it Mallampati score here I’m not sure if you call it that there but I asked- [Jaz]The same yeah as well yeah. [Priya]Okay so stick their tongue out I’m looking at what I can see in the back so I’m looking for the Mallampati score. There’s a lot that I’m looking at and the whole time my assistant’s taking notes I’m looking for missing teeth. So I’m looking for a lot in that part just to kind of give us more clues as to maybe how they got there and so those class two div two patients. The majority of our tmj patients. That class two div two just sort of doesn’t allow the mandible to come down and forward where it usually wants to be where the muscles joints and ligaments are the happiest and so we see that a lot the class you div two especially with our patients that are- [Jaz]As a restorative dentist they’re also the patients that just give us so much trouble in terms of destructive treatment planning, longevity or restorations, the amount of resistance they put on restoration so yeah no one likes these class two div two patients sorry if you’re class two div two but you give us a lot of hard work. [Priya]He does a lot of hard work. [Jaz]Brilliant. Yes absolutely carry on. [Priya]Yeah. So that’s it I mean once we do the occlusal exam. I say you can sit up and have a seat back in your original spot and then I just go over everything with them and I always start with you know we talk a lot about tmj and we talk about tmd at our practice. And I said tmj I always say tmj is not it’s not a diagnosis it just means temporomandibular joints but if there’s a problem within those joints it will manifest as clicking, popping, crackling noises or episodes of the jaw locking so if they have any of those I say clearly there’s an issue there. And then I say tmd which is temporomandibular disorder or dysfunction it recognizes that there’s a group of muscles that work together to guide and support the jaw if or when those muscles become dysfunctional usually due to chronic clenching chronic grinding sometimes even just the way the teeth fit together. Unilateral crossbites can be very dysfunctional for the joints. So I say sometimes even just the way the teeth fit together or imbalances along the postural chain can make these muscles dysfunctional they can get trapped in a chronic pain and spasm cycle and when that happens it can lead to a lot of different symptoms with number one being headache closely followed by ear and neck related concerns, jaw pain, tingling in the jaw, in the extremities. There’s just so many things that go along with it that tmd is often called the great imposter disease because there’s just so many different things that can come along with it and so depending on which one they have more of or if they have both I just explain everything and then how we treat it and how we can help them. [Jaz]But the most amazing thing is that I don’t think the literature on tmd will ever reveal the truth because there are so many confounding factors right including the fact that the current accepted model in literature is the biopsychosocial model of disease so we know there’s more to it than just trauma. Like there’s so many patients that have really severe signs of bruxism but they will never manifest as having pain or tmd. [Priya] Never. [Jaz]And when you have these other people who don’t have as much history of micro or macro trauma but then they suffer so much more so I don’t think the evidence will ever be able to find the truth in that whatever the truth may be because it’s just impossible to study, it’s impossible to get the end numbers, it’s impossible to get the sleep studies, it’s impossible to account for every single factor that can be contributing. So where do you think because that’s what we can discuss theories and opinions because that’s the best we have because the other arms of evidence-based dentistry are clinical expertise and the patient experience and patient values and we have to remember that those two make up the three arms of evidence-based dentistry. So tell me your theories on the most common reasons that someone will turn up to you with tmd and while others who also may be chronic clenchers grinders they won’t get tmd what’s your take on that? [Priya]Yeah, so my opinion is and I know i’ve been talking a lot about this but it goes back to the postural dynamics, it goes back to the history, so I had one patient who’s class one molar occlusion overall her occlusion was beautiful, right? She had two fillings replaced and boom suddenly her whole right side began hurting especially just right up in here felt like her scalp was on fire, it felt like somebody was hitting her in the head with a 2×4, her jaw was constantly aching, her whole life changed because of those two fillings and she said what happened here. So we got her in I made her the orthotics, I started treating her and with her history what came out is she had suffered four really severe whiplash incidents in car accidents over a matter of like five years and so her cervical vertebrae were totally not in alignment and when that happens the muscles that attach, there they start compensating everything starts compensating and eventually something gives you can only compensate for so long if it’s very extreme compensation, right? And so it was staying open for those two minor fillings I mean they were class two fillings they were tiny. They weren’t anywhere near the nerve but just staying open it just triggered everything and all these symptoms came on and now we’ve got her back to like 90% of those symptoms are gone maybe 95%. I think last time I spoke to her but I mean it took a toll on her life she had two young kids. She was just crying all the time, she was debilitated so I guess what I’m trying to say is those incidents that of whiplash even if you think you’ve recovered or you’re okay but your neck is just a little stiff or a little painful sometimes they can come back to haunt you later and so these people that have had multiple accidents it’s usually very active people too snowboarders, skiers, we see a lot of musicians, violinists that are holding their necks in a certain way I think that plays into a lot of it and like you said there’s not a lot of research on that. [Jaz]Zero because i’ve been really delved deep into literature in fact one of my comments on your YouTube videos some while ago was discussing literature and stuff as you may remember but I have to admit I know nothing or very little about the postural chain and I would like to learn more about that I’ll probably be watching your videos more and more did learn more about that but yeah I know nothing about that so I’m the first to say that so in my view of the world I think the reason why some people switch and get the signs or the symptoms they complain of tmd issues is adaptive capacity. Is that something that you’re familiar with the adaptive capacity theory? [Priya]Well go ahead and tell me. [Jaz]Sure so the adaptive capacity theory is that in a way also interlinks with the weakest link theory that so there’s the teeth, there’s the periodontium, there’s the muscles and somewhere along that sort of system in the masticatory system something is the weak point that for example some patients will get a myofascial pain but not so much intracapsular and the teeth will not wear down so much whereas other people they will destroy their teeth but the adaptive capacity i.e. the ability for that system to heal or how resilient that system is above the threshold of them getting pain and again we don’t have the evidence to prove this so it’s just one of those theories and one of those things which I like discussing with clever people like you because there’s not enough tmj geeks out there and it’s nice to have that so if you don’t mind I won’t just want to because I know dentists are thinking this while they’re listening to this is that specific patient that you mentioned who had those two restorations and it maybe it was her mouth staying open for that long or you know a change in occlusion that affected her either the postural chain or her adaptive capacity in whatever way how just give us a flavor of how you treated her. [Priya]Yeah sure so we got her into my tmj practice and we did our full workup and so we always take a cbct scan and so that gives us information about the bony components of the joints, it shows us we take a good look at the upper cervical vertebrae and we’re looking for rotations in them we look at airway we look at a lot of things in that. And so we got the cbct and then what we do right after that is we get of course molds of the teeth if they’re able to open enough and after the molds then we use a tens unit a muscle stimulator and it gets the muscles in the head, neck and jaw nice and relaxed. And so we use that to deprogram those muscles so they go to their correct resting length and then we record that position with a very sophisticated jaw tracking technology that’s precise down to tenths of a millimeter. So it’s telling us exactly where to position the mandible so that the muscles are in their most relaxed position so for her it was all myofascial. There were no joint issues at all and so just getting those muscles relaxed was super important when we used the muscle stimulator the tens machine. I also put an Aqualizer in her mouth I wanted to disclude her teeth, I wanted to get those muscles as deprogrammed as possible and so even when I took the Aqualizer out to measure that really relaxed position I said don’t touch your teeth together. Don’t touch your teeth together at all and we’ll kind of go from here so then once I got the information I needed we made her a daytime orthotic and a nighttime one. With the orthotics with the daytime one we always ask our patients to take it out when they eat or drink anything but water and then eventually we wean them off of that daytime one as their symptoms get better and better so we give them the orthotics and then we see our patients once a week for our own therapy in our office so we have several rooms with those massage tables that I mentioned earlier and what I do is I do kind of like a subtle head and neck massage a release of these muscles right at the base of the occiput and then I do a little bit more work extra orally and then intraorally I go in and I release those lateral pterygoids that is not a fun thing for these patients those muscles are very hot a lot of patients sort of tear up when I do this and I just say there’s a good reason for this we’re bringing fresh blood flow, fresh oxygen to those muscles and promoting lymphatic drainage it doesn’t feel great but it helps a lot and so again like I said a lot of these patients I see an increase in range of motion, she wasn’t one of those, her range of motion was fine. But once we got her into therapy she noticed that her symptoms improved by 85% within a month. It was very fast I mean she felt relief within a week that 85% was within a month and I said what are we missing what can we do to get you to 90%, 95%, 100%? So we went back to those whiplashes and I just said I still think this is playing a role and she was seeing a chiropractor at the time and I said you know you’ve seen this chiropractor a number of times and I hate and I don’t ever do this really because I don’t like stepping on toes and I just said ‘would you perhaps just because you’re in so much, you were in so much pain be open to seeing someone that I recommend’ and so I really work well with these upper cervical chiropractors so here we call them NUCCA, Chiropractors National Upper Cervical Chiropractic association or atlas orthogonal chiropractors, they do things the same way, they diagnose the same way but NUCCA treats with their hand and atlas orthogonal treats with like a percussion instrument but the adjustments that they do are not forceful or cracking or jerky it’s very, very light pressure applied to the atlas c1 to help it get back into alignment followed up with other things. And so they do a lot with the upper cervical vertebrae particularly c1 and so she said she was open to that and once she started seeing the NUCCA chiropractor I told her I said the first three visits with that chiropractor I want you to come back and see me within 24 hours of your adjustment because these adjustments change the head posture which can change the bite against my splint, my orthotic, we want everything working together right so I don’t want my splint holding her back from progress with this new adjustment she’s had so those first two or three adjustments are the ones that make the biggest difference typically so that’s why I say for the first two or three come back and see me so once she started seeing the NUCCA chiropractor that got her to 95%. So she’s still not at 100% but her quality of life is so improved and I’m still working with her I’m not going to give up I want to get her to 100% but she’s thrilled. [Jaz]Brilliant. Well. the geek inside me has to ask you we’ll cover this quickly because a few more things to cover but difference between a daytime and nighttime orthotic just simply but also are you familiar with Jankelson’s orthotic is that what you’re referring to? [Priya]Yeah, so the Jankelson’s orthotic I don’t know about that but we use his method, the neuromuscular scan, yeah. [Jaz]I think it’s that it’s just to be using the tens machine to find out the corrected length of the muscle and then building the appliance to that lens so yeah fantastic so you and that is that going to be applied to both the daytime and the nighttime or just give us a flavor of the difference. [Priya]Yes so it’s the same prescription built into both appliances one different thing that we do from Jankelson’s method is we also look at the cbct and the position of the condyles we take that scan when people are in centric occlusion and so it shows us where the condyles are when their teeth are together and if they’re too far posterior what we usually see is Jankelson’s method is actually asking us to move them anterior. I’ve never really seen it yeah so but if it’s not anterior enough I’ve done this now long enough to sometimes I don’t go exactly with Jankelson’s. Sometimes I go a little bit anterior to it or a little bit I’ll kind of fudge it a little bit to where I know they’re going to have a better result so that’s kind of how we do it and with the daytime. [Jaz]It’s that mostly with the airway in mind? [Priya]Airway in mind and position of the condyle because if it’s too far back it’s impinging on that retro-distal tissue so both and I do encourage sleep tests for a lot of my patients as well not all of them want to do it they’re like I’m here to get out of pain just get me out of pain but I I tell them what I see and then the difference between daytime and nighttime orthotic same prescription built into both. The daytime one is made out of an orthodontic invisalign type material but what we do is we build up pads of triad on the posterior aspects and even on the canines so canines back we build up pads of triad with indentations bite indexes to guide their upper teeth where to rest putting the jaw in the three-dimensional rest position and then the nighttime appliance is a lot thicker essentially because it’s a lot more force can be generated at night and so we don’t want it to break so it’s quite a bit thicker but same prescription built into both. [Jaz]Brilliant. Fantastic. You covered that really well as well what percentage of your patients is a, quick fire around, what percentage of your patients do you think have the signs of bruxism? [Priya]95? [Jaz]Yep, I concur. What percentage of patients that you send for a sleep test come back with a positive diagnosis or high enough H.I index that you know they actually are diagnosed with sleep apnea? [Priya]Oh 95. Really high. [Jaz]Isn’t it just amazing? It’s just fascinating how it’s like this really this elephant in the room is something that we need to as a healthcare profession as dentists we need to be screening more of this and I’m on a real mission here to I don’t, I can’t teach stuff because there are people out there especially in the UK where I am who can teach us better but in the UK we don’t have enough clear pathways to get patients help when I send these patients to a GP. The GP was the doctor was never taught about airway in the medical school so it’s a real lack of clear referral pathways I’m a very frustrated dentist for that reason I think in the US do you have better pathways in place I feel? [Priya]We do and we have an institute called The Breathe Institute in southern California that is all about this and so really what I see with a lot of my patients too is that low tongue posture, the small airway, they have to breathe through their mouths and so I did a video called Tongue-tied airway and tmj disorders and I feel like that would you know again my channel is more for people looking for answers for themselves but I feel like dentists can learn a lot too it’s just not that technically. [Jaz]We can learn so much, Priya, honestly guys you if you listen to this and you like what Priya’s saying and in the sense that her style is so good it’s very educational hese videos that she makes for patients I guarantee you’re going to learn so much so please do check out her channel Priya Mistry, the tmj doc. It’s absolutely phenomenal i’ve learned so much from it as well I think it’s great and you know what the problem, Priya look problem with us, UK dentists and I’m you know I say this that we sometimes we’re very much like oh the evidence the evidence the evidence whereas what I want to do with my podcast I want to bring differing opinions so a lot of people will listen to this podcast thing whoa what you’re saying about the posture because we weren’t taught it then school they’re like wait what’s going on what’s going on but I always encourage my listeners to keep an open mind there’s so much so many unknown unknowns so I’m loving the direction that went in. Another quick fire question is when your patients come back with a positive diagnosis of obstructing sleep apnea, do you change your appliance now to a mandibular advancement splint? [Priya]If it’s mild or moderate sleep apnea, yes. if it’s severe then I just say cpap and use what we give you because most of the time we move them anteriorly anyway so it opens their airway a bit but to really know what our appliance is doing they have to take a sleep test without it and with it and most people don’t want to do that I mean these sleep tests can be very expensive they’re not always covered by insurance and that’s why I’m super excited about the breathe institute they’ve actually set up a way to ship my patient a sleep test they take it and their ENT, their medical doctor. Their ENT actually looks at the results gives us the diagnosis and their sleep test is really really great too because they have a lot of questions that come along with it they’re trying to determine not just sleep apnea but upper airway resistance syndrome whether this person is a mouth breather and so I haven’t incorporated that into my practice yet but I’m looking forward to doing it because it’s a way for me to offer these sleep tests but they’re still read by an MD because as dentists we can’t diagnose sleep apnea. There’s a way to do it that’s cheaper for the patients where it’s like we don’t have they don’t have to spend two thousand dollars on a sleep test we can do it for a couple hundred dollars here you know so I’m trying to incorporate all that but I haven’t done it quite yet. [Jaz]Fantastic and it’s far more than we’re doing at the moment and too far I’m also looking for a good home test solution so if anyone’s listening to the podcast and can help me with that in the UK but especially I’d love to hear from you guys. The next one I’m going to ask you then is at which point you think GDPs, general dentists, should be referring to someone like you who’s limited their practice to the treatment of tmd? [Priya]I guess the way we look at our patients is I always say there’s we look at our cases based upon degree of difficulty with four levels four being, four levels four being the highest so fourth the highest level is a locked jaw that’s the most difficult thing to treat jaw locked closed and then the third level is some myofascial concerns as well as some joint involvement, clicking, popping especially clicking at the end of opening that indicates the disc is more displaced than at the beginning of opening so that’s kind of our level three, level two and one are really no joint involvement it’s all myofascial so what I would say is level two, level one anything myofascial without joint involvement try to treat it at your practice you may be surprised at the success that you have I would just make them a nighttime appliance with an aqualizer bite and I again I have a video on that I’m not trying to plug my channel every five minutes but it’s way easier to have you watch my videos. [Jaz]I want to plug it I think you should see it and it’s a video that I found you on a fantastic video and I so I’ve got loads of these aqualizers in the fridge and I like to give them for so people coming to acute pain and stuff but your video so I don’t do because. Here’s the different opinions of what not I do. A lot of midpoint stop appliances but the downside of that is that yes the airway impacts having whereas I think the with the tens approach that you take I think it puts them in a better position for the airway so I do like your approach as well and I’ve got a couple of patients i’ve identified would be beneficial for that but going back to your point the advice you gave there was to give it a go, try it because myofacial pain is the most common, thankfully, diagnosis and people in that level one area there’s more of them than, thank goodness, for people in level four classification is really helpful. [Priya]And really to ask, start asking every single patient if they have headaches, if they have neck pain, if they have jaw pain they won’t necessarily think to tell their dentist about their headaches or their neck pain right of course jaw pains are going to tell you but they don’t think and you’ll be surprised at how many people say yeah I have headaches all the time or I’ve had migraines for 20 years or whatever you may hear you can lessen those headaches drastically with these appliances if they’re made correctly if you’re putting their muscles in their happiness. [Jaz]Amen sister. [Priya]And it’s amazing to do that for someone they look forward to seeing you they’re not coming in for something they’re dreading they’re like you made me feel better I mean it’s so gratifying it’s wonderful. [Jaz]You’re so right on the money there because look I love doing my restorative dentistry. I love doing teeth straightening and stuff and I get that perfect onlay on I’m happy but you know what none of this compares to when I have that patient that young lady who’s been taking painkillers for headaches and I’m the first dentist to ask her about headaches and I just make an appliance and I give her some patient education and then suddenly her headaches are gone and then I get a thank you. That means so much and I absolutely love that but you know what I’ve explored already our approaches are different which is amazing, right? We have two different approaches. I do a lot of anterior only appliances and then you do the way that you describe but they both work so there is a lot of crossover in terms of how we can get our the muscles of the patient relax in a better state and I think as a profession we can learn more through research and stuff in the future I don’t know if we’ll ever get that high quality evidence that we need but it’s just the beauty of it and I think we just have to accept that there’s no unified theory and that’s the beauty of it instead of getting frustrated by it. I’m very mindful of the time but yes carry on. [Priya]Sorry just to add to that I mean there’s so many causes of tmjd. There are a lot of solutions too I mean it would make sense that there’s not just one right approach and with tmjd keeping an open mind continuing to learn is so important it’s not as simple as doing a class one filling like we’re all taught to do that the same way but tmjd can be a whole body issue for some of these people and so just keeping an open mind like you said palpating the lateral pterygoid I had somebody already multiple people approach me that’s not even possible. [Jaz]Well I think it is, so you know it is what it is yeah, what, really excuse my French but what really pisses me off right is when dental professionals right like we have this like closed mind and we don’t accept that there are other ways there are unknown unknowns and they go by the very poor quality evidence that exists, right? So I hope when I commented on your video I hope you didn’t feel like I was like disagreeing with you I was just coming at a different angle I kept a very open mind because exactly what you said we don’t know the answers and we need to keep an open mind and appreciate there are other ways to think about this. So I would encourage all dentists to think more openly and I don’t see the point of saying that’s not possible just because someone says it is we don’t know we I don’t I think there’s a lot of unknown unknowns. No don’t stop making content for that reason keep going. [Priya]You were really kind in your comments. I’ve had people come after me i’ve had i’ve been called a [ moron ] people are very mean online so your comment was totally great and gracious. [Jaz]Above board. Good good and that’s the way we should approach it we should we should be approaching a healthy discussion and whatnot and wanting to learn from each other and I appreciate your reply as well and wanting to learn my perspective as well which is really wonderful so thank you for that. My last question then is when do you involve so you talked about the nucca chiropractors already when do you involve physical therapists or physiotherapists as we know in the UK and also do you ever involve like psychological interventions like cognitive behavioral therapy do you ever get those specialities involved? [Priya]I usually get the nucca chiropractors, the physical therapists and I have I’ve talked to patients about the cognitive behavioral therapy but a lot of them don’t want to go that route I had one that is doing transcendental meditation and it helped her so that’s one but a lot of people don’t even want to go that route I almost wish I could just say can you just do it and then tell me how you feel but you know if they don’t want to do it they don’t want to do it so a lot of them are open to seeing the physical therapists and we have some great tmj physical therapists just very close by to my office here and they have a biofeedback machine. So it’s showing you which muscles are firing in different postures and so they actually have you do different postures and they kind of train you to when you feel stress or anxiety coming on to assume these postures that bring the muscles back down to a calmer level so they give you kind of tools that you can use at home they do a lot of myofascial release they show a lot of exercises that bring relief to our patients and so I do utilize the tmj physical therapists I adore them the ones that we work with the nucca chiropractors and like I said I wish more would do the cognitive behavioral therapy but a lot of them just don’t want to go that route for whatever reason. [Jaz]Brilliant and for these complex cases is definitely a team approach I found. sso last question is i’ve been doing a fair amount of research on what is the best way to treat someone with a disc displacement without reduction okay and the literature is very much we don’t know because so many different ways actually work so I want to hear Priya’s view. What’s doctor Priya Mistry’s most successful intervention or recommended intervention for someone with a disc displacement without reduction? [Priya]Yes so what we do at my office is we actually say you know if they’re not even open enough for us to get impressions we’ve got to get them open more, right? So we’ve got to get that disc reduced or at least the muscles calm down a little bit more so that they have a more a better range of motion. So what we do is we say we call them emergency appointments which sounds a lot scarier than it is but we just say it’s about an hour long we have the patient come in and we use the tens with an aqualizer in the mouth for 45 minutes once that’s done we turn the tens off we take the aqualizer out. And like I said we do that muscle release at the base of the occiput we do a little bit more extra oral work but the intraoral work is really what’s unique in this in terms of getting the jaw more open so we do that myofascial release with the lateral pterygoid, the temporalis tendon insertion, that area and for a lot of these people it’s quite a bit of pressure you have to put in that area to get those muscles to kind of let go because the lateral pterygoid attaches to the disc, right? So the superior head does and so once we’ve done the myofascial release on both sides a couple times then what we do really that’s really unique is we actually do osteopathic manual jaw manipulation. So my mentor, Dr Parker, he studied with osteopaths, tmj physical therapists, naturopaths, he’s traveled the world I mean he’s been around before google and he’s worked with some of the best people but he’s a big believer in osteopathic work hands-on manual therapy and so he with all of that he’s developed a method to actually manipulate the jaw so we do one side at a time and then both together. And manipulating the jaw so that we can get the condyle and the disc back in the proper relationship. And so it does not always work at that first emergency appointment so typically we’ll see the patient once or twice a week and we can get them unlocked usually the second or third time and as soon as they’re unlocked we take impressions because as soon as they leave they can lock up again. So tmj work is often two steps forward one step back two steps forward one step back and it can be frustrating for everybody involved but I always make sure to tell my patients that like it’s not going to be it. Took you a long time to get here it’s not going to be fixed overnight and some of these people with jaws that are locked some of them totally get it and other people just they just want to be fixed right away and it’s really hard it’s hard emotionally for them. It’s kind of draining for me a little bit too but I would imagine it’s hard to have your mouth stuck you know so where you can’t open you can’t eat and you know quality of life goes down a lot and so that’s how we treat it. [Jaz]Priya, I just want to ask you I mean it’s great you mentioned that it’s amazing that by third appointment you can get that result but I just want to explain for the dentists who perhaps have no insight into what happens during this once you’ve got the disc to recapture onto the condyle that’s going to change their occlusion. So how do you manage that and where does a potential prosthodontic or restorative work come into the future? Is that always necessary? [Priya]That’s a good question yeah. So when they actually lock that’s when they notice ‘hey my bite feels a little bit off’ and so if it’s a little bit off if we can get them unlocked and get it stable we see how they are after four to six months oftentimes we can regain the bite it’s not an issue but there are some times that we cannot and so there was one patient that came in locked and her bite was so off and she was fixated on it. ‘Will my bite come back? Will my bite come back?’ And finally Dr Parker and I just said we don’t know it probably won’t you know and so we didn’t want to guarantee that and it didn’t. So we sent her to an orthodontist after we got her joints stable. So the way we like to describe it is sort of like the two joints and the teeth coming together fitting together like cogs on a gear it’s like a tripod effect and what happens when you cut off one leg of a tripod the whole system goes out of balance so if the disc is completely displaced and the jaw is locked of course the bite’s going to be a little bit off right? And if we can get the disc back in alignment there’s a chance we can recapture that bite but what if the bite becomes totally off, right? Because the patient’s been compensating for so long and she was a patient with the bicuspid extraction retraction orthodontia it was clear she had been trying to grind her way out of that position for years and years and years, she’s in her 60s and her teeth were just beat up from all of that. So it’s like you know we think of another way to describe it too is like a door with the two hinges and the opening and closing portion of it if every time you close the door you have to kind of shove it by the doorknob to get it to lock eventually the hinges give out. So you replace the hinges but you didn’t fix the original problem so same sort of thing and so she finally accepted it and she went to go get orthodontia once we got her joint stable so you can’t always recapture that bite. [Jaz]Amazing! Priya, you’ve answered all my questions and you gave so much value today and we discussed interesting theories some controversial stuff and that’s the beauty of it and I think you were so humble the way that you delivered that and you were so accepting the fact that you know what some dentists may disagree and that’s fine but I just want everyone to play nice let’s all listen to the different theories and share together but I definitely think what you’re doing on YouTube is such a great thing if not for dentists but for patients I can see the comments that you’re getting on YouTube it’s just phenomenal how much your content is helping so please do continue that and thank you so much for coming on the podcast. [Priya]Yes, thank you for having me it was so much fun thank you. Jaz’s Outro: There we have it I hope you enjoy that perspective the varying opinions like I don’t believe that we can palpate the lateral pterygoid but Dr Priya Mistry and many other great clinician feel you can. So there’s a beauty in this. There’s a beauty in varied perspectives It’s just the way dentistry is we’re never going to have this unified theory when I had Villa Pancho on the podcast the physiotherapist she had her own views and there’s a lot of overlap but there’s a lot of difference as well so let’s appreciate the beauty of it all. So I hope you’ll join me same time same place next week when we join another episode of your favorite dental podcast please do leave a review write a review. I love reading them so if you’re listening on apple don’t just give me five stars or how many stars you want to actually write a review I read every single one I really appreciate it. Thanks so much guys for tuning in. I’ll see you next time you.

When it comes to the management of Temporo-manidbular Joint Disorders, we often NEED to adopt a multidisciplinary approach. I am a strong advocate of Dentists involving TMJ Physiotherapists (yes, they exist!) to help their patients. In this episode I am joined by The TMJ Physio Krina Panchal! https://youtu.be/5KcMOfdoDhg TMJ Physios are invaluable in the multidisciplinary management of TMDs Need to Read it? Check out the Full Episode Transcript below! Interestingly enough, Physiotherapists in the UK do not cover the TMJ in their studies – it is a postgraduate niche that Krina has travelled the world to learn – which is why I respect her even more! Protrusive Dental Pearl – have you checked out the ‘Bruxchecker’ foil as a tool to help diagnosis of Bruxism and much more? I comprehensively reviewed this product and thought it was very clever! https://www.youtube.com/watch?v=eQLGFc82EM0 In this episode I ask Krina: Whats the evidence that Physiotherapists can help our TMD patients? What does she think is the biggest aetiological factor for TMD? What is the most common diagnosis she makes, and what is her management of that diagnosis What should a Dentist do if, after a long procedure, the patient gets acute disc displacement without reduction? What kind of cases should we be working with physios for? I will add the promised downloads on to the Protrusive Dental Community Facebook Group (are you part of the Protruserati?!) If you enjoyed this episode, check out Stay Away from TMD – why you should think carefully before niching down to TMD as a Dentist. If you want to learn about Occlusal appliance as a protective appliance, to help with pain or as part of pre-restorative management, do check out the SplintCourse which launched a few days ago with a big bang! https://www.youtube.com/watch?v=2-Yt5YmEyes Click here to download the full Course Outline Enrollment ends 19th March at 10pm UK time so I can focus on Monthly Coaching! Thanks for your support, Protruserati! Enroll now to SplintCoure Online to finally understand Occlusal appliances! Click below for full episode transcript: Opening Snippet: Because I think my most difficult patients who have found some success with splints I think you raise a great point that they're not wearing the splints during the day and I think that's where really you guys come in to re-strengthen and to stretch and relax everything. Jaz’s Introduction:Hello, Protruserati. I’m Jaz Gulati and welcome to another episode of The Protrusive Dental Podcast. Today, I am recording this introduction on international women’s day. I’m so proud to be sharing this episode with a fantastic woman. Her name is Krina Panchal. Krina Panchal is a TMJ physiotherapist and I’m a huge believer in physiotherapy to the management of your TMD patients. And I’m going to let her explain why it’s so important and how we can collaborate. So this episode basically covers when, why and how to involve a physiotherapist in the management of your TMD patients like I often refer to my patients especially when they have chronic pain. Chronic pain is a completely different beast to someone’s got acute tmd. So chronic is like when it’s been more than six months and what happens with chronic pain is that they develop something called chronicity meaning that the the nerve signals that fire from the brain to the site of pain they get sensitized over time and even though that initial inflammation or strain it heals, the pain signals are still firing. So chronic pain is a completely different beast. So we can’t just rely on advice and appliances, we need to involve a fantastic speciality of physiotherapy because they are really really useful for helping our patients who suffer from tmd. And if you’ve ever wondered how to get in touch with one, what kind of diagnosis they can help with then this episode will clear that out for you. Protrusive Dental PearlThe Protrusive Dental Pearl I want to share with you today is something I actually learned from Krina Panchal’s instagram. She saw a dentist who made her a brux checker. At that time I had no idea what a brux checker was. But it seemed really interesting like right up my street, on the theme of bruxism and parafunction so I did some more research and I learned a lot from her video. It’s basically like a thin foil imagine like a really thin essex retainer like a foil and it’s red and what happens that when you grind or clench when your patient with parafunctions on the foil they make a little mark, they make a little pattern. So it’s helpful in diagnosing people who’ve got parafunction but more importantly which teeth touch and when do they touch? It gives you that sort of diagnostic information, I mean in the literature for the brux checker it’s referred to as the ecg of occlusion and bruxism which I found very fascinating. So I made a youtube video about six minutes all about the brux checker giving my honest reviews because what I did is I tried it on myself, I tried it on my nurse, I tried on my patients and I have to tell you to give you a spoiler I’m a big fan right? Like I’ll make it tangible, I had this one patient who came to see me because he wanted some bonding and he came to me as a second opinion because his existing dentist my principal was not quite ready to do some bonding on him because some other bonding kept chipping and so my principal thought you know what I think there’s some bruxism going on. I think you should see, Jaz, because this is the kind of stuff he deals with. So he came to see me and I wanted to know the chipping that he was having on his anterior composites was it due to bruxism or not or was it something that was not bruxism related i.e the composite was too thin or something he was doing not at nighttime i.e was he biting on sellotape or biting his nails that kind of stuff. So what I did is I made him a brux checker and I mean I had seen that he had signs of bruxism and parafunction so I knew he would create a mark in it. So he went home he wore it for me and then when he showed it to me it showed that at no point did he touch or go near the composites that we were concerned about and so whether he could he couldn’t have bonding on the premolars I think he could because actually it showed that he had canine initiated disclusion and he didn’t come onto the premolars which he wanted bonding. So as long as the occluding scheme is respected and you conform to it I don’t think there’s any issue here in terms of chipping from bruxism because I think his bruxism is happening in all the right places. It was happening on the canine which didn’t have any bonding on them so this was a cool little thing to do and I’m hoping I’ve shared some of those photos with you for those who are watching on youtube to gain some value from that. So let’s join the episode with Krina Panchal on the importance of tmj physiotherapy Main Episode:Krina Panchal, welcome to the Protrusive Dental podcast. Our first ever physiotherapist and I am so pumped to have you on today. Thank you so much for coming on. [Krina]Thank you, thanks for having me. I’m very excited as well. [Jaz]I actually knew your husband Kartik from just social media and I think I met him in a course some of that and then when I stumbled across here when we started following each other on instagram. I was like wow this is amazing because I’ve been looking for a physiotherapist who niches into the temporomandibular joint for so long and i did find one but he wasn’t as good as you, Krina. So I’m so so happy, the stuff you put out the content you put out the dentist and the surgeons that you are associated with in London is just wow mind-blowing like you work with some really top people in this field who also just love this area so kudos to you but before we just dive right in tell us a little bit about your background. I know already because we had a little chat on the phone but tell us how you as a physiotherapist ended up specializing within tmj of all things. [Krina]Sure. So basically we do our degree and you come out as a general physio. I guess I like general dentistry really and then you work for a few years and you think I need to specialize in something. Nothing was really taking my fancy you know like if I want to do musculoskeletal and neurological or specializing the knee and so and then I actually met my husband Kartik as you know he’s a dentist and and he introduced me to the TMJ and he asked me what can you do about it? And I said well actually we’re not even taught the tmj at university because we’re only tall neck down. So we don’t even know what’s actually going on in the head which is ridiculous really because in other countries they are. Anyway long story short, I started reading about the joints and I thought it was really interesting. No one’s really treating it that well in this country in terms of physio, why don’t I do some studying on it? So then a little bit of studying and reading turned into doing some courses. So I guess I went over to America first, Atlanta and there was a physio there he was doing a lot of recognized courses. So I did a course with him as Jeff Krauss then i went over to Columbia university in New York and they’ve got a head neck and facial unit there department where it’s full of maxfacts dentists, physios, psychologists and they’re very multi-disciplinary and they were basically all of them were treating these patients and I was able to see that. So I did like a sort of work placement with them just to see how they work and then try and bring it back to the UK. Then I started pitching as a mini pitching to max facial surgeons and dentists and said this is what I’m doing. Are you guys interested? As I started working with the joint and then I went on to do some more qualifications with university of Liverpool. They do a master’s module called the differential diagnosis and management of the tmd and- [Jaz]That’s specifically for physios right? That’s not for dentistry specifically for physios? [Krina]Yes. The dentist can go on it if they wanted to learn more about I guess what we were doing and how we could work together and so I did that masters module that was about 2015. Then I went on to do something called crafter which is an academy based over in the Netherlands and it’s called it’s actually a cranial facial therapy academy and they teach about all the cranial bones, tmj, headaches, migraines tenses all of that. So anything to do with the head, neck and facial region. So I did some courses with them then you know I went to Lithuania and did some Rocabado courses so for those who don’t know who Rocabado is and he is a very very experienced physiotherapist in Chile and he only treats tmj. He has lots of courses that he provides and he’s doing lots of research on this area as well. So I did his courses to learn his assessment and treatment and then alongside that there’s all the treatment courses like doing pilates, dry needling, myofascial, taping laser that sort of thing. So it’s been a journey but- [Jaz]And now you work? Where do you work? [Krina]Yeah so and now I work over. I have a clinic in Mayfair and I have a clinic over in Johannes class as well. So I’m working there a few days a week and yeah I mean I don’t treat anything but head, neck and facial pain disorders. That’s all I do now. I don’t have any knees or shoulders anymore. [Jaz]Well I’m so excited to learn from you because I think we can make this a really really impactful episode for dentists because look the tmj is like this, it’s a dark art right like you said when as a physio you came out and they don’t teach you anything about tmj well yes we learn anatomy of tmj but ask any dentist okay and that most dentist ask them to draw you a temporomandibular joint okay and you’ll get a really, really, really, small drawing. So small on purpose that you can’t really make out what’s right because we’re not confident on this, we’re not confident on tmj, we’re not confident in the management of clicks, we’re not confident on temporomandibular disorders. It’s a massive area that is only really delved into in postgraduate and even then there’s this class amount out there. So I think I’m so excited when I learn loads about from you today. I first learned about Mariano Rocabado a few years ago then I learned about the Rocabado Pain Map now. Pain map now I think earlier on in maybe the episode six seven eight some of that i actually gave that as my protrusive dental pearl like you could download the Rocabado Pain Map and so it’s amazing when I spoke to you on the phone that you said that you had training from Rocabado and these great institutes and you’ve been chasing these institutions to to be really at the top of your game so that is absolutely amazing. So I’m gonna crack on and ask you the first question okay? So you’ve told us about your journey and niching down into tmj. Tell us what evidence is out there that physios or tmj physios are actually useful for tmd? Like there is some evidence about like you know acupuncture and is debatable whether the evidence is good enough to say that acupuncture is good for tmd even the stuff on splints is abysmal like there’s a lot of evidence suggests that splints don’t do anything at all, other studies will show certain types splints will make things worse but there isn’t high quality evidence. So where is the stance on the evidence behind physiotherapy for the temporomandibular joint? [Krina]So evidence basically I think if we start with the nice guidelines which was published in 2016 by Andrew Sidebottom. He was one of the authors and he’s a maxillofacial surgeon, he specializes in tmd in terms of surgery. But actually I’ve spoken to him recently actually and he does not advocate surgery for tmd at all and he would rather that these professionals deal with patients who have tmd. So that would be a dentist first you guys already know what you guys do and expense but then also it’s important to know that psychological services like cognitive behavioral therapy is really important as well because there is always a psychological distress in these patients and anxiety. But then also lastly this is where I can help him is with physiotherapy and they’ve collated a lot of evidence to show that physiotherapy in especially alongside splint therapy works better because if you imagine when you have a splint the patient doesn’t have relaxation of muscles instantly it takes some time. Plus they’re not wearing it during the day. Usually you know they’re giving instructions to wear it in the night time and there is something called daytime bruxism where people are clenching habits during the day as well. So that’s where physiotherapy can really help because we can actually relax all of those muscles and give them exercises and try and just help alongside splint therapy as well. And then the other guidelines that we use as well is by The Royal College of Surgeons of England where in 2013 and they recommended physio as long-invasive treatment instead of having surgery and trying that first before they go and do any irreversible treatments really. And then I searched for systematic reviews rather than individual journal articles really and in this systematic review in general rehab 2010, they found that there’s already some evidence following and that the following can be effective in alleviating tmd pain and that was occlusion appliances, acupuncture also then draw exercise and postural training which is what I can help with. [Jaz]Amazing. Do you want to show some more? We’ve got loads of evidence. [Krina]Yeah and then after post-op surgery procedures and said that physiotherapy was really important in achieving good results again another and systematically saying physiotherapy is useful and then- [inaudible]. [Jaz]So that’s amazing and it looks like there’s plenty of evidence out there that you guys are an important part of the team. I don’t think enough dentists refer to their physiotherapists enough and I think there’s a huge benefit and to the extent that yes I knew about in the UK, we had the ACPTMD like this is where you can find a locally trained tmj, a tmj physio if you like I struggled to find one that I could, that was close enough to it to my patients that I could really have a chat with. And have a connection with so actually I took it upon myself and I hope you don’t take offense by this, Krina but actually read up and I’ve learned a few of the exercises that you guys prescribed and some manipulations that I started to do to help but now that I found you, Krina, you’ve already had one referral for from me already last week. So I’m definitely sending them to you because you’re the girl who knows what to do but I think every dentist can learn a few things so that if their patient will take some time to find a physiotherapist that a few simple things might be able to help their patients. So I think it’s great and I’m so glad that like I said I’ve found you. I’m very very grateful for that and of course for this episode. So you’re going to share so much more. So we’ve talked about the evidence, what do you think and I’ve just switched over the questions a little bit Krina, is of all the things, what is the biggest etiological factor for tmd? What do you think in your cohort patients, what’s the biggest ecological factor? [Krina]So this as you probably already know is a very big question. I can’t really say that there’s even one or say there’s the top three but there is some evidence out there. So this is the OPPERA study which basically means oral facial pain perspective evaluation and risk assessment. And this was released in 2011 and what they did it was based over in America and what they did is that they recruited about 3,000 tmd III participants. All aged between 18 and 44 men and women equally and they did lots of physical examinations, filled out questionnaires, had tissue samples collected and they agreed to having follow-up re-examinations and questionnaires. And what they basically found was that 3.5 to 4% of those 3 000 participants actually developed tmd. And then what they wanted to see is what were the risk factors and what was causing them to have the tmd. So they actually found that the incidence of first onset tmd was three times higher if someone had IBS. It was twice as high for people who reported lower back pain three times as high if people reported genital pain which is a bit vague but that was interesting and those who had tension headaches, it was also sort of associated as well and as well as fibromyalgia, fainting, insomnia. So what this actual study is showing if you look at the flowchart, if you look at the pink part at the bottom that’s basically telling us that genetics is involved with tmd where everything is subject to genetic regulation for whether something is upregulated or downregulated. Then it goes on to say that high psychological distress is also related. So most patients who have tmd will have some sort of psychological and distress and that could be depression, anxiety, mood disorders. But then what was also interesting is that with the purple area where it’s got the high state of pain, they basically had a decrease in pain inhibitory pathways and an increase in pain disintegrated pathways. So they were prone to actually feel more pain because their physiology was programmed that way. And all of that is then also subject to the environment that you are in. So if you live in a certain area for example if you’re in London you have very stressful life with commuting or the pandemic is going on that then adds to whether you would get tmd or not and all of this contributed to the onset or more importantly the persistence of tmd. So then to find actually one ecological factor is actually quite difficult because it’s so multifactorial and what I usually find with my patients is that there’s so many patients who brux for example and some are not in pain at all and some have a little bit of teeth wear and actually they’re in 10 out of 10k and what is it? Because they may have loads of psychological distress and you don’t know what genetics are like an environment may be super stressful as well you know why they are not in pain. And I think really what it comes down to is something called adaptive capacity where is their ability to adapt or cope or how many physical revolutions they have determines their threshold to actually developing tmd. [Jaz]Krina, I totally agree. One of the splint episodes actually I talked about this as well about. I talked about two things: the adaptive capacity and you’re totally right. Resilience is such a great word to use there and the other thing I talked about was the weakest link theory is that you know some people their weakest link might be the teeth or the periodontitis, that’s why the teeth are loose. For other people their bones are hard, their teeth are resisting it but all sorts of damage is happening in the temporomandibular joint. But the theory I used to have Krina, some years ago is that I used to subscribe to this theory, very dentist based like we think that if there’s true trauma that would result in pain for example. My background is I thought temporomandibular joint disorders were caused by micro trauma and macro trauma. So macro traumas like a punch to the jaw or a road traffic accident or a brawl on saturday night or a micro trauma would be the clenching, the grinding and the pen biting, the nail biting but the problem with that, Krina I’m sure you’ll agree with me here is that’s a very biological model i.e this trauma hence that causes pain and problems. But I’ve since learned that pain is so complex and this is why I treat my chronic pain patients with tmd very very carefully and from now on you’re going to be seeing all my chronic pain patients because they are tough because pain like just like you said in Dentistry we were taught that how you feel pain varies by a factor of four. So the same injection that we do an id block for example one patient in the same technique we’ll say that’s a two out of ten pain, the next patient can say the same input is an eight out of ten pain and that’s a real pain. So because pain is so complex because as you said the adaptive capacity can vary so much that is a huge part and it’s not just biological. Now it’s the bio psychosocial, have you come across the bio psychosocial model?[Krina]Yes. Basically I mean that’s one of the core modules when we do physiotherapy as a degree and we have to work in the biopsychosocial way and that’s why I think the OPPERA study is so important for tmd because it actually showcases the biopsychosocial model and urges all practitioners who are working with tmd to actually look at these things. And it’s not just a case of just looking at the joints or just looking at the masseter and doing botox for example there’s so many other things that you should be looking at and it takes time if you’re treating a tmd patient to have a quick 10, 15, 20 minute appointment is never enough. I don’t know if you think the same, Jaz but- [Jaz]These patients drain you. I mean this is why I actually said in one of my first episodes i did in the splint series was like hey you know what? Don’t refer me to your tmd patients. I don’t want to see them no offense, I’m happy to stick to my orthodontics and smile makeovers and general dentistry. I don’t want to be bombarded with tmj patients. Learn to treat your own because they’re complex and one of the other things that we haven’t mentioned yet but I know you’re going to come on to is even their sleep quality can be important because that’s all related to the pain and everything. So this is all their sleep apnea whether they have that and how well they’re exercising and you might have listened to the back pain episode I did with some physios? [Krina]I haven’t. No. That’s the one that I haven’t listened to yet. [Jaz]Oh you might like it though. You’ll be like holding the whole way through these are really cool physios but I’m so glad i’ve got you on today for the tmj. Is there anything else you want to tell us about the OPPERA study? [Krina]No, that was just it. Just the fact that it was psychosocial and it’s important to take all of that into consideration. [Jaz]Perfect. So Krina, what’s the number one thing that you treat i.e what’s the most common diagnosis you will make? So for example dentist listening we have these diagnostic terms we use like for example now hopefully we’re not just writing tmd for everyone because that’s so vague right? But that’s what a lot of dentists do like you know diagnosis: tmd. There’s so much more to it than that. So within tmd there could be intra-articular, there could be muscular, there could be all sorts and you know I’ve shared ones for the different classification system is very complex but what’s the main diagnosis that you see? [Krina]The main diagnosis I see would be myofascial pain, usually referred from the neck to the face or vice versa. Now I think maybe if I explained what my facial pain was a little bit. So basically what ends up happening is that you get myofascial pains, trigger points within muscles but what’s a trigger point? So a trigger you have a muscle okay and it’s made up of fibers and they’re in nice straight lines right? And then when you want to do a contraction these fibers come together and when you want to relax the fibers are apart. But usually with someone who’s got tmd for example in their masseter or their pterygoids. their muscles, their fibers are together like this because they’re contracted and in sudden but then they’re slightly twisted as well so then during function if you’re trying to open or close or use the muscle it’s hard for the muscles to come apart. So then you’re only using the other fibers that are left surrounding, this trigger point to then do the work for you is the muscle is not as effective. But what actually happens at this trigger point because the trigger point is in the middle there where the neuromuscular junction is and effectively in simple terms, it’s a knot in these ones that you can feel in your masseter. What actually ends up happening there is that you get a local inflammatory response to a small level. You wouldn’t get swelling there but there’s inflammation there and then you end up with a loss of oxygen and lots of nutrient supply and the shortening of fibers which is why you’re also contracted and that creates the trigger point in that area which is the knot okay and now you can have active trigger points. So that’s where maybe if you’ve been for a massage somewhere and someone really digs deep into your knot and you’ve got that sustained pain, what you can sometimes feel is that of course you’ll feel pain where they’re pressing down. But then you may feel pain somewhere else and you think well that’s so far away from where they’re actually pressing that is what myofascial pain is where you have a knot in a muscle up but then it is referred to another area. So then when it comes to tmd specifically if I share a slide here. So this is basically so if you have a look at the masseter you can see that there’s a trigger point within the mass I mean there’s lots of trigger points that’s just one but you can see in red where it refers to. So it actually can refer to the tmj joint within the ear so a patient may present to ent for example and say I have ear pain and then if you can find nothing because actually it’s coming from the masseter for example. Pterygoid is the same refers to the ear but then if you look at the other three pictures where you’re looking at the neck and the neck muscles and really these are where if someone’s got a forward head posture they’re going to have trigger points in these areas so they scan sternocleidomastoid trigger points within there refers to so many parts of your head and face area so this is basically one of the main areas that I treat. And then in terms of treatment what I would usually do is find where all these trigger points are of course, note all of that down but then I do something called dry needling which is specifically for myofascial pain where it’s the same needle as acupuncture needles. It’s based on western medicine rather than Chinese. It’s just the same needle and I’m basically putting the needle into the knot so instead of using sustained pressure I’m putting down on the knot and I’m putting the needle in instead. And what that does is a few things, increases both flow into the area but also because basically I’m putting the needle in and I’m causing microtrauma there. And then that then allows us to heal ourselves in that area and it realigns the fibers so rather than us being so twisted like this the fibers are able to be apart okay and separated but more importantly they are now over here which means they are in a relaxed lengthened position rather than contracted. [Jaz]What would cause, you know you said just now sternocleidomastoid is the most common muscle you get, did I interpret that correctly? You said that’s the most common area you treat? [Krina]Well yeah as well as probably the tweezers and some obstacles as well. [Jaz]Okay so subacceptables trapezius and steroid mastoid so why would cause it? Is it postural related, is it anything that people are doing that’s causing the knots to happen in the first place if you know what I mean? [Krina]So it will be sustained postures so it doesn’t necessarily have to be forward head posture it can also be that you may have great posture test work and they have great posture chair, great desk everything but maybe they’ve got several screens and they’re just looking to the screen onto the side constantly and to maintain that position is what then can cause a trigger point. So like dentists for example like I see every time I go to the dentist and my husband as well it’s like they have loops but they’re in this position for such a long time and he has loads of trigger points. So it’s sustained positions, it’s not always poor posture. It’s a more sustained position. We’re not made to stay safe so still. [Jaz]It reminds me of what the physio guys shared in the physio episode, Matt and Sam they said your best posture is your next posture i.e keep moving which I love always. I always remember that movement is a healing agent. And I love what you guys do the physios you know you guys really have got that all just so it’s just it’s great movement is medicine you know that the whole saying itself it really gets your patients thinking. And what I learned from you guys is that quite a lot of times patients because of the initial acute pain they had which then turns into chronic pain and their muscles they sort of almost enter an avoidance pattern they’re avoiding, they’re bracing, they’re not using the muscle and then that makes things worse and then oh I’m only sticking to soft foods but really what I learned from you guys so far is that they should be stretching they should be using now correctly if I’m saying anything wrong because this is your episode you’re the expert I’m just someone who who’s a dentist has an interest in this area but am I right in saying that you guys are encouraging more movement and not the whole “stick to soft diet don’t talk too much” that kind of stuff? [Krina]Completely and really as physiotherapists what we want to do is improve mobility, reduce their pain and more importantly establish normal movement and rehabilitate towards function so when it comes to the TMD really what we’re looking for is that are they eating and all foods? Are they chewing on both sides? Are they really strengthening wise? Should you only need food for your meals to strengthen the jaw, you don’t really need to do extra chewing gum or anything any extra exercises like that’s enough. But it’s about making them aware as well what tmd is and making sure that they’re using everything that they should be using towards functional. Chewing on the warning properly or they’re avoiding certain things and so that’s exactly what we want them to do is we need to have more movement not stop doing any sort of movement. [Jaz]Awesome. So you touched on myofascial pain, you said that you’re using a dry needling a fair bit and the prescription of exercises is the main thing that you would do? Is there anything else that we should know about the treatment that you provide for myofascial patients? [Krina]Yeah so there’s I think in literature when they talk about physiotherapy they obviously talk about the exercises but there’s also something called manual therapy which is where we are mobilizing a joint you can do all joints and so it’s not like chiropractic treatment where you’re cracking anything. This is making joint movements within your normal range of movement, okay? So at the tmj joint we will do a distraction technique I put some gloves on thumb inside your mouth and then distract the joints I think it’s only a couple of millimeters which is what i’m showing there but basically this is the direction you’re going and what that does is that it gaps the joint so you can increase blood flow into that area but in terms of myofascial pain it then allows us to stretch the temporalis and the masseter as well and then we do a lateral movement as well still internally and that allows us to work on the pterygoids and possibly the disc as well. So that also helps stretch that muscle so that the trigger points don’t happen as often alongside the exercises because otherwise all you’re doing is loosening something, someone off and then what once they stop seeing you it’s all going to come back again. So the strengthening part and then being compliant with these strengthening exercises is really important. [Jaz]I often liken what you guys do a little bit to how we as dentists treat perio disease. So what we do the deep cleanings that we do at the practice is important to remove the biofilm but what they do at home thereafter in terms of their maintenance, their tp brushes is what really does the treatment so same you guys do your manipulations or sort of joint manipulations and you but you prescribe the exercises for them to continue at home and that’s what’s strengthening everything is that is that a fair analogy? [Krina]It is and you have to make it easy for the patient. I’m sure you guys do as well. There are a couple of take-home messages really so I’ve done a video of me doing the exercises. So that they’ve basically got no excuse to not do them and also they’re compliant and there’s no way that they’re doing something else because you tell them one thing and then they come back saying yeah I’ve been doing it and actually they’re doing something completely different. So I have videos and I explain like I spend about 45 minutes with them for a session because I really want them to understand their own condition how they are responsible for it as well, not just moving in hands-on work and I think I’m still working on it I think I can I’m able to get that message across. [Jaz]Awesome. Perfect. Next thing I want to ask is a very clinical question in terms of dentists. We see patients who have their mouth open for long periods of time let’s say we’re doing a root canal treatment or a difficult extraction and obviously the muscle is responsible for mouth opening primarily there’s others as well but primarily we’ve got the lateral pterygoids and that contracts the lateral core, it shortens the muscle, it can go into spasm. Now it has happened and I know you’ve seen these patients as well where the dentist has said okay we’re done with the procedure you can now close and then suddenly they’re in masses of pain and what’s happened is that the disc has acutely displaced anteriorly and now what they have is an usually it would be a closed lock where it can actually mean I’m trying it can be an open lock as well because the disc has gone posterior, you tell us what you see more of but how can we prevent it? I’ve sort of given a few hints then decide how we can prevent it and what I think but I want to hear from you but also how do you treat that and see if we don’t have a physio near us, how can we treat it? Just acutely the acute management of that really painful situation? [Krina]Okay. So you’re right it’s basically the lateral pterygoid that’s gone into super duper spasm. So when I say if I was treating that patient, if I got that referral then things are- [Jaz]Ideally you wanna see them fresh right? You wanna see them the same day right? Imagine or my- [Krina]As soon as possible but same day would be great because then that way I can really bring the inflammation down that’s and bring the spasm down quicker otherwise it’s just going to get more and more tighter as I ideally gets the first day but then I would do I have a laser a low level laser, that i use which works on pain and inflammation. So i would do that around the actual jaw joint and I always take it down into the masseter because those muscles starts going into spasm as well after a while and usually with these patients who end up with these acute marks they probably already had underlying tmd symptoms before but it wasn’t recognized maybe the dentist never realized before they did and they didn’t think it was that bad. Sometimes patients have no idea that they even have a click or a part or they grind or clench. [Jaz]Krina, I just add one thing for dentists out there that we all have these, Krina. We have these patients, we hate them right and it’s this kind of patient who you say open and within about six seconds just usually a six second mark they start closing again and they say open again and they keep closing okay? These are the patients these are one risk factor that you can see that hey why does this patient keep closing they’re obviously struggling in a muscular state to keep open so these are patients that will really benefit from using a mouth prop to take that load away from the lateral pterygoid but yeah that’s one type of patient that we should be looking out for that ‘hey this patient could be at risk of this happening after a long procedure’. [Krina]Exactly. So yeah so and then I would do the mobilizations again so because of the mobilization I said with the destruction technique I’m able to gap the joint that then allows if the disk is displaced anteriorly allows the disc to possibly come back as well but then because of the lateral movement I do I end up stretching the pterygoid as well so if i’m able to gain the length in the pterygoid then the disc can also come back onto the condyle as well and then I will give them some- [Jaz]Is that painful, Krina? I can imagine them really being a lot of pain when you’re distracting or not? [Krina]No. It’s not. You just feel stretchy at that stage I’m not I could really go for it but I don’t, I make sure that it’s all within their comfort levels and just because I don’t want to increase more information there cause there’s already information that so you don’t want to do that and there’s a lot of TLC involved with that stage if it persists then yes I do then a little bit more aggressive with the mobilization side but initially no it’s not painful and within the first couple of sessions you’re able to resolve that anyway and you never really need to get to a point where it’s persistent. So if I’ve seen someone a few months down the road and actually there’s a lot of adhesions in there but yeah no it’s resolvable. And then once it has resolved i will then reassess them to see do you actually have tmd associated symptoms free dental procedure and usually like a hundred percent they do and they just don’t know. So then I say you know do you want to address this and usually they do because they like you say they struggle with opening. But then there’s the opposite patient who can open so wide and can stay open and then those are also patients that probably a physio needs to see because you know they’ve got like 50, 55, 60 millimeters of opening. [Jaz]Hypermobile. [Krina]Hypermobile yes and they’re moving around everywhere the sense of throat hinging and rotation doesn’t really exist with them. So those are also the patients that probably need to see because they need strengthening and because their ligaments are so lacks the muscles have to compensate so just a little bit of strengthening work will just allow them to stop subluxing as much- [Jaz]And that patient I described comes in an acute scenario and you see them. Is it typically an open lock, i.e. their mouth is open or is it a closed lock and they cannot open? Which one do you see more of or is one more common than the other? [Krina]Closed is more common from what I see by far yeah. Closed is more common where that is designed to really displaced. It’s very, it’s red, I’ve seen an open bite. [Jaz]Yeah that was my understanding as well I thought close is more common because the disc is stuck in front of the condyle and you can’t open beyond that 15, 20 millimeter is on one side so I imagine in that situation you see a lot of them where it’s happened on just one side unilateral and the jaw is deviated one side? [Krina]Yes. Exactly, so when they’re opening it’s a straight line deviation it’s not the s shape, it’s a straight line deviation to the same side because the lateral pterygoid has pulled them over onto that side and then you when you see them basically centralized as the lateral pterygoid relaxes. [Jaz]And in terms of prevention do you think it’s fair as a dentist to recommend using a mouth prop, firstly identifying who may be at risk? B) using a mouth prop and C) you know referring to using our physios even before you get to those long appointments to help strengthen things to help the patients heal and function better and hopefully if they have headaches and stuff that you guys can help them right? With headaches? [Krina]Right and because I get this question a lot from dentists like how I should be as a dentist assessing the patient quickly. So and then I know whether they are attracted should i be taking other things into consideration should I even be referring to you and i usually basically tell them is that it’s not really you don’t have to do loads of things really maybe, when the patient comes in or before their appointment you can send there’s this questionnaire that physios use where there are objective markers as a baseline of and we’re checking their oral habits, we’re checking any limitations in this call. There’s a question there called the draw limitation scale and maybe sending the moves out to patients whilst they’re sitting in the reception getting them to fill that out and it also then checks their psychological state as well and then assessing them from both of those points. I think it then allows you to see do they actually have a tmd condition and are they in a high psychological state right now as well and then you can think well actually maybe i do need extra information, maybe I need to put this prep in maybe I need to send them for physio but maybe sending those questionnaires up might help and the dentists that do use it they have found it useful because otherwise then if they end up with an acute afterwards that’s more trickier to deal with whereas just giving them the questionnaire and then putting the block in and sometimes the patient just needs, they need acknowledgement that this is being taken into consideration as well especially if they’re perceiving a lot. [Jaz]Are these available okay like can I share these with the little community listeners, the Protruserati. So if you could send those to me I’ll put them on the Protrusive Dental community facebook group and then link it back to this episode so then those people can listen in and learn more. Would that be okay? [Krina]Yeah and I think maybe the other thing as well is there’s like the myofascial pain chart as well so I think if dentists just learned where a few of the trigger points were and if they found that actually they were active so not just palpating actually on the joint but palpating maybe some of the neck muscles as well that might also help you to reach the diagnosis of actually maybe then really those are the kind of patients I should be seeing as well or any physiology you should be seeing as well and especially if their symptoms don’t resolve and after all of those things then. [inaudible] [Jaz]Brilliant. Have you found, just a few excessive questions they want to ask you, have you found that the most complex patients are those chronic pain patients that have also got fibromyalgia and all the other things going on multiple systems and your line of work I mean it’s difficult like any medical practitioner any physio any dentist we can’t always give 100 percent guarantee. We can try our best but in those most difficult patients, what percentage of success can you get on those do you think? You may not be able to promise complete resolution but you might be saying look we’re hoping for an improvement in your very complex case give us a flavor of that. [Krina]So when I get referred a patient like that in my assessment process there’s a lot of talking, it’s a conversation it’s not just me telling them what’s actually going on in that I will tell them that because they have fibromyalgia ibs it’s been going on for 10 years for example and it’s difficult to say what the actual success rate is going to be and I’ll list out let’s say the OPPERA study and just my own experience as well is that because it’s so multifactorial. All I’m actually doing is working on the joint and the surrounding muscles now if that is if that is 100% the reason why they are in pain or whatever their presenting symptoms are then I’m quite confident that I will be able to resolve their symptoms but if they’ve got a person at home that drives them crazy and they’re adding to their stress and that’s 50% of the reason why they’re in this situation then I can do nothing about that and so i’ll try and explain it to them like that and that it’s so multifactorial and there’s a lot of sales management involved and so I mean success rate varies. It just depends. [Jaz]Oh no I love what you share. I love the way you put it. If these areas are 100% contributing to your pain. So I say the same thing for my splint patients because as a dentist I cannot treat headaches and I don’t treat headaches okay? So as a dentist I don’t know for the record any dentist we do not, we cannot treat headaches, we cannot diagnose headaches be careful. However I will take a headache history and i will say look what I’m treating here is prevention of your parafunction, prevention of your grinding damaging more teeth and some of my patients have found that if that was the the trigger that was causing the muscles into overdrive that was then also contributing to your headaches and that’s the percentage of success we’re going to get with your headaches and I love that what you said because it’s very similar to how I say as well but I think there’s a definitely a role in there for you because i think my most difficult patients who have found some success with splints I think you raise a great point that they’re not wearing the splints during the day and I think that’s where really you guys come in to re-strengthen and to stretch and relax everything, that’s everything and i think there’s a whole adjunctive therapy alongside the splints that we provide and i think it’s a huge role that you guys have. [Krina]Yeah and I don’t think it’s either. So it’s not like you see a dentist or you see a physio ideally and in my training all allied health professionals, we are trained to work as a multi-disciplinary team. So when I entered the world of tmd and specializing in it, it was just surprising of how one multidisciplinary it is like everyone’s doing their own thing and actually I think that if we all just grouped together and said okay well you’re great at this, you’re great at this and so when I see a patient who has but you’re great at that I can send them to you. So what I really really want to do is create awareness on what I’m doing. I want to know what other people are doing, I’d love for people to get in contact with me and say “oh you know this is how I can help you and this is how I can help them with that” and just creating awareness that this exists because sometimes splits aren’t working or sometimes nor tip totally and elaborately isn’t working for them or maybe they just don’t want to do it they’re not complying with those sort of treatments then there are other things out there and I think if we were able to get in contact without the threat really and then it’s only to the benefit of the patient really. [Jaz]I completely echo what you’re saying because I think we do need to work more as a team and I think many of the dentists listening to this today they’ll probably be like if it wasn’t for the earlier tip I’d given as a pearl to check out ACPTMD they’d be like what there’s physios who do who do tmj? What? I mean these dentists probably don’t even know you guys exist so that’s the point of getting you on today so we can discuss this kind of stuff and it’s been it’s really great talking to you about this I think I’ve covered the main questions but I just wanted to give you a quick fire question according to what you believe can you palpate the lateral pterygoid or not? [Krina]I, personally, so there’s a lot of controversy on this. I personally think that you cannot because so we were taught that you put your index finger through up to the zygomatic arch and then you go cranial and then that is basically the lateral head. So then you do that okay then at the university of louisville when I did the master’s module we had divers and they when we actually lifted all the flats and tried to find where the lateral torque was actually we were touching the medial pterygoid so I just thought what there’s I don’t know whether I’m on the lateral or the needle here in a patient um so I concluded that you can’t some people believe they can- [Jaz]Yep same here I agree with you and um although I haven’t I mean I’ve worked with cadavers before as a first year dental student but back then I didn’t know what tmj was so I wasn’t even looking for the- I don’t know what lateral pterygoid was back then. So now that I’ve read the studies where they’ve done worked on cadavers to see hey through a cadaver while we can see, can we palpate using the technique that we use in the chair can we palpate the lateral pterygoid and these studies have shown that no you know we just can’t do it you can’t predictably do it at all and you know the pain sort of perception that people when you do this test suppose a test for that lateral pterygoid there’s a hundred percent chance to a patient going ah that really hurts okay so it’s not a great test but for that reason as well so what I do is I test for that pterygoid by against against resistance yeah for my hand so those listening put my hand under the chin get them to open up against resistance and that’s obviously putting load if you like or give providing resistance to the lateral pterygoid, is that how you would do it as well? [Krina]That’s exactly how I would do it and then I would then safely say that actually there is tightness up there natural thyroid or displaying that depending on what and then also measurements from you know lateral excursion and seeing if the discrepancy there that also adds to the picture of what’s going on and then deviations s-shapes that sort of thing so that then all just adds if you don’t have to just palpate to then say the lateral there’s other ways as well. [Jaz]Absolutely and but there are some eminent physios who would say that no I can’t feel the electrical work this is definitely pterygoid so this is the beauty I always used to look at this kind of difference that ‘ah this is terrible why can’t we all disagree but this is the beauty of dentistry. Now there’s the beauty of physio that there are different opinions. I’m sure there’s different schools of thoughts within. I’m sure what you do there might be some physios thinking ‘oh that’s very controversial or whatnot and I’m sure you see other physios doing that hang on a minute, that’s not right and it is the way it is this is how our professions work. So it is brilliant you’ve answered all my main questions. Now I want to give the mic to you to just any advice you want to give to dentists getting into this field and B) How can we follow you on social media? Give us your social media handles so we can learn more from you. [Krina]So maybe advice to dentists would be is that so as physio hopefully through this podcast I’ve actually highlighted that we don’t just massage the masseters and now we actually have a different range of treatments that we’re actually able to do and things, we’re able to treat as well but also I think if you’re able to get the muscle chart maybe I can send it to you and people can download it and I decided a muscle chart to actually look for the myofascial pain because that’s probably 70% of the patients that most people treat with tmd and then I guess people can find me on my website which is krinapanchalphysio.com and I’m also on instagram where i’m probably the most active @krinapanchal and can see lots of patient videos interviews that i’m doing with lots of maxillofacial surgeons I’m working with at the moment as well and just showcasing how this can actually be treated. [Jaz]Amazing. We definitely. I’ll put the handles on that and the website and any downloads that you do email me over please remember, Krina, so I can add those on and I just thought the story actually the first time about two and a half years ago I actually referred a patient to a physio, tmj physio. Found him through the ACPTMD this is when i was working in oxford and I was amazed I had this patient who had this acute episode where he ate something hard and he felt a crunch and now he’s a bit of pain but now he cannot open and his opening was about 35 millimeters and I was like wow I don’t know maybe I should send you a physio and then when one session and one treatment he was able to get him to 51 millimeters I was like wow that’s amazing that really opened my eyes you know all those years ago I suppose but you guys as we covered today see so much more than that and I think you guys are a really important part of the team in managing “TMD” which is a massive umbrella term but I urge you all to find a physio near you that you can refer to. You’ll get so much more success, success with your splint. So I’ve got the splint course coming out very soon and I’ll be adding a whole bit on that you know make an alliance with your physios, they will help you and for your toughest cases you need them because chronic pain is tough. Your splint will not help chronic pain that’s why I try to stay away from it. I like to cherry-pick the easier cases. It’s so much your success rate should be so much higher that way but Krina, thank you so much for coming on and sharing your time and expertise with us today. [Krina]Thank you so much for having me, it’s been a pleasure. Jaz’s Outro:Guys thank you so much for listening all the way to the end. I really appreciate it as always. If you’re listening to this and it’s like this is a brand new episode then wow I have just pretty much launched my splint course or it’s about to launch so on friday I’m launching the splint course. splintcourse.com I’m so so proud of it. This is my baby. It’s taken so many years of video recording, late nights, early mornings to finally bring this 10 or 11 hour course into fruition. I say 10 or 11 because it depends on whether you count the bonus modules or not so I’ve got lots of content on there I won’t bore you because i’ve already told you all about the splint course already and various opportunities so please do check it out if you’re interested in learning more about occlusal appliances check out splintcourse.com. Krina was one of my beta testers because I was really keen to hear her opinion of what she thought I was teaching dentists because I wanted to have a whole section on there, on the importance of conservative care and the importance of physiotherapy. So check out the splint course if you haven’t already and I look forward to seeing you there. Otherwise I’ll see you in the next episode and hey if you found this useful do follow us on @protrusivedental and also follow Krina Panchal as well her instagram handle is @karinapanchal. Thank you again everyone and I’ll catch you next episode.

How do you obturate yours? When I have had the equipment (and training) I have used warm vertical compaction – no doubt that IS the gold standard. However, what is the humble GDP using all over the world? I would argue that not only are we using cold lateral compaction with sealer, but in many cases, we are sticking a big, fat, tapered GP cone in the canal with a splodge of sealer around it. Is that legit? https://www.youtube.com/watch?v=GkWR7XzTHCs The million dollar endodontic question that no one asks! Need to Read it? Check out the Full Episode Transcript below! Obviously the landscape is changing with the popularity of bioceramic sealers in Endodontics – I use this time to ask Dr Ammar Al-Hourani about this too. Is single point obturation cheating? Should GDPs start using bioceramic sealers? Does it even matter? I hope you enjoy this group function – you can follow Dr Al-Hourani on Instagram via @theendoguys If you enjoyed this, you might also like my episode with another talented Endodontist, Kreena Patel, on why we hate cracked teeth! Click below for full episode transcript:  Opening Snippet: Hello, Protruserati, I'm Jaz Gulati and welcome to this group function where we answer one burning question. Today's burning question has been sent in by someone regarding endodontics, is single point obturation good enough? Jaz’s Introduction:What I mean by that is you prepare your chemo mechanically prepare your canal and now when you come to the obturation stage you just stick one of those fat master gp cones in there potentially a matching size to a rotary file you just used and then you just fill up the rest with the sealer is that good enough? See? I think this is what GDPs all of the world are doing. We’re not doing warm vertical compaction, we can be doing cold lateral compaction as a whole but a lot of times you stick the fat gp cone in and it fits well enough and there’s not enough space for cold lateral compaction. So is this technique of obturation up to the mark? So that’s what I’m going to find out today from Ammar Al-Hourani, who’s a specialist endodontist and we’re going to jump straight away. Just one thing to say is the splint course is now just under two weeks away. I’m looking to launch it on March 12th. It’s the first time I’m revealing this. So on March 12th it should be launched online. This splint course is 100% online. It’s packed full of videos like my resin bonded bridge course. I thought I’m really proud of it. It got loads of rave reviews but it lacked video so I took that several notches further with the splint course and you’re basically like watching me like you’re like over the shoulder kind of training while I’m adjusting splints, while I’m going through the diagnostic process. It very much teaches you the very basics of anatomy as a gdp and building up to a diagnosis and how to choose which splint will help your patient the most. Sometimes we’re looking just use a protective splint but also with that protective splint to protect your restorative work or prevent the patient from pathologically destroying their teeth, there’s a bit of a decision-making tree as to which splint why and when and what are the risks of certain splints. So I’m going to go through A to Z of that including the delivery from a stabilization splint to AMPSAs, the whole lot in between. So I’m so excited to share that if you’re interested why don’t you download one of my flow charts I’ve got a free flow chart for you to download which pretty much even if you don’t do the course you’re going to find it valuable because it’s going to show you when I prescribe certain appliances. Now just a disclaimer I made a flowchart and really it’s a guide but you should be deviating away from guide any sort of guideline you should always be happy to deviate away from a guideline because there’s no such thing as a cookie cutter approach to occlusion. So just read it with caution is there just to help my students of the course get an idea as a generalization and if you don’t understand anything on that it’s because it’s very much there to accompany the course but feel free to that’s www.protrusive.co.uk/flowchart you can download that straight away. So let’s join Ammar Al-Hourani to answer the question, is single point obturation good enough. Hello everyone and welcome to this group function, today we’ve got Ammar Al-Hourani, okay? He’s a specialist endodontist, he works two days a week, teaching undergraduates in Plymouth, he’s three days a week in private practice in London and he’s part of the endo guys. And this episode is where we answer one burning question and the burning question today thanks to Ammar’s going to join us for this, is single point obturation okay? So I’m going to spend just one minute here. I’m also going to check to make sure that we definitely are live. But spend one minute just set the scene about how this question came to be and basically when I was a student we got taught and in our endoclinics and we first started with k files then we moved on to sort of hand protaper actually in dental school and then we moved on to rotary eventually which was cool but initially we started cold lateral compaction with the like iso files and iso gp points and then eventually we got taught how to use the matching gp cones or the pro taper and when it filled that canal so beautifully I realized actually there’s not much space in there for the your cold lateral compaction. And then eventually what happens is that you accept some compromises and practically you know you want to be quick so eventually I had a gp cone with a lot of sealer around the edges and if there was a bit of space I tried to jam in a little accessory point. So my first question Ammar is okay so thanks for joining me. My first question is as a gdp let’s forget about bioceramic seeders for a moment as a gdp, is that acceptable? That scenario I just described. [Ammar]Yeah I mean that’s the scenario that’s probably going all the way through the UK and I’ve got a lot of my own colleagues I work with that probably do the same thing with h plus I think let’s take a step back I think we just need to understand the fundamentals first about why we’re doing what we’re doing. Endodontics is relatively straightforward. It’s really broken down to three parts, get the necrotic tissue out, create a taper in the canal and wash it and then obturate. So obturation is the very last thing. Opening up, remove the decay, remove the leaking restoration and then once you taper it, the cleaning part is the most important element of the whole project okay? Now why do we obtain it? That’s the point of obturation? Obturation really just fills up your space that you’ve created once you’ve cleaned and you’re happy with everything. Now we obturate, the reason why we obturate is a number of reasons you want to fill up the dead space you want to clog up the dentinal tubules from the bugs and you want to seal them all off so they can’t suffocate them from nutrients and then you want to stop any percolation of fluid back in from the apex or from the lateral canals okay? Now if you use gp, we use gp and we use sealers for that traditionally and we still do okay nothing’s really changed over the last 40-50 years really. Now if you use gp on its own the problem with it is if used as a warm vertical compaction technique it will shrink by about seven percent and it doesn’t really have a hermitic seal towards the dentine so you’re going to have a gap between the dentine and your gp. And that in itself forms a void and that void creates areas in which bacteria hasn’t been sufficient you can’t entomb that bacteria and that’s it there’s a biofilm that is going to regrow, spore, release their you know their toxins and they’re going to then affect the outcome okay? So then you have to produce something like a sealer okay to prevent or close that gap. Now the sealer does a few things for you. It’s antimicrobial, it fills all the gaps in turns the bacteria as much as possible or goes into the dentin tubules and it gets into the nooks and crannies that you know your gp can’t get into okay? Don’t forget you’re preparing a circle within an ovoid you know and all we’re trying to do is disinfect the canal as best as possible and reduce the bugs to a point in which your body then starts to clean things up. You’re not going to sterilize the tooth, you’re going to just disinfect it okay? Now traditionally the sealer that we use is tubular seal or more recently AH plus. Problem with tubular seal which is antioxidant, the eugenol itself is quite an irritant it goes through the apex it’s really uncomfortable, it sort of dissolves over time, it doesn’t really have a good bond to your canals and then if you want to put a post in there you’ve got oil and you can’t really bond to it very very well. The whole thing becomes an oily mess. Some people still use it. I’ve not used it for a very long time probably since I was a gdp five six seven years ago. AH plus came along a nicer material, resin-based sealer. It’s a bit thinner, it bonded a little bit better to the dentine but it’s still hydrophobic. It’s a resin. It’s antimicrobial has got a nice high ph. It’s great on a radiograph especially the new stuff AH plus jet, it’s like putting an ir core in the canal and then but the problem with it again if you used a warm vertical if you use gp, the single cone add AH plus, AH plus itself as a resin shrinks by 6.5%. So why am I talking about shrinkage? Why is it a big deal for me? Well if you look at Angutal studies which came out a few years back she talked about voids. Voids is an issue for us because that’s areas within the root canal system don’t forget we go back to the original position which is you’re creating a circle with your file within an ovoid canal. So you’ve got areas which are not being touched by your file. And that’s it is therefore which only the arrogant can to and then hopefully your sealing material and if your ceiling material is shrinking then that’s areas where you can then have repopulation of the microorganisms bacteria and these are voids where things can regrow again and cause failure in the future. So is single cone with those materials is a good idea? I’ll go to the next point which I think personally as the most important element with both of these things is the irrigation and your coronal seal. [Jaz]Ammar, that’s a given okay? I’m going to take control because that’s a given okay? So we have to have a clean canal. I’m totally with you but I want to really twist your arm here I’m trying to really twist your arm and try and get the answer in terms of the gp cone right? So basically but here’s the situation you’ve mentioned about warm vertical compaction but you know most of the audience here we’re gdps right? We’re using cold lateral compaction okay and a lot of time like whether you can get an accessory point and extra gp cones in it depends on what kind of a canal you start out with right? So that scenario where you can’t get another accessory point in there but the gp cone let’s say an f2 f3 the pro taper system and again f3 matching cone and you stick it in there there’s not enough space to put an accessory cone in there but you still see that it’s not as snug as you want in the coronal portion. So that all the tubules that you’re using whatever sealer AH plus is all around okay? What should we do in that scenario with cold lateral compaction or is that pro taper system is not, it was never designed for cold lateral. [Ammar]Well the new matching systems have obviously been designed for the single cone technique in the sense that you want to use it as a warm vertical compaction technique okay? So you’re cutting it back you’re getting that really nice tug back at the last five millimeters where you know most file systems now are not a progressive taper they’re available taper. So the first four five millimeters off the canal you know the apical part of the file is really what the gp is fitting into and then the rest of it should be technically warm vertical compacted. But we don’t have these materials these are very expensive materials they’re technic sensitive you can put a lot of pressure on the root so from that point of view as long as you’ve got in my opinion a clean canal dried well you know you don’t have any fluid going back in there because you’ve got inflammation or inflammatory acidity and you’ve got a really good coronal seal I think you should be absolutely fine. I think it would be okay. [Jaz]Yes! Okay I’m so glad you said that I was actually really worried because when I did that I felt guilty. I have to say. [Ammar]No it’s not guilty but you need to understand that there’s still limitations from the sealer material. So the sealers haven’t really truly been designed for this purpose but as long as you’ve got good coronal seal if you’ve looked at ray and drop studies if you’ve got good coronal seal even with a root canal treatment that seemed to do fine so maybe we’re looking at the finer technicalities of things. And at the end of the day let’s be honest let’s be honest we’re always judging the outcome of root canal treatment by the white line and if the white line looks great then we all assume everything’s good on a two-dimensional x-ray. Don’t forget it’s not that’s not from a three-dimensional point of view. So that’s why I think that bioceramic sealers in my opinion now sort of take over. I think they are the future because- [Jaz]So I mean I want to come to the bioceramic sealers I want to come back I just want to say at this point because we’ve got some people live right now so I want to encourage at this stage that if anyone’s got any questions send them over because then, So Nicola, hi Nicola and Nicola’s based in Italy he’s saying hello. He’s talking about bioceramic hydraulic sealers which you’re going to come on to now so if anyone’s any questions okay you can send it here. We have had one question from instagram already which we’re going to come on to at the end. So in the first half this group function which we’re doing amazingly for timing you’re really good that you really answered my question beautifully, Ammar thank you so much I’m not just saying that because you’ve given me the wink, right answer. But no it makes you feel good that all those observations I did where I thought you know I don’t have a warm vertical compaction system I’m just cold lateral compacting and there isn’t much space so I’m relying on my sealer but you’re right as long as the disinfection was good and the coronal seal the rayon trope studies 1985 I think it was, classic studies you probably know that the date but I will but that’s amazing. So now with the bioceramic sealers give us a flavor of what most endodontists you think are doing now with the bioceramic sealers and how as gdps we can implement that for our more simple endos? [Ammar]Okay well we have to understand the science of the bioceramic sealer if you give you a few minutes just to discuss that with your colleague some people don’t really understand what up bios don’t understand that we’ve not really gone into the technicalities of bioceramic it’s not something we’ve been taught relatively. It’s not new, it’s been out since 2007 but bioceramic sealers are really derivatives of mta. MTA was obviously discovered by [mahmoud turbine] quite a few years back and we took some of the active materials from that so the tri-calcium silicate, dicalcium silicate, calcium phosphate okay and they put that into sealer. And the nice thing about that is that if you look at all the studies from bioceramic you know with bioceramics it showed that it was by you know bioactive so it was osteoconductive in a sense it created healing or it stimulated the bone to heal, it’s a stable material it doesn’t shrink it actually expands by 0.2 percent so it expanded so therefore it’s a stable material, it’s hydrophilic, it actually bonds to dentine through alkaline etching, it’s a high ph of about 12.8 an initial setting which is highly antimicrobial and it releases calcium hydroxide as a byproduct. So as a material if you were to have asked me as a gdp many many years ago, create me a sealer that would do everything for you this is the closest we have to a sealer that sort of overcame all the limitations of the past. Don’t forget, what we were doing before and the technique of obturation before, was our technique was sort of being guided by the sealer that we had because we had limitations to the sealer. Now that sealer does is actually pretty good and the gp really only does one thing for us it’s a vehicle to push that sealer to where we want it within the zero two millimeters that is what we’re aiming for because if we do that then that means we have cleaned to zero two millimeters and that apical third is where we have most of the ramifications the lateral canals where we have most bugs are difficult to clean especially with big lesions with vital cases you can get away with it. With a non-vital case with a chronic implant on that you need to clean that area very very well. So now I have a material that’s really stable. It does everything I want. It stays where I want it to be sets nicely but where’s the problems with it? The problems with it is retweeting it is going to be a nightmare okay because it’s attached well don’t forget we go back to the original thing you’ve created a circle with an ovoid canal, that ovoid part on the sides you’re never going to really remove 100% and if you’ve not prepared it to the zero to two millimeters it’s going to make my life extremely difficult trying to get patency. If you look some of the studies patency was very very difficult to re-ascertain because this material is rock-solid you can’t dissolve it, you can’t wick it out, you can’t use chloroform on it you can’t use anything on it you have to literally either drill it out or it’s going to stay there because it has high affinity- [Jaz]That begs a really interesting question then so we obviously know that a lot of endodontists I know are using bio ceramic sealers with a warm vertical compaction system with gp obviously as a vehicle as you say you put it so nicely there. So that’s great so that’s what endo guys are using, gdps, what do you want us to use? Do you want us to use like imagine we’ve done everything to a high standard? We’ve used sodium hypochlorite at least three percent heated and whatever we can go into in that whether it’s necessary or not we’ve used edta 17%. We’ve done a good sort of chemo mechanical cleaning and then we come to obturation and we may not have warm vertical compaction but we’ve got a bioceramic sealer and we can squirt inside or place inside a nicely fitting gp cone that’s going to be snug in the apical few millimeters. Should we use the bioceramic sealer which may make it difficult for you, if you’re going to see it for re-treatment in the future or should we just stick to using the tubule seals and the AH pluses because of that scenario that we just discussed? [Ammar]Ultimately at the center of all of this discussion is the patient? Okay so the patient really needs to get the best outcome out of all of this. If you are sure that you have located all the canals you’ve gained patency which improves your outcome by doubling it you’ve done a really good chemo mechanical preparation you’ve really cleaned that tooth well you’ve done it edta red to remove the smear layer and you’re happy with your working length PA and you’re within zero to two millimeters then go ahead and put your biceramic in there. I have no problem with that because it’s not going to be difficult for me that gp is going to act as a quasi glide path I’m going to get back in there and be able to get to the apical two millimeters and the apical 2 millimeters is the most important element for me because that’s why I need to I need to clean that area very very well. So if you have achieved all of these areas and you’ve ticked all those boxes then by all means go ahead and use bioceramic sealer. It’s as simple as that but if you think you have it- [Jaz]If you yeah if you meet all those objectives you’re probably not going to get to see it because it’s probably going to be a success- [Ammar]It’s going to be a success it’s going to be great, it’s going to look great on an x-ray, it’s going to be it’s technique the technical sensitivity is nothing it’s easy to learn it looks great on a pa you’re going to fist pump your nurse in the end of it you’re going to look you’re going to feel like a hero and so why not use it? If it’s there and you know it’s going to do a great job and we know the science is really good behind it, use it. But if you don’t get to those points then please don’t because that’s when it’s going to be very difficult for someone like myself or a dentist specialist or even other dentists to retreat and therefore that might be pushing us towards surgery straight away rather than a retreat and that’s makes it more difficult then you’ve sort of for any root canal treatment we need to remember one thing, if you do any treatment in dentistry you need to always think about what am I going to do when it fails not when it’s going great. Always think about failure, what do I do next? If you think about it this way it makes things a little bit easier to plan and us endodontists are like that we do the endo but then I’m always thinking if this fails what am I going to do next? Am I going to do surgery or am I going to get back to what I’m going to do? So I use bioceramic sealers but actually, Jaz, you’re going to be surprised by this. Not all Endodontists used bioceramic sealers. I would say it’s still a 50-50 mix okay? I like it because I like the science I enjoy I like what it does it makes me feel and I’m I’m a little bit lazy so I like it you know whereas others like to make their life you know they want to use the AH plus that’s what they’ve been trained with, they like warm vertical compaction they like it you know how it looks in a PA, they like the skill set involved with it different people like different things but for me it just works. It works in my hands and I’m getting really good outcomes and that lesion that I’ve got is disappearing or getting smaller over time. So for me it works but will it work in the long run you know we just need to wait also for the long term studies as well we still have to wait. [Jaz]Well I really like those answers and I think you summed up very nicely as a closing summary of this segment if you like is that as a gdp now this is as a gdp perspective based on what I’ve just learned from you, if you’re, everything’s going well use the bioceramic sealer use gp give your nurse the fist bump as you said. But if you have any doubts that the root canal which you’re approaching from the best intentions and maybe you just feel that one or two elements are not you know you haven’t got patency but it’s not bad enough that you want to refer it or you need to refer it because now you’re sort of you’re invested into that root canal right? Maybe in that scenario you should be using the tubule seal or the AH. plus or whatever to make a potential re-treatment easier. Do you think that’s a fair way to put it? [Ammar]Yeah fair analysis because even then don’t forget the coronal part we’re going to you know most dentists are going to probably flare with the gates so it’s going to be overly flared a little bit so you’re going to have enough space to still put a few accessory cones and give yourself some good lateral compaction. So I think it’s fair to say yeah if you think you’ve cleaned it very well but you just can’t get to the very don’t forget patency is still one of those things, it’s debatable concept some people think you know some scholars believe in it and some scholars still don’t you know some of the big scholars still don’t push for it you know so as long as you’re- [Jaz]But we all have that gut feeling. Am I right? gdps we all have that gut feeling that okay we know that this is going to be going well. So I think I like it let’s leave it that gut feeling and then base your sealer on that but then let’s not get into the fact that bioceramic sealers are expensive so is there use it that kind of stuff but I think you’ve covered it really well, Ammar about ‘is single point obturation acceptable’ so I think you’ve given, you’ve done this group function justice so in the in the latter bit now we’re going to take some questions because I have got some questions so we’ll take that out- [Ammar]One last thing what I’m trying to say is that the obturation part is just one element of the whole thing. If everything is being done well it’s just one element you can’t put down your whole success or survival of a tooth or things going well on the obturation it’s all about everything else fitting together so there’s a lot of enamel elements and you can’t ever do a study to say it’s definitely the obturation system or the sealer is what caused the whole thing to work. So if you’ve got a dirty canal and a poor coronal seal no matter what you’re going to put in there it’s just not going to work it’s eventually going to come and blow up, you don’t put rubber down you get saliva leaking in there it’s not going to work. And it’s just common sense as long as you’ve got really you’ve done a really good job if you obturate it relatively well you should get a good outcome your body really heals very very well you know the healing potential of the body is phenomenal and you’ve seen a lot of terrible root canal treatments I’m sure that are still surviving 10, 15 years down the line if not longer. So it just shows you that as long as we reduce it, the bottom line is reduce enough bacteria in that canal and tilt the balance towards your body and your body will clean everything up hopefully. [Jaz]Has anyone ever told you that as you get more passionate you become more Scottish? I just thought I’d let you know in case anyone hasn’t told you that. Thanks so much tuning in but he’s asking can I ask about restoration of the pulp chamber, is it better to place gic barrier or can we directly etch and bond over the orifice before placing a composite core? And then the second part of that question is who should place the core restoration to gdp or the endodontist? So the first part was restoring on the pulp chamber over your gp, gic barrier versus composite and then the second one was who should be doing the core? [Ammar]Okay so first thing first question I think the most important thing is that you need to cut back the gp to the cej don’t leave it hanging in the pulp chamber because if your coronal seal starts to leak that’s going to leak very very quickly. So make sure that at least you’ve cut it to the cej okay? First and foremost. Secondly two schools sort of thought really here some people like the the the gic because there’s been some leakage studies that showed that if the filling came out it gave you about 30 days worth of protection against saliva others you know are saying put the composite straight away the likelihood if you’ve got a really nice MOD or MO or occlusal restoration the likelihood of that composite popping off just in one piece and just leaving the gic is highly unlikely. So I think if you can get it you can cut the gp to the cej get your lean the pulp chamber really well, make sure it’s nice and clean, etch it and bond it should be absolutely fine. That’s not a problem you don’t have to have the gic. I like putting on gic because I’ve read the books and I just feel happier and warmer inside me. I’ve done a better job but am I doing a better job? I don’t know. That’s the reality of probably costing the principal more money. Second question you were saying about who does the core? I personally think if the patient’s already in the chair you know they’re taking time off just get the core in there, put the rubber dam on how long it is going to put. I use sdr or or bulk fill it’s going to take me how long ten minutes maybe five minutes saving the patient another appointment, another journey more time off and then I think the dentist is going to be a bit annoyed if I put gic in there drilling out gic is a bloody nightmare you know that there’s more than anyone else. So why not just leave us doing everything for you and then you just take the glory shot and get the crown on there. It looks like all nice people remember you for having a nice crown and that’s it you know just so make your life easy, make our life easy. [Jaz]I 100% agree with you on both counts with the composite and with the fact that whoever does the root canal just do the core at the same time and with good bonding protocols. Two more questions now one is my question actually which is, what’s your secret to getting a lovely clean looking sort of pulp chamber? So once you’ve done your obturation quite often I look at it and it’s a mess. You see these three orange heads and then you see all this like white sealer mess and debris and stuff like that so I mean I do air abrade and then try and clean it but it never looks as good as you endo guys like it’s almost glistening and shiny like as if you guys have got like baby oil on it like what do you guys use? [Ammar]So first thing I use an LN bur just to really clean you know literally cut the gp point to the cej, secondly if I use AH plus I use alcohol, rub alcohol ethanol, isoprophyl alcohol will dissolve the whole thing out that gives you everything to the surface just no not percentage you could just buy it from qed I don’t know what percentage is isoprophyl the whole alcohol’s up the whole probably 100% or 70%. That’ll dissolve everything, the ultrasonic tip is really good just the cavitron and your three and one just you know, just give it a really good rinse and a clean and then just that acid etch really really brush your bond onto the canals. And on the floor on the walls brushing is the most important bit, not just a little bit of a dot here and there and everywhere literally brush it until it’s glistening. Then like here it glistens, it shines back at you and then you know everything’s well and then that’s when you go for it. [Jaz]That’s it. It’s so good you said that because with the bond you get a better wet ability for your actual resin that goes on as well so that’s wonderful. Next question from Mohammed Adam is solubility of bioceramics? Do they meet the iso standards? I hadn’t even thought about that but there we are. Is there a question mark over the solubility of bioceramics do they meet the iso standards? [Ammar]The bioceramic sealers are not as are not as soluble as say zinc oxide eugenol but they’re actually very very stable and they set in moisture. So they’re not you know that’s why they you know the more dry the canal is in fact the irony is it takes much longer for it to actually set. So solubility you know it’s a stable material it actually expands a little bit so it’s actually pretty stable as material it won’t just the ones that are very soluble like zinc oxide and the calcium hydroxide based sealers those ones will dissolve really these are the ones you should be worried about but this one. [Jaz]Brilliant. Fine. We’re going to take two more questions before the end of this group function. So the next one is from Jack hope you doing well buddy. He says okay we got one more from jean-marc like I never I hate letting him down he always has good questions anyway, Jack says bioceramic sealers for open apa apex cases versus your traditional mta plug? Any opinion on that? [Ammar]I think it’s really difficult to manipulate a gp to open apex so it’s just a lot easier to use something like mta or biodentine and I find biodentine to be an exceptionally brilliant material for it. Compared to other materials out there it is actually quite inexpensive so using that as a barrier is much easier to do and it’s much more predictable to do. And plus don’t forget that down the line that patient’s endo fails you’ve pretty much done the retro prep you just do the surgery and just shave off a little. You don’t have to shave anything off you just have to clean it all off and you’ve already got the retro prep ready. So with an open apex it’s just a lot easier to do that way. Manipulating gp by time you put that in and down pack it you might push some through it just isn’t the same. [Jaz]So yeah, MTA is the way to go? [Ammar]Correct mta or bioceramic putty you can biodentin these are I think the way to go. [Jaz]Brilliant. I’m going to ask one from we’ve got quite a few now so quick follow round questions for the last six minutes. For a young patient 17 years old, irreversible pulpitis doesn’t say which tooth with apex fully formed, is there any special risk for gdps taken into account or shall I refer to an endo specialist? So I don’t understand that maybe even 17 year old patients irreversible okay, yeah. [Ammar]If they’ve got irreversible pulpitis you’ve got two options here if you think you can open it clean it and do a pulpotomy and use something like bulk you know biodentine and and you know basically a vital pulp therapy case yeah if you’ve got the protocol but you need the magnification to know whether or not you truly have the pulp stumps are actually not bleeding because you don’t really know one could bleed, one could be vital, one could be non-vital so yeah with that if you could send. If you want to save the tooth or do pulp, vital pulp out send it to a specialist if it’s a relatively straightforward root canal treatment. I think you know you should give a pretty good goal because you also need to learn right, you need to learn somehow. [Jaz]Good man allowing gdps have some cases as well thank you. Next question from Shannon Patel says what’s your method. [Ammar]I hope she’s Shannon Patel, not Shannon not shannon. [Jaz]He’s definitely trolling you no it’s not it’s not Shannon Patel I know Shannon. What’s your method of sealer placement: put it on the gp or squirt it in first and then place the cone? [Ammar]Is that for bioceramic or is that for AH plus? That’s a very different thing. [Jaz]Why don’t you answer for both okay so let’s go for AH plus and then for bioceramic if it’s different. [Ammar]Okay I have AH plus I usually will put a little bit over the orifice and just a little bit at the very tip of the gp point and I’ll just put it in slowly okay not quickly slowly to the working length and that should be pretty much all you need you don’t need that much don’t put too much because then AH plus is quite runny you’ll just get a massive sealer puff and it’s it’s quite uncomfortable for the first eight to ten hours it’s all by sealers. Bioceramic or otherwise are cytotoxic at the beginning okay some less solar so bioceramic not as much as the AH plus or zinc oxide eugenol. So yeah not a lot you just need a little bit not a lot you should be fine and if you use the AH plus jet you don’t need any at all it just literally lights up on your pa. Bioceramics a little bit different I usually will fill up the first third so the coronal third and then I’ll unscrew the top and I’ll put the gp point into that and then I’ll put it into the canal and that gives me a little bit more control of the bioceramic okay and I’ll use less material. [Jaz]That’s also very important, economical. Let’s see, Wajiha wants you to repeat the name of the bur you use for the removal of gp? [Ammar]Well you can get a few it’s called the LN bur or you can get the comet endo bur just call the comet wrap they know which one it is it comes in either 29 millimeters or 31 millimeters these burs can be reused over and over again because they’re tungsten carbide and they’re great because you can actually physically see what you’re doing they come in different diameters so it makes it much much easier to look at they’re about 150 pounds they’re not very expensive. [Jaz]I mean I’ll tell you what I do and most of the time this isn’t successful but tell me what you think of this technique I get a gooseneck fat rosehead bur right? So a gooseneck being extra long in the neck of it so it can reach down to the apex and I’ll just put it on really high rev no water and just you know melt, stroke, ablate or cut away the gp exactly what I want. Is that a slightly risky method? [Ammar]It should be fine but just the only worry is you you could be stripping away a lot of the paste on cervical dentine that’s the dent a few millimeters above the cej and a couple of millimeters below and that we know from new studies now coming through for the last maybe a few years you remove a lot of that dentine and then that’s the dentine that you can never really replace and that really weakens a multi-rooted tooth okay and no material can replace the strength of that area so if you want use something like an alarm bear or use a smaller head and do the same thing not a big fat head something a bit in the middle like maybe a size 120 should do the trick. [Jaz]I mean if anyone’s going to be doing this you know tomorrow morning just make sure you’ve got you know you should do anyway but make sure you’ve got decent tug back on your on your gp and it’s not like just otherwise they’ll just fly at your face. Okay the last question which we haven’t addressed yet which is from the instagram which is what do you do and such a common scenario am I right? We prep to let’s say f2 f3 pro taper other brands are available and you get your gp cone and but it’s you know your file has been there your f2 f3 file has been there to the apex to the working length but your gp cone is just not going it’s a couple of millimeters shy, what should you do? [Ammar]So a couple of things we need to first let’s just give you a quick science lesson very quick 30 seconds all files that we use now are a bit more martensitic than they are austin citic what does that mean? They’re a softer file they bend they’re not straight and rot you know like rigid as before so what that means is that the file itself will create that shape of an f2 or a waveone primary but it doesn’t create a hundred percent because it’s a softer file okay? And your gp point will always have a little bit of discrepancy as well okay so it doesn’t fit a hundred percent so you might have an 07 taper, a 2506 or 2507 but it’s not a hundred percent 2506, percent, not 100% 2507 okay? So to correct this problems two things one you might have a you know the older style gp where it’s fitting at the top so it’s a bit fat at the top thin at the bottom so it’s basically wedging itself at the top so that’s coronal tug back okay so check for that buy the newer gp points that’s tops you have in that okay. Second thing is you might have a lot of smear layer in there and dentine shavings and debris so you might need to wash that out so activate the arrogant or gp pump which is really cheap and just liberate all that gunk that’s in there get some edta it removes the smear layer dissolves the dentine and that might be stopping it’s a bit like turkish coffee I don’t know if everyone’s anyone’s had greek or turkish coffee coffee’s at the bottom the bit at the top that you drink and that is your dentist that bit at the bottom that mud you can’t need to get rid of that okay so that’s the second point. Third point is your gp point is sometimes not fitting bang on because it’s just not been designed 100% perfectly so if you’re using an 06 taper by 04 taper gps and that stops you that means you’ve got good apical tug back and it’s not tugging back on the actual taper okay on the sides it’s tugging back only at apex and therefore it really fits beautifully at the very very tip you will not get that problem so go a taper shorter not a size charter a taper shorter so if it’s 046 buy some o4 tapers you can get that from any shop you know any distributor in the uk we’ll get you that and they’re not they’re not very expensive another thing. [Jaz]I love that analogy of Turkish coffee. Actually, that was genius. I love that very much. Okay we’ve come to the end episode just tell us a little bit about how we can learn more from you. I really like your sort of style today. I like your down to her style and I just love the fact that you actually I think you you understand us as gdps. Obviously you’ve got the endo guys but tell us about love about because I sort of did your intro for you I’d like to know for those listening a little bit about yourself and what you get up to and how can we learn more from you? [Ammar]So basically I really didn’t enjoy endo, as an undergrad I absolutely hated it, I actually had to go and supervise our shadow an endodontist to actually understand the principles and from that point on I’ve always thought you know I never understood it maybe I was just a bit thick I don’t know maybe other people understood it better than me but the long and short of it is I never wanted anyone to feel like that again you know I wanted people to get you know education which is relatively cheapish I don’t want people to pay over the odds for courses I wanted to be accessible for everyone and me and my friend always had that dream that we wanted everyone to be able to have you know if they want education they should be able to afford it you know I came up with horrendous amounts of debts like everyone else which had to pay back so the endo guys really is a simple concept we show you our cases we tell you what went well what didn’t go well, learning points. We’ve also got the endo guys academy that we do with coltin again. It’s you know we do it for a relatively cheap fee 250 to 295 pounds of course and we go through a principle, a protocol. So we do access cavities canal location and one principle on how to get a good coronal, middle and apical prep with glide path files and we just want to show you how you do it well so that in practice you could do you could use any file system you want and as long as you understand the principle you should use anything and anything should potentially work okay and that’s what we’ve wanted to do and that’s what the Endo guys stands for you know being there for everyone, being accessible for everyone and being you know if you want to text us, phone us, email us whatever we’ll always get back to you. Because we felt the pain that you guys have gone through you know we never understood it till I. became a specialist and even until now I’m sometimes going to work and I’m like it’s damaged limitation I still make mistakes it’s just a matter of you know I make maybe last mistakes or I pick the right winners you know I don’t take every case on I’m comfortable to say no. Once you learn how to say no or this tooth is goosed then things become a little bit more liberating and maybe that just comes with experience more than just training you know and that’s what Endo guys is all about they’re for everyone basically. [Jaz]I really appreciate that. What’s your Instagram handle? [Ammar]It’s just called the endo guys. It’s really easy, let’s just type that up. [Jaz]Fine, find it you can follow the endo guys, Ammar thanks so much for covering that really well honestly, I always worry about doing these short episodes because the answer is usually to any of these complex questions the answer is usually it depends right? I’m so glad you didn’t say those two words together you never said once, it depends so thank you for not saying it depends but one last thing because Daz has just asked a really quick cheeky question for the LN burr slow hand piece or endo motor slow handpiece? [Ammar]Slow hand piece and use the middle always start with the middle because the middle of the size is not too big, not too small if you find it’s too small, go one big if it’s too big go on small simple as that keep it simple. Jaz’s Outro:Amazing Ammar, thank you so much for coming on the show today. It will be on the proper podcast very soon and it was an absolute pleasure thanks so much.  [Ammar]Oh my pleasure, thanks so much for inviting me.

Sometimes associates moan that they can’t improve their Dentistry or provide better outcomes because their principal/corporate will not buy them that fancy composite/instrument/air abrasion unit/orange floss (okay maybe not the last one!). Here’s a tip: buy it yourself! https://www.youtube.com/watch?v=JQKiaZgHbk4 Need to Read it? Check out the Full Episode Transcript below! I’m not saying you should go crazy and buy ALL your materials – thats the role of the practice – but if after having a good conversation with your principal about investing in the new gear and it is not bought for you….there are some major advantages of buying it yourself. In this episode I am joined by Dr Rosh Panju who, as an associate, bought his own intra-oral scanner (iTero) – that speaks volumes about his mindset. In a nutshell, this episode is about making your own luck. For those asking about where to buy the ‘associate box’ to transport kit between practices, here it is: https://amzn.to/3v1li3S If you enjoyed this episode, you will like the episode on Emotional Intelligence with Richard Porter – check it out! Click below for full episode transcript: Opening Snippet: But you okay went out and you bought your own Itero right? So I just want to let that sink in guys okay and I'm not saying that for you to show off in any way, Rosh, nothing like that okay? I just really value your mindset. Jaz’s Introduction:Welcome, Protruserati to episode 62 of the Protrusive Dental Podcast. In this episode we’re going to explore some very big themes about as an associate, how can you make yourself indispensable to practice? And what we can learn from Dr Rosh Panju, who is a friend of mine, who is known for many reasons, good reasons but he bought an itero scanner. Now these things aren’t cheap. So what goes inside the mindset of an associate who goes out to buy his scanner versus the associate who refuses to even buy a flowable composite for example. And the associates that are missing out on using the best techniques for their patients just because my principal won’t buy this for me and therefore they’re not living up to their true potential. They’re perhaps not doing the dentistry to the level they want to be and they’re blaming it on the materials that they don’t have because of the principal that won’t buy it for them but then guess what, sometimes you have to make your own luck. So part of the Protrusive Dental Pearl I want to give you is A) make yourself indispensable to your dental team. If you’re an associate listening to this, how are you indispensable to your team? Do you help out with team training? Do you boost team morale? Are you really helpful in collecting reviews for your practice? Because nowadays we can’t be leeches but it works the same way as a principal, are you providing value for your associate? So I think there should be a synergetic relationship between an associate principal and we’re going to cover some of those themes today in this episode. The second Protrusive Dental Pearl, oh my goodness you’re getting two is when I used to work between three different practices I found it really difficult, a real challenge to transport my camera, transport my loops, transport all the composite and stuff that I actually bought a lot of instruments over the years. How do I transport that around? So I’m going to show you one way that I did it. I was using like this big black parrot box. It wasn’t actually parrot brand but I’m going to show you an example, there’ll probably be a video now playing in the background as I’m speaking here but essentially it’s a big box that you could buy heavy duty and you get these like cut out foam areas that you just have to sit down one day and do the hard work and design the measurements yourself. So that you can slot your camera in perfectly. Because what you don’t want to do as an associate is have to dismantle your camera every time you’re moving from one practice the next practice and then reassemble the lens and the body and the flash every time you join a practice or have a barrier to taking photos or in the middle of treating a patient be like oh just one moment I have to go grab something and go find and troll through your bag to find that thing that you use between practices, it’s just not going to work. So this is something that I bought some time ago. It’s been useful to me to transport my equipment between surgeries so I’m passing that on to you as an example. So I hope that helps some of you associates who are working between practices and thinking oh my goodness how can I transfer my equipment from practice to practice. So let’s join, let’s give our ears to Dr Rosh Pan or if you’re watching this on YouTube or Dentinal tubules welcome and I hope you enjoy this episode. Rosh Panju, my friend, welcome to the Protrusive Dental Podcast, how are you? [Rosh]I’m good. Thanks very much. Thanks for having me. I feel like I’m a little bit like an imposter because I’m nothing like your other guest but- [Jaz]Don’t be silly, just like what you did you mentioned you messaged me some time ago because something interesting happened right? You told me for some years now you’ve been listening to the podcast and stuff and I really appreciate our engagements and our chats and stuff. But then you said that there was one episode you didn’t listen to because the title didn’t interest you right? Because it was the airway one right? Because now that’s not important but then you listen to it and you’re like oh my god this is one of the best episodes I listened to. So I actually noticed this in my stats when I look at my stats. A lot of people who use this in the episodes have skipped that one but it was amazing to hear your feedback and this episode Rosh, today will be just like that. Because you think that ‘you don’t have a story’ but I’m telling you I’m going to extract a story out of you because I’ve really seen value in what your story is. So before we dive into that, tell the listeners a little bit just a little bit about yourself before we go into your history and why I think you’re such an awesome guy. [Rosh]Thank you. Basically, I graduated from Liverpool in 2012 and at the moment I’m living and working in Surrey. So I went to Liverpool as an international student and now I’m a dental associate at a number of practices. [Jaz]And you’re doing mostly implant work or restorative or? [Rosh]Yeah, I love anything surgical even from university. Actually in third, fourth year I loved extractions. I loved the surgical side of it. It was always something that I enjoyed. So at the moment I’m doing two days a week, general dentistry and then all the rest of the time I’m doing implants at a number of different practices. So at the moment I’m overall I’ve got seven jobs but only two of them are general dentistry. [Jaz]And you told me something crazy like you do work quite a lot of the days of the week right? [Rosh]Yeah and it can get confusing but I think we’ve got a system now. So I know like the first and third Mondays of the month I’m in one practice, the second and fourth time on other Thursdays are the same. So I do work hard and I think post covet for some reason. I’ve been working flat out for six months, no breaks, I get a few days off here and there but now I think towards Christmas we’ve got my indoors here, it’s nice to just take a break a little bit. So I’ve got a few days off coming up now in December. [Jaz]Well people who don’t know this I’m going to reveal it. I hope you don’t mind. It sucks that your in-laws are coming to you and I don’t mean that because they are in-laws. I’m sure in-laws are lovely but it sucks that they’re coming to you rather than you going to them because what you don’t know guys is that Rosh’s in-laws live in the Maldives right? So this Rosh visits the Maldives on an annual basis? [Rosh]Yeah I do, it’s a brilliant place. When I told my current principal that my in-laws are from the Maldives he just laughed and he said you can’t choose your parents but you can choose your in-laws. [Jaz]That’s a great way to put it. So I think that’s amazing but you know the fact that you go to such a beautiful country. I mean I went there for my honeymoon so that’s just amazing. I always remember the fact that when I first learned about you that always stuck to me. Hey Rosh, the guy who married the Maldives lady, who gets to go to Maldives every year so you absolutely smash that out of the park. So you’ve got a life management strategy all in place. I know that already but this episode is about some unique things that I think associate dentists can learn in particular from your story but also dentists who maybe are afraid to make the jump into private dentistry. So why don’t you kick off with your story because you’re international student, you’re from Kenya, you did your BDS in Liverpool but because of some certain reasons you could not follow the traditional path of going straight and working for in the UK, it’s the NHS public sector but the you had to, you were forced to go private. So tell us a little backstory about that. [Rosh]Yeah so exactly like you said. I came here from Kenya and when you come here to study dentistry from Kenya in my you know my case in particular there was no way that I was going back. I think dentistry in Kenya is very at least in the place where I grew up in Mombasa, it’s just emergency dentistry generally speaking. So I knew that as soon as I came here I wanted to settle here. It was very interesting the first few years. The culture was so different for me. It was a little bit of a shock but eventually I think I adapted and now I’m very comfortable over here. So when I graduated the VT was still covered as a student visa so I was quite lucky. But beyond that there’s only two visa options. One is either you work as a self-employed person but then you have to invest a couple of hundred thousand pounds in a business or you work as an employee but dentists are unique in that sense aren’t they? Because they’re self-employed without having to invest in a business. So there was no visa category for me. So I went into the hospital and I spent about two and a half three years doing the different rotations and- [Jaz]Was it surgical? Was it purely surgical or what kind of stuff were you doing? [Rosh]Six months were mixed, the other two and a half years were all surgical and I hated it literally. I remember I was working in the regional trauma center and the oncology center. My first job out of VT, I started on a Wednesday and I was on call on the weekend alone and literally after the ward round the consultant in fact the consultant doesn’t come on a Saturday. So registrar did the ward round with us he went home and two hours later I get a beep from the nurse patients had a carotid blow out on the bed and by the time I got there the bay was evacuated, all five liters of blood was on the floor and I’m just thinking what have I done you know I qualified to be a dentist. I’ve done dentistry. Day three on the job and this is what I’m dealing with and it was- [Jaz]The patient survived did he? [Rosh]No. [Jaz]Oh man that’s tough. [Rosh]It was yeah. And we had a few of those during the six months that I spent there but retrospectively. I think it’s the best thing I’ve ever done because now I mean everybody will come to a point in their career especially in their early career where things go wrong and I think it helps to put things in perspective. At the end of the day you do mess up, it is the truth. It’s not someone’s life and when things go wrong I just remember that actually that you know things could be a lot worse. [Jaz]I like how you said that because it gives you a different perspective, it appreciates that it’s just teeth okay it’s just teeth and it’s nice to have that and I always make this joke I don’t think i’ve made it on the podcast for so let’s do it now like no offense to any of the professions about to name here okay so hygienist right? Some great hygienists I work with see too much calculus in one place oh my god look at all that calculus right? Then the therapist might say oh my god this my composite has a flash lingually oh my god okay? The dentist will say okay that’s no big deal my crowns have open contacts okay and then another specialty might be like oh my god oh my god worry about these things and then the maxillofacial surgeon was like none of this matters okay because as long as your maxilla is in the right place and everything, you’re breathing is it’s all okay so I think giving you that level of sort of perspective is important to have and a lot of people have done maxfacts I’ve shared that with me actually so it really makes you almost karma in when things go wrong in dentistry because if you get a bit of a bleed while you’re doing a crown fit like yes not ideal but it’s like okay there’s bigger things in this. [Rosh]Definitely 100% Yeah so I’m glad I did it and I know if I was British because in fourth year we will go to the oncology ward and stuff and I think if I grew up here and I didn’t have the issue of visas. I probably wouldn’t have done it and I would have lost out actually so I’m glad I did it and I’m glad that my path in a way took me there. [Jaz]Do you think that you would not be placing implants and being interested in surgical today was it not for your experiences that you had that you’re forced into? [Rosh]Yeah. 100%. So basically after my hospital job they basically went a maximum of three years because beyond that you either become a registrar and go on a training pathway or you go back into dentistry and give somebody else the opportunity to do that. So every year I have to renew my visa and when it comes to that point June-July time I’m like will I get a job? Will I not? And you’re always a couple of months from being you know going back to Kenya and it’s quite stressful because my parents don’t have a home back home and everything they had they put into my education. It’s not cheap being an international student in the UK. So going home isn’t an option so you have to try. So when it came towards the end of my third DCT year, I was like what am I going to do and then my wife kept telling me why don’t you just apply to dental practices and see what happens? And I was like I know how it works, they can’t. They have to apply for a sponsorship license from the home office, but the home office isn’t giving them out. So I just didn’t do it and then she without telling me, went on to the home of this website and went there’s a list over there of almost a thousand businesses that have a tier two sponsorship license from the home office and she went through the whole list and she found seven dental practices that actually were sponsors and she wrote a cover letter and she took my CV and she just sent it to all seven of them. [Jaz]All behind your back? [Rosh]Yeah so towards the end she is when she told me ‘Rosh this is what I’ve done, I’ve sent it.’ [Jaz]She’s a dream woman oh my god wow. [Rosh]Yeah so she sent it and then three responses came back and she was like ‘Rosh you’ve got three interviews’ and I was like wow this amazing. He was one of the practices that I got an interview at and the other two were remote. One was somewhere in King’s lane I think near Northridge and the third one was in west Wales in Naboth and that’s the one eventually that I got and we opted to go for. So we packed a bag from north west England and we went to a little village called Nabath and that’s where we spent three years and- [Jaz]Was this private or was this NHS? [Rosh]It was a private salary. So it was quite a low salary compared to what my colleagues were earning on the NHS. But actually I think salaries in the UK are very arbitrary because where we are now for example if you’re earning 70- 80 000 pounds it’s an okay living whereas in west wales what hours on 35 000 pounds a year you could live like a king out there. You could and the people are lovely, the nicest people I’ve ever met. We are 10 minutes from the beach and it was actually a good place and I would never have gotten that job if it wasn’t for my circumstances I think and we had a great time and I think that was just private, no NHS. [Jaz]How did you feel? Tap into the feelings that you had because I had and you must have listened to episode three when I talked about transitioning to private where I was feeling like the word you used was imposter right? And so I’m putting myself in your shoes, you’ve done purely maxfacts, you haven’t touched a diamond bur, you haven’t touched probably done any tooth dentistry, restorative dentistry in that while and your wife has just all done this amazing puller, pull a rabbit out of the bag trick and you’re moving now to Wales. Well you’re not having any anxieties about but not just private dentistry but just going back to dentistry again? [Rosh]Absolutely so absolutely you’re right because I did my VT, three years in hospital I haven’t touched a drill and now you’re going back first into dentistry and secondly, three years of not charging patients because hospital work is all free and then talking money to patients is a huge barrier. You’re almost apologetic about charging what you’re charging and I don’t think I was that bad but I just feel like sometimes I would tell the patient a crown is 500 pounds and you’re nervous but I think yeah it was definitely quite scary for me. [Jaz]You forget that don’t you? No one talks about that, you all talk about going from maxfacts to maybe dentistry and then thinking ‘hey the lack of dentistry and lack of experience recent experience and having anxieties about that’ but then also yeah you’re right about going back into a system where’s fee per item charging and how you get along that. So how have you because now we can just go down this little channel past, how do you think you can advise someone who’s in a similar place as you where they’re going to position where they have to now charge patients and they’re feeling the same things that you feel like ‘hey how am I how I’m going to do this effectively? How can you get out of the break of the shackles, break free of the shackles of discussing money with patients and any advice you can share? [Rosh]The first thing I would say is to believe that what you’re advising the patient is the right course of treatment for them because as long as you don’t believe it there is no way that they’re going to believe it and as to patients are not they can tell straight away whether you’re off or you have doubts about the treatment. So just believe in your plan yourself first and then the second thing is just you have to say it with confidence to the patient this is it you know there should be no doubt because there isn’t because what you’re doing is right? And then in the beginning what I would say is because in the beginning what happened to me is when I’m telling a patient the cost in my head the filling is 120 pounds and by the time it’s come out of my mouth it’s 95. So what I started doing was just writing it down. It wasn’t computerized where I was and you have a little piece of paper with the cost fee and everything so write it down before I tell the patient to generally think about what the cost is according to the practice that you’re in. Put it down on the paper and then you know you can’t change it and then just be confident the patient needs this and if you actually don’t do it because it’s happened to me if if the patient doesn’t go ahead with the treatment plan they’ll come back for, if they don’t do a filling they’ll come back for an endo, if they don’t do a crown they’ll come back for an extraction. So in my head I’m thinking I know selling is a bad word but I have to convince that patient but that actually they want to have this done for their own good and I think that telling them that you’re not going to change the price is the cost. It is what you’re doing you know for that patient and I think you just say it and I think the more you say it with confidence I think the more the patient believes they need it and I think that’s how I went about doing it. Do you have anything? [Jaz]Yes, no I 100% agree with you. I went through the same struggles yet it’s called the neuro fiscal drag. So from here to here you lose 30 40 pounds like just from just this direction from like that right? So I’ve totally been there man so I would to add on to what you said all the fantastic things the other thing is eye contact make sure you can look patient in the eye like so many people like I’ve seen they give a price and they’re like is because i’ve been in a consultation room is that can that be a thousand pounds and looking away that’s not good okay. And also watch your voice tone so don’t go like high pitch because when you say high pitch it’s like you don’t get it or you’re not sure yourself but if you if you say something on a lower pitch and you say as it is like this could be 800 pounds and we will do this this and this it you know patients can sense it and it’s important and totally the biggest thing that you said I think is that if you do not provide this service for that patient which is totally the right treatment plan for them based on your expert opinion then the consequences will not be good, in terms of the outcomes and if the patient says I want to be able to choose steak and by not by not having this treatment with you they will not be able to meet their own goals then you’re deserving the patient. So I completely agree with you and it’s great that over the years you’ve overcome that in a way and you’ve shared your feelings about going back into private dentistry and that can be quite you know it drives anxiety. [Rosh]Yeah a hundred percent. I think with that job as well I think my principal was quite good. He mentored me well into talking about prices with patients and what he did in the beginning was he would do the checkups, make the treatment plans and then send them to me so it became a lot easier to get into that side of it. I didn’t have to in the first few months I didn’t have to. I mean this was you know six years ago and now it’s a bit different because I do feel a bit more confident in talking about these things to patients. So the mentorship was great in that practice from everything from discussing just customer service management going from the NHS where they’re waiting in any for you for three hours to having that mindset of meeting them at the front desk and walking them in, walking them back out at the end of the appointment. It was good. I’m really glad I went into it. [Jaz Interference]Hey it’s just Jaz here again. Interfering with this episode to tell you that this episode is brought to you by makemeclear. MakeMeClear is my favorite tool to use when I’m presenting a treatment plan to a patient so anything that’s deemed as expensive dentistry, I will make a MakeMeClear treatment plan because they are beautiful, they’re really easy to understand and my patients find it really thorough but not overwhelming. So i’ve been using this for almost six months now and I’m loving the results I’m getting so if you want to check out MakeMeClear go on the website makemeclear.com Join me the 21 day free trial and if you like it use the code protrusive that’s p-r-o-t-r-u-s-I-v-e. protrusive. To get 25% of your plan just join the 21 day free trial and you will see for yourself why I love it so much so check out makemeclear.com to get on that straight away. [Jaz] Back to EpisodeSounds like you gained a lot in that post and look you’re now an associate multiple practices and I just think we need to talk about this following thing like, on some of these Facebook dental groups you see people posting like ‘hey you know what, I would like to use air abrasion but my principal won’t buy it, are there any alternatives? What can I do? Should I use pumice or whatever you know fast forward two years later, oh yeah I’m still not using air abrasion yet my principal won’t buy it okay?’ Just go out and buy the air abrasion yourself right? Just go about yourself and people think okay fine air abrasion 450 pounds 500 pounds maybe if you want to get the poshes one is three grand it’s the Aquacare for example no association’s going to do that some maybe do but you okay went out and you bought your own itero right? So I just want to let that sink in guys okay and I’m not saying that you know for you to show off in any way, Rosh nothing like that okay? I just really value your mindset. Okay I really value mindset and I’ve been a big fan of buying my own stuff because what here’s what happens right? When you start buying your own stuff one of the reasons the principal might say no is because I think new principals, they want to keep their associates happy but they also want to run a business. And I think all principals have had the following happen to them: they buy something that the associate wants and then the associate doesn’t use it or it just doesn’t bring any value to the practice. It doesn’t add anything or anything like that and that is really disheartening right? But then when you as an associate when you buy it yourself and you demonstrate to the principal ‘hey I’m using this daily and it’s actually improving my outcomes and there is an ROI’ even if it’s just like the perception of the quality that you’re giving then there’s no principal in the world worth their salt who when it comes to restocking or rebuying when something breaks to pay for the rest and then buy another one or whatever what do you think about that? [Rosh]A hundred percent, a hundred percent. The amount of times I’ve been to a practice where the- what the fanciest Endo kits sitting around doing nothing, why? Because the new associate doesn’t use this system, they use protaper and then they’ve had to buy them so absolutely it’s quite bad from a principal’s point of view to get everything and then by the time the associate leaves and that’s the other thing about my generation, we don’t stick to a job, we don’t see our failures and we’ve moved on in a couple of years and I think the principal sitting with expensive equipment doing nothing.  Absolutely and I think the whole way this started was when I started doing implants I did my courses, my mentorships. I had a general dentistry position one day a week in a practice in hampshire and I could see the potential for implants and that’s why I bought my whole implant kit, my motor, my surgical kit, condenses sinus lifts everything the whole kit and within six months I made all the money back and by that point basically I was able to it’s one of the few places where I’m still getting 50% as an associate and I think that’s the reason for it because beyond that six months I’ve just made all that investment back and the principal has seen you know the value in it and I think I think that’s exactly spot on what you said. [Jaz]You need to think about Corey Ferran. I need to get Corey on the podcast. I’m a huge fan of his actually, one thing he says is that principal right? They have the fear inside them because they’ve got such a business to run at the end of the month they need to make sure that all the staff are paid right so and what he argues that associates we don’t have the fear alright? And I agree with him sometimes we don’t because it is so easy for us to go home and you know we’d have to worry about if the nurses are sick so much as is a principal’s problem right? In a way and whether the practice is profitable or not as long as you’re associated you get your money on time you’re usually not moaning right? That’s how it is. So it’s a different mentality but when you switch that around and you think like you did like you bought your kit you brought your own implant motor that kind of stuff had you not bought it you would never done the number of cases, had the clinical exposure, the experience, the income from that right? So I am totally with you, Rosh. I think that what you did is fantastic, you make your money back and then you grow as a clinician and you’re able to offer more of those services and I’m sure your principal respects you massively and should anything happen to your implant motor I have no doubt that you’re if you just have a proposition to your principal I’m sure they’d get it for you. [Rosh]100% and the other thing that you said actually about the fear that principals have in running a business, I 100% agree and I think that’s the one thing that associates sometimes we struggle with that we feel in our head that charging a certain amount to a patient is unethical but actually discounting that is unethical to the principal because at the end of the day if the principal’s business can’t survive then you’ve got lots of nurses, receptionists out of a job and the business shuts. So you have an ethical duty to the principal to make sure that the practice is running for the sake of the thousands of patients registered with the practice but also the employees who survive based on that business running. [Jaz]Absolutely and I think if you look at the running costs per day of the surgeries and then you have to factor in all the other expenses then you when you give a discount right even if the discount is 20%, let’s say it’s a thousand pound treatment and you discount 200 pounds and now you get let that patient walk away and they like you more or whatever for 800 pounds. Maybe your personal bottom line may have suffered a little bit but as a practice that’s a huge loss because it’s something like some stat maybe you know it, maybe don’t but I remember listening to it somewhere where like if you discount by 20% this actually affects your final take home by like 50% or something like much greater than 20% because the fixed costs are still there. [Rosh]Exactly. 100%. And a lot of your patients wouldn’t actually appreciate it I think in the sense that associates will put a discount but sometimes they feel embarrassed to tell the patient they’ve actually given them a discount so the patient goes home not even knowing that they’ve had it discounted and you it’s not actually made a difference to that relationship at all. [Jaz]Amazing. So rule number one is don’t give a discount. Rule number two if you give a discount make sure the patient knows they have a discount right? So they can feel that special warmth that you know really you shouldn’t be discounting but if you do at least tell the damn patient that you’re going to discount so they can feel it as well otherwise what a massive waste. What a huge waste. So tell me how do you lug this itero around to multiple practices? [Rosh]So it was a huge decision whether I should buy the flex or the element 2. The flex is the laptop version much more portable and easier to carry around but actually you need a really good functioning laptop. If there’s any issues with the laptop you have to get another one. And it’s a bit slower. It doesn’t look as slick so I was really scratching my head over which one to get but I got element 2 in the end. It’s a lot bigger but it comes with a portable stand, so I’ve got a little suitcase with warm memory foam and all that and it’s not as difficult as I thought it just takes about maybe three or four minutes I’m packing it up, three and four minutes on you know unpacking and it’s quite easy so I’m taking a little suitcase so in my boot there’s implant kits that I lug around with me everywhere and there’s a huge itero suitcase so there’s no room for anything else there and it drives my wife crazy actually. [Jaz]Man, I’ve been through that man my wife was driven crazy by the boxes I’ve had I mean I remember in Singapore I had this massive silver box case and now i’ve got something that’s like a parrot but a cheaper version I don’t have it anymore now because I’m mostly at one practice now and then the other thing is I just keep it at practice but maybe as part of the pearl from this video any associates working in multiple practices and you’ve got loads of equipment I might just show you my setup so I might put that in there. Anything else you want to add about the itero or buying equipment before we move on to your MBA? [Rosh]Yeah, no I think the itero has been a great tool. It makes life easy. The patients love it and when I got it a few months ago my principal actually told one of his colleagues about it and I got offered a job based on that. So I’m two days a week I mean two days a month I go to this other practice and do a little bit of work for them there purely based on itero and I think it’s a little bit like patience sometimes when we ask for a 20 pound deposit for a patient to come in, it’s just getting that little bit of commitment to make sure that they’re committed to coming for their appointment and it’s a bit like that with the associate like I think the principal knows that this guy is committed to getting you know good quality dentistry done and I know he’ll be a good addition to the practice and I think that’s how I got that position and he made my books full, the new principal I’ve only been here you know a few times and he’s asking for more days but at the moment- [Jaz]You deserve that, Rosh. You deserve that because the reason you’re here today is because you know your mentality. People will be listening to this and a lot of people will just not get it, Rosh there are still people who listen to this and they just won’t get it they’ll be like no I still don’t get it how can associate by terror or why should an associate have to buy an itero these people just completely missing the point I’m sorry guys but you’re missing the point. What you done there is thinking a little bit differently to what you know what the norm where the principal should always provide everything for the associate but you’ve seen the benefit you reap the rewards already this led to another opportunity for you and you took it and you’re very happy there, you’re busy there so more power to you and I think there’s a lesson here for all associates, don’t be afraid to pull out your wallet buy something that you need or you want that’s going to elevate your dentistry take you to the next level gain you more experience and you will not regret it I think. [Rosh]Definitely 100% agreed.. [Jaz]Tell me about your MBA. Oh my goodness, this is exciting. Tell me. I mean how do you squeeze it in? I mean this lovely wife of yours who’s done so much in your journey like do you even have time for her? [Rosh]Exactly I’m in trouble a lot of the time but honestly she’s so supportive it’s great it I am lucky in that sense I think but yeah the MBA so I think so growing up as an Asian in east Africa Gujarati I was quite embarrassed with my business skills because we were meant to be some of you know my dad was a was a great talker a great person at you know talking to people in that way and I think I just felt like it’s something that I’m not geared towards and it’s something we never learn in dentistry like you know it’s shocking that we don’t learn in dentistry I think there should definitely be some modules on business in there because even if you don’t want to practice just the running off of practice and some of those things are useful information says so that’s why I did it, that’s why I bought into the MBA and I think I’m a year into it so it’s six modules and a dissertation at the end so I’m module three is due now and I’ve learned so much it’s just amazing. [Jaz]So where is it? Which institution is this MBA with and how do you squeeze it? Is it online learning webinars? What is it? What’s the format? [Rosh]So the MBA so there’s two kinds of people, who do an MBA one is somebody who wants a very good managerial position afterwards and in that case the university does mention but the tuition fees are like 80, 90 grand so I’m one of the top places in London in fact I before joining my MBA I spoke to Nilesh because I think he did an MBA as well and I think he went to one of the top universities for me I just wanted the knowledge I’m not looking to go into it so I went for a cheaper online version. So it’s Arden university, they have I think they have campuses in Birmingham and one in London as well so that’s the university I’m with it was about twelve thousand pounds and I think so far actually it’s really good it’s really good learning the first three modules the things we’ve covered one of them was leadership styles so that’s great leadership styles I think there’s different types of leaders different things work with you know different people that you’re working with so that was something very relevant to us I think when- [Jaz]Can you give us one gem can you share from the two modules you’ve done? One maybe tangible damn gem that you think actually no this could be applied to dentistry and this tip will help dentists anything that you’ve come across so far yeah this is really valuable that might help dentists? [Rosh]Okay I’ll brush over one quickly please one was culture I think appreciating that we live in a global society and learning about different cultures is important when you’re talking to staff and different people but the bigger challenge for me I think was my current module I haven’t finished it yet but it’s on change management and I think change management, it’s just relevant right now because one of our, my colleagues in in my general dentistry practice where I’m working is retiring we’ve got a new colleague and I think the whole system is changing because the practice the way it’s been run, it’s been there from the 80s, all the staff have been there from the 80s. I didn’t change anything when I went there. I just came in and worked and the new associate is quite new and young and dynamic and we want to change and I think the way to do it is quite tricky. You can annoy a lot of people when you’re bringing changes to do anything in life and I think just you know how to just bring in you know two three changes at a time and get people on board with why you’re doing what you’re doing and make it their idea let them own it and do it themselves. So I think that’s working quite well. I think that’s the biggest one for me. Leadership as well I think it was a great module but I think this one I’m only saying it because maybe it’s not that important but it’s very relevant for me I think at the moment. [Jaz]I think change will always be met with I mean I’m sure they talked it will always be met with resistance like any time a new contract comes up right it’s that met with massive resistance right even though it may be better or worse whatever but it’s always met with resistance any type of change covered stuff is relevant and I’m going to give a shout out to my buddy Carm Jandu, who works in the in Glasgow right? He’s a dentist buddy of mine and I love what you said about making it their idea because it’s sort of something that I picked up from somewhere and I told Carm because I told Carm of my current working situation where I work in a practice where we work from 8 a.m till 2 p.m. like a shift pattern and then the next week I’ll work from 2 p.m. till 8 p.m. right and I love this it’s amazing for having a family life and the podcast for me is it’s just wow it allows me to do so much more outside of dentistry as well but then imagine you had to implement this in a in a practice right because this practice i’ve been working has been doing it for like 25 years or something so Carm loved the idea and and Carm was like how am I going to implement this I’m like it’s going to be really challenging you have to double the staff overnight you’re going to meet so much resistance and both we both concluded that hey come we need to do it in a team meeting where you need to sit down with your staff okay not in a manipulative kind of way but be like we want to make two bubbles or we want to make work more dynamic uh has anyone got any ideas and let them come up with it as a team and honestly he’s been loving it so that’s awesome man that’s so amazing you’re doing MBA man honestly it’s a massive respect to you I’m really excited to see what other things you learn maybe I’ll invite you back for part two so you can do an MBA in half an hour with Rosh Panju. that’d be pretty last question I want to tell you and then I opened the mic to you to any other input that you wanted to do is do you sometimes wish that going back to when you qualified that actually you weren’t an international student and then you followed the pathway that was more normal for a UK grad you sometimes think that or are you now thinking different? [Rosh]See I think that would have been an option I think a lot of people that come here the easiest route actually is to get a spousal visa and I was a rebel, I went and did my own thing so that was not an option so I think NHS dentistry I think the only thing that I missed when I because I didn’t do NHS dentistry was volume and I think it’s very good in the first couple of years you’ll do loads and loads and loads of stuff that in private dentistry you probably volume wise take maybe four or five years to cover it’s a good thing and a bad thing I guess. It’s a good thing because you learn fast I don’t know if you read this study once there was I think it was in Japan I’m not sure but what they did is they put two groups of people in different rooms and they told one group you have 12 hours and I need you to make 60 parts you’ve heard that one haven’t you know I haven’t I’m really fascinated go for it so they told the one group you have 12 hours I want you to make 60 pots, a clay pot in that 12 hour time and you’ve got to be quick because otherwise you wouldn’t make it and they told the other group of people you’ve got 12 hours and I want you to make just one part and it has to be perfect. It has to be spot-on everything should be great about it and by the end of it, the group that made 60 their 60th one was actually better than the other groups one part because they’ve been learning from their mistakes they’ve been doing so much of it but by the time they’re doing the last one that it was it was a lot better so I think that’s the one advantage within assist industry that you will do so much work that you will get really good really fast at general dentistry and I think you know when people are asking about courses and stuff in the beginning I think you know that’s one thing to bear in mind don’t quickly jump into just any course there’s maybe a few courses that are are useful like occlusion or communication but I wouldn’t jump straight into complex you know complex big courses like you know implants or ortho or anything like that just carry on doing really good general dentistry and then move from there I think so that’s the one thing I missed with nhs dentistry apart from that I think u I you know I would probably have been an nhs dentist if I had my British rights and everything but I think retrospective there’s no regret for sure 100% I’m really happy where I am now. [Jaz]I’m a huge fan of these stories about how adversity happens and this happens but then that leads you to the next path and because you went and did the max facts that you enjoyed surgery and then implants and then because of your mentality and your grit and your just the nature of the person you are, Rosh. You invested in itero which led you to the new job so it’s like the butterfly effect you know one thing leads to one small action in the past you know leads to these massive waves in the future so I’m a huge fan of believing that and I think for those listening from outside the UK, the NHS is like a a treadmill dentistry and I don’t mean to offend anyone over that but let’s face it you’re seeing a multiple factor of patients compared to in the private sector and is about volume and but the volume what Rosh was saying was that volume is a good thing sometimes when you’re a young dentist because it gets you working fast, it gets you to diagnose fast, it gets you to take lots of radiographs, lots of restorations lots of teeth, extractions whereas if you go fully into private and in a quiet list then how you’re going to get those failures, how are you going to get to making your 60th clay pot right which is amazingly I’m so glad you shared that story with me, not a story that study with me I guess I didn’t know about that but I love it love it for sharing that. Rosh that’s it, i’ve really enjoyed talking to you but have you got any final things you want to say? [Rosh]Okay maybe I think with associates I think obviously dentists you know we’re a small world we know each other well and I think it was on your podcast or maybe on another one where I heard somebody say the best associates are the ones that treat the principal business like their own and I think that’s quite important I think and that’s what I have noticed everywhere you just go in there you treat it like your own face you treat it like your own patients you know and I think that you’ll definitely get successful in that way not financially but just be a very fulfilled dentist because you’re going to work and you know the patients feel like they’re not in somebody in a corporate structure they feel like there is that personal touch the staff feel that you know the same thing like I know sometimes when reception is busy at the end of the appointment I’ll just go into soa book the patient’s next appointment and do everything myself before they go out so reception just has to take money and you know that’s it and I think that’s quite important if you can treat it like your own practice then I think you’ll do well in that practice the principal will appreciate you and I think it’s good for everybody. [Jaz]I totally agree with you if you see some rubbish by the you know on the driveway or practice pick it up know the name of your cleaner that comes every day to clean your practice okay? Know all the protocols for when things don’t go right so you can support your principal and I think I totally agree with you that’s only going to breed the right culture right it’s not going to be the right culture and I think from that people will to see how much you care and when you show the universe you care the universe will reward you in ways you can’t imagine so honestly I really enjoyed talking to you and I told you it’d be an awesome episode and you doubted yourself. So again thank you so much for coming on buddy. [Rosh]No brilliant thanks for having me. I look forward to you knowing your next podcast. Jaz’s Outro:Well there we have it, Rosh Panju, everyone thank you so much for joining me on this podcast it was really fun to record. He’s just a down to earth guy and I think he’s exemplary associate not just because he bought all that you know scanner and stuff you just listen to him and you think that he has something to give, he has some value to give to his practice that he works in and he cares for his staff he cares for his principal. So this is how we think we should model ourselves, be like Rosh. Thank you so much for listening all the way to the end. Check out the next episode with physiotherapist Krina Panchal, where we discuss tmj physio this will absolutely make a massive difference to your patient base if you’re seeing patients with tmd and of course if you haven’t already signed up for the launch offer for the splint course which I’m so excited to release. It’s taken years of hard work to actually put something together that covers everything from diagnosis to examination to which splint when which is the biggest most confusing thing that we have as dentists, how to know which splint is the most appropriate one for your patient. I broke it down and made a system out of it which I am so proud of now so check it out on splintcourse.com sign up for the update. When it launches I will let you know.

No Ferrule? No problem! Dr Peter Raftery, Endodontist, discusses the contemporary use of the ‘Surgical Extrusion Technique’ to make hopeless teeth restorable. Crazy, I know, so take a listen because the science makes sense! https://youtu.be/gXN-2tgxtbU Need to Read it? Check out the Full Episode Transcript below! All the way back in Episode 9 with Dr Aws Alani (Restorability with a Restorative Specialist) we briefly mentioned this technique in passing…which led to a cascade in events and Dr Raftery reached out to me with enthusiasm because I called out to the audience if they knew anyone using this technique! I love that! Essentially you are (gently!) extracting a tooth and then intentionally re-implanting the tooth, except this time you are going to be a little greedy and ‘grab’ some ferrule. Then, a customary Root Canal Treatment 2 weeks afterwards, and you have yourself a restorable tooth. As someone who loves saving teeth, this is just fantastic. We know the science works because we DO re-implant dirty, grotty avulsed incisors of 12 year olds with some decent success rates. Protrusive Dental Pearl: have you used Viscostat clear? It is my preferred astringent and will not interfere with bonding How to restore teeth which appear to be restoratively hopeless aka no Ferrule Compared to SCL or Ortho extrusion – could this be more cost effective and less invasive? Surgical Extrusion technique – either with humble luxator or a posh Benex device I will have to add the resources later – right now I am running late for work! Click below for full episode transcript:  Opening Snippet: So yeah odds of it still being there 12 years later still 93% and that was with forceps removal so I’d argue that the Benex only stands to last longer... Jaz’s Introduction: Okay, so you have your patient they’ve come in, they’ve fractured their upper premolar at gingival level. Kaput. There is no ferrule like you can maybe get your perioprobe inside and feel maybe a millimeter subgingival but there’s hardly any tooth structure left. What are you going to do right? Because most of the times it’s going to be for the bin right? Like it’s hopeless, let’s extract it. Now if you want to get really extravagant you could arrange for orthodontic exclusion which takes time and it’s costly or you can do surgical crown lengthening also incur a fee but also involves surgery obviously and it will also mean that the patient will have potentially black triangles and the gingival zenith of that tooth will now no longer be the same as the adjacent tooth so again that all takes time and money and effort so a lot of times people say let’s just take it out and stick an implant in, a bridge in, whatever. Now what if I told you there was one more way? This way I was exposed to it on social media actually in about 2017 and in 2018. I attended a bard lecture about the surgical extrusion technique and it was interesting. It was Italian chap Dr Bachiani talking about this technique and it was the first time I’ve seen it presented in a scientific way. And then if you remember in 2019 I did a lecture or a podcast with Dr Aws Alani restorative consultant it was restorability with the restorative consultant and I discussed a technique whereby you can partially extrude, surgically a tooth and then gain ferrule and restore it. And I said in the podcast hey I don’t know if anyone’s doing this technique in the UK please get in touch if you are. And fast forward a year someone’s doing it in the UK and they’ve done a lot of cases and he got in touch so Dr Peter Raftery is joining us for this episode. Protruserati, welcome this episode on the surgical extraction technique aka the partial exodontia technique and this is going to blow your mind if you’ve never been exposed to this you’re going to think whoa how is this even possible? It’s basically taking that aforementioned broken down tooth and extruding it surgically so be it with a luxator or with something called a benex device and now you let nature heal it maybe with a splint okay like one of those wire splints not the kind of splints I bang on about all the time. And then a few weeks later you go back in to do a root canal and by now the tooth has fully healed which is amazing like biology is amazing right? And now you have a ferrule and you can now restore this tooth which was otherwise unrestorable. So today with Dr Peter Raftery, who’s an endodontist based in Portsmouth we’re going to be talking about this technique. He’ll walk us through the all the stages of this technique, case selection, things that can go wrong, what advice he would give to a person doing it for the first time and we also take a look a little bit at the evidence space as well for this because I think this has a place in general dentistry and now we know that implants are not the panacea we once thought they were therefore I think this technique could be pretty worthwhile even if for the odd case here and there maybe for us upper second premolar as your first case that you want to just surgically extrude it and give this tooth a second breath of life. So I’m going to dive into the interview and before I do obviously I owe you a Protrusive Dental pearl. What do you guys dip your retraction cord in or what do you use to get hemostasis? I’ve used a lot of things in the past like ferric sulfate, expasyl that kind of stuff but you know what my favorite still and this isn’t sponsored or anything this is just me sharing for those who don’t know about ViscoStat Clear is 25% aluminium chloride and what I love about it is the hemostasis that it achieves without that horrible brown nasty residue which you can sometimes get with ferric sulfate. And also did you know that ferric sulfate can interfere with bonding. So any time I’m doing like anterior crowns and I’m using retraction with cords, I’m always going to be using ViscoStat Clear in fact anterior posterior I’m just using ViscoStat Clear everywhere I ordered this big tub of it and my nurse knows that it’s the only astringent I guess I will use so a big shout out to ViscoStat Clear which has just been brilliant and I’ve really enjoyed using it no more horrible brown mess. So I hope you enjoyed that material selection pearl of ViscoStat Clear. Let’s dive into the episode so we can learn more about this surgical extrusion technique aka partial exodontia technique. Dr Peter Raftery, welcome to The Protrusive Dental podcast, how are you? [Peter]Very well, thanks. Excited to be on. Thanks for making it happen. [Jaz]No. Thank you because what we’re talking about today is something really cool and at the moment I would say it’s very much niche, it’s very much eyebrow raising. Some people, maybe an implant dentist, might say what’s the point? And basically what it is and there’s so many different names for it but before we get into the beautiful part of the sort of discussion where we talk about the technique and what it’s all about is just tell us, set the scene for us a little bit, Peter, where are you based? What do you do? What’s a normal week for you? [Peter]Yes, an endodontist. I’ve been a trained endodontist for maybe 10 years now. You sort of forget after about three or four don’t you? But I am down in Hampshire, the majority of my week is my endo practice in haven’t and I’m a day a week in Central Portsmouth one town over like a micro dental school I think it’s called Portsmouth dental academy and it’s primarily involved with training nurses, hygienists and therapists. But my involvement is with King’s College London, so that’s the biggest dental school I believe, maybe in Europe and I assume that the massive final year has 160 of them. They can’t all get a dental chair maybe at the same time. So Portsmouth is called their outreach one of two places that final year king’s college London undergrads come down and I’ll supervise those final years primarily in endo with a bit of everything so that’s my one day week and that’s how I got to hear about your podcast actually. So it’s whilst endo can be a little bit blinkered you know single not quite single-handed practice I’ve got an associate but you know you are at the cold face and you’re a little bit head down whereas I love my Thursdays in that I have colleagues and we can chew the fat and stuff like that. And over lockdown, everyone turned to podcasts didn’t they? Everyone tends to research them out and listening to them clearly you’ve been producing them and a colleague David Brown, he said to me, Peter, the thing you’ve been banging on about was mentioned in a podcast I was listening to last night so I then look it up? And I don’t know. A few days later I was instagramming you and you know four months later maybe we found a date that could fit so. [Jaz]You’re a very busy guy. You’re very difficult to get hold of, Peter. How many kids have you got? [Peter]One of them they’ll be wandering any minute now. Like bbc style but yeah down here absolutely married to gp four kids. [Jaz]Four kids, amazing. Fantastic, well I’ll set the scene for those listening in a moment. You quite touched me because you had been told about that episode and it was something we sort of mentioned in passing in towards the end of the episode and the episode was restorability with the restorative consultant was Alani and I’d mentioned this to him and I forget whether he was very familiar with this technique or not to be honest with you. But I mentioned it to him because in January 2018 I went to a lecture at the BARD, the British academy of aesthetic dentistry and there was a chap I’ll read his name. It was a Doctor Ricardo Betchiani and I probably said that horribly wrong but that was one of the first times I’d seen a scientific presentation on the technique. So pretty much two years ago now I saw a scientific presentation but the first time I ever saw it was on Facebook and I was gobsmacked right? But then after seeing the scientific literature and then now seeing your cases on social media, it makes so much sense but before we dive into the nitty-gritty. Can you just tell us what the different names for this technique are and what essentially is it? [Peter]Yes, so I know it as benex and we’ll call it benex Benex is, what’s the word portmanteau I think of the guy’s name. The Belgian I believe that maybe, let’s say, invented it. And extrusion or extraction because it’s a method or a device for extruding or extracting teeth and I have my endo practice and we’re just an endo practice. So I don’t have all the other specialties nearby and the reason I mention that is if I did I would maybe say it doesn’t look savable but you know what next door is the prosthodontist guy or the oral surgeon guy or whatever but so I do feel this real, I do feel a duty maybe? Even more than most to try and avoid saying I can’t help to the patient or the dentist okay? And one of the style of case would be the old-school post and core crown that has no ferrule and the white bit has fallen out and so it’s flush at gum level right? The dentine is flush at gum level and yes a restorability and avoiding saying I can’t help were a big deal and I heard it was at a British endo society meeting that the distributors of the benex device had a stall and kind of sowed the seed and I attended a course maybe a year and a half ago now with a professor from oral surgery from Birmingham Dental school Thomas Diedrich. Dietrich, a German guy and he was great and there were endodontists on it and there were implant dentists on it. The endodontists are interested I guess in extruding let’s stick with those decoronated teeth, extruding the tooth to hey presto, get ferrule. So now it’s not unrestorable and the implant dentists on the course were most interested in the most atraumatic of extractions to minimize I suppose the need for bone grafting or delayed what’s the word placement while they wait for the bone I don’t know what I’m talking about now when it comes but I suppose delayed placement of implant because they’ve lost the bone or something or that kind of thing. Atraumatic extraction for those guys and for me it’s extruding teeth. [Jaz]Well sometimes to understand a new technique, we have to look at potentially new techniques that are different, it depends on what the origin of it was and we’ll get into that but sometimes to appreciate a new or a different way of doing things, we have to look at the alternative. So the alternatives of a tooth let’s say an upper first premolar okay common tooth to have fractured at gingival level maybe you’ve got half a millimeter of ferrule palatally and mesially and then the rest is maybe equigingival and you can maybe in the sulcus feel an extra millimeter but for a lot of people that’s unrestorable so extraction and maybe for an implant. For some people if you wanted to, you can do surgical crown lengthening right? You can cut some gum away, cut some bone away and hey presto you now have some ferrule and I guess the other way I mean those are the real two ways I can think of to make. Oh orthodontic extrusion, so using orthodontics to extrude a tooth but what you’re talking about is surgically extruding a tooth. Now you mentioned the benex device but interestingly the lecture I went to in 2018 the guy was just using a laxator right? Which has his risks we can we can talk about hazardous risks So imagine just luxating a tooth until it’s just loose and you can almost just pull it out but instead you then suture it and you tack it to the adjacent teeth and you let biology do the work, the root canal happens and for you I want to find out from you exactly when to do the root canal it’d be nice to hear the sort of sequence of things. But then it’s a very innovative way I think to make an otherwise unrestorable tooth or needing a very extensive other slow work to make it restorable so that’s amazing. So tell us how many cases have you done and tell us a little bit about how you found it. [Peter]So the course I went on was maybe a year ago and I’d say so. Funnily enough he’s running one soonish. By the time this podcast goes out we’ll have the info for those who are interested. It is probably good timing but I about a year ago when the course bought the thing there and then and I maybe have done I’d say 20, 18, 20 something like that I’d say. What I love about it is there’s nothing electric, nothing battery, no battery I’m no batteries, no iPads, no nothing rechargeable nothing to bluetooth to anything else and I love that it does rely on some really old school stuff that everyone is familiar with. So I’m talking probably everyone has in their window, I do of their practice. What to do if a tooth gets knocked out right? Kid’s tooth knocked out everyone knows, put it back in again. So avulsed teeth on we all know can have a second lease of life if managed correctly and everyone also knows that chief among those priorities is get it back in quickly. So teeth that are extra alveolar for a short amount of time have a pretty rosy outlook for the future. And another thing that really relies on is supposed to in a ParaPost, it’s a lot like in a ParaPost, so we’ve got this, the upper premolar roughly drill down to gum level you can certainly see the root canals, let’s say the pulp chamber is exposed in example the roughly decoronated example where we mentioned so I will then take an x-ray. I want to know that the roots are not very curvy, not like a banana because I’m trying to scooch this thing out so it is broadly limited to straight-ish rooted teeth. [Jaz]What about not just the curves, what about if they’ve got a bulbosity at the end that is also going to complicate matters. [Peter]Yeah I had a nice one just the other day. It was about the most curved one I’ve tackled and it came out without a bother again. I’ll try and prove and I’ll try and show you what I mean so 18, 20 cases I’ve got a wild vast experience. I haven’t had the big bulbosity. I might well resort to the more widely understood accepted known surgical crown lengthening but you get the extra long white crown that no one loves and the periodontist fee is big along with my endo fee along with some crown placing fee. [Jaz]Might as well have an implant. [Peter]I don’t know whether I think that once I was especially as endodontists have to involve a specialist periodontist and there’s a crown in the in the offing as well whether it’s realistic economically or whether the patient’s going to go you know what I’ve done a back of the fact packet some and an implant would suit me better or ortho extrusion, we’re talking months. The one time I formally saw that as realistic from a specialist endodontist down here, it was three four months I’m pretty sure it was so long ago but I’m pretty sure it involves actual train tracks not just like three teeth I think it involved train tracks and certainly the build was even bigger. So I found it to be the most realistic instance. So I’ve got this tooth again. I can see the canals so I will then put let’s say a gate glidden or an essex. [Jaz]Can I stop you, Peter? If you don’t mind. I can’t because I’m liking the journey I want to put into chronological order. So you’ve identified your patient ,you’ve checked the PA, you’ve noticed that okay it’s not curved which is great you’re now going to use the benex device and maybe towards the end you can share a case showing how to use it and for those listening on the podcast I’m not going to bore you guys by having too many visuals for you to listen to it that wouldn’t make sense. So go back and check the video and check Peter out on instagram and whatnot is social media to see the images whatnot but I think it was still interesting for you to listen to the workflow and be exposed to this. So you’ve got your PA, you’ve used your benex, you’ve got it extruded now. Let’s have a little debate here because some of the images you sent me, you took the tooth entirely out but I would say to you, is that really necessary? Can’t you just extrude it a little bit and keep it in and therefore you don’t get any air time of the cells? [Peter]Sure, yeah so desiccation or what have you of the PDL is the biggest deal of all but the argument and it’s a neat one and it’s not mine, I’m just parroting the what I heard on the course but it was that you want to know if you’ve perforated this tooth as you’ve sunk down the canal this like a ParaPost drill, it’s a lot like a ParaPost drill. So you want to know if you’ve perforated it, I guess you might want to know if it’s cracked. You perhaps want to know if the root has come out intact or whether that banana hook on it has snapped off and those are the things. Kind of inspection of it really- [Jaz]That makes sense because I sort of forgot the long sort of post-like ParaPost-like structure of the benex and that makes sense now and also premolar is a teeth that raises, it’s acceptable to cracking and to be able to see that visually. I didn’t appreciate that before and now I can see that so you’ve inspected it, you’re going to put it back in now tell us what happens now. [Peter]Yeah so the device that is a winch-like thing that you’ve because you’ve again you’ve sunk this ParaPost style, drill down the middle and you pick up the matches in dimensions. Let’s call it a screw because it then does tap down the hole you’ve drilled it does tap because they’re very sharp threads it taps in and you get this wonderfully firm grip and then you attach that we’ll call it we’ve done a ParaPost like hole and we’ve screwed the screw down and the screws got a very bulbous head on it and you attach that bulbous head to something that looks a little bit like I don’t know fishing reel but you then dial this, turn this device and it very very slowly winches that winch is on or winches at or yanks at that tooth and eventually I’d say four five minutes it just gives. Suddenly the tensions off the, start to see a little bit of bleeding in the sulcus you put away your apparatus, benex and you then pull out on that screw you then you’ve got the tooth on the stick and you inspect it and you get a photo for instagram and then put it back in again. You put it back in again less far so that you’re happy with the amount of supragingival tooth structure you’ve now got. [Jaz]And how much are you aiming for, Peter? How well are you aiming for? Supragingival?  You could be a little bit greedy you know? You could just be ‘hey you know I want a little bit more’ I mean how much is good? [Peter]I’ve got some of the cases I’ve got, I’ve only noticed in hindsight if that makes sense but there’s no post involved you’d think. So having done the benex to gain an adequate ferrule, I’ve then found I didn’t need a post whereas I would have thought I’d be maybe relying on a bit of extra ferrule and a post and I really switched on restorative dentist but it hasn’t required the complication of a post which has been great so far. So yeah from the x-ray you’re identifying your non-curvy roots, bulbous roots and usually on these anterior single straight rooted teeth you’ve got a wealth of root buried in bone. So you can’t, you can be greedy-ish. I guess case-dependent but you put it in less far the average seems to be an extrusion of order three give or take, two three four millimeters and then you put it back in. Then I suppose you unscrew your screw so at this point you’ve taken it out had a look clearly you don’t want to touch the ligament which is why I’m emphasizing that you’re holding the stick and you’re not holding the root because these cells these nicely cleaved pdl cells are all important. Put it back in again and maybe now’s the time to mention I suppose you haven’t gone at it with forceps so you’re not risking damaging the cementum because you know there’s that no one understands external cervical resorption very well, me included but cemental damage is proposed as one of it. So with your full steps and you’re grabbing you haven’t damaged the cementum I know that when teeth are decoronated and I go after them with some forceps I’m often tearing the gingiva a little bit you know meaning to or not but if there’s no two structure there super gingivally that’s why we’re doing this any in the first place. I think I’m often tearing a little bit of gum. So with the benex you’re avoiding the soft tissue damage and the heart tissue damage. And maybe the final point if I was cheerleading for it would be, can you imagine like the cross-sectional shape of that upper premolar? It’s not circular. So if I’ve got my forceps on it and I’m rotating it, because it’s not purely circular. It’s almost like an anti-rotation feature that you sometimes see in a post. When you go to grab that post that hasn’t Endo on it, you’re turning it you’re like ‘oh my gosh I’ve snapped you know, you’ve maybe snapped..cracked the root but then so when you go to grab on the course,one of the most impressive videos was a guy trying to atraumatically but with forceps extract an upper anterior tooth. But you could see in slo-mo as he rotated it with great skill but as he rotated it you could just see the buccal plate break because it’s vanishingly thin as you rotate it it’s not circular so it got a bit fatter on I don’t know what the physics or the maths term phrases. The circumference got bigger suddenly and it just broke that buccal. So mark the benex way, you’re avoiding that hard tissue damage, soft tissue damage, you put it all the way out, put it back in again. Less than 15 minutes is the absolute key number. The longest I’ve ever got near was about eight minutes because that’s how long it takes my tricalcium you know my mta or biodentine to set. I’ll come back to that maybe later but more often than not, if it’s a case, a simple case just one where there’s no tooth structure, the mta or biodentine I mentioned was like when I’m repairing say a perforation or an external cervical resorption defect or that you know I’ve got to get at a defect which is underground so to speak like external cycle absorption or something like that but if it’s just. There’s not enough tooth structure left and that would be the case to start with, no carries just a decoronated tooth. That’s someone to start with. Those they’re coming out for just as long as it takes to take a photo and inspect it and it’s going back in so we’re talking for two minutes. [Jaz]Which makes it make sense you want to minimize extra time as much as possible and I mean that’s the most efficient way. [Peter]And when you see risk or decreased prognosis, stratified you’re always going to see the zero to sort of five minutes so I would argue you got like if you’re four minutes in and out you’re as good as zero minutes you’re in the best. So less time, the better but you do want to inspect it and put it back in. The shorter the amount of time the less coagulum you might be dealing with. I have found maybe one of those eight minutes waiting for biodentine to set. It’s a little bit harder than I would have liked putting it back in I don’t know why but I wonder if it was a bit of a jelly-like clot I wonder but it goes back in easy you then de-thread the screw from your tooth and then you are splinting it which again I’d go back then to trauma guidelines that’s probably a rigid, no semi-rigid ie flexible, two weeks- [Jaz]One tooth either side or a couple of teeth per side? [Peter]Well, it would be one. I’d say one one either side. [Jaz]So if you’ve got the upper premolar you’re putting on the canine and the second premolar and you’re attacking some composite under any sort of enamel dentine and cementum maybe whatever you can get hold off and you’re probably being quite generous with imagine with the composite on the extruded tooth because you want as much locking as possible? [Peter]I wish I was better at bonding so everyone will be better at me than the splinting of it. So I’ve found a top tip for beginners at b2 with locals kicking in, I would be etching and bonding when ever the environment’s bone dry and everyone’s calm I would be etching and bonding my two teeth next door and perhaps even applying a layer of composite there and then so that when the tooth is out and it’s a little bit mild chaos isn’t the word but mildly stressful and there’s bleeding crucially, inevitably then you want to leave as little bonding to do at that point. So I’ve learned that the hard way I learned that myself. [Jaz]That’s the top tip right there. Has ever happened where you’ve started to reintroduce the tooth back in and then blood has just squirted out the socket onto the adjacent teeth and you’d have to start the bonding again? [Peter]Yeah absolutely I’ve had some 20 minute overruns trying to etch something for the 15th time. No one’s as bad at etching than me and adhesive dentistry. All my buddies were the one thing I’m going to be texting them is tell me again, how you get good- [Jaz]I appreciate that insight. This is very very honestly good of you and this is the nitty gritty details that we love on this podcast but I want to ask you any sutures because the Italian chap Dr Bechiani, he because A) he wasn’t using a benex and I’m sure he’d love the idea of using benex because even in his lecture he said that he uses a luxator and he’s very gentle takes his time but you have to warn the patient that hey if by using the luxator a good chunk of the tooth breaks away which it can do then it’s capiche we’re going to commit to the extraction whereas with the benex, yes I’m sure there’s risks and issues and perforations and little things like that could happen in the benex but it just seems like a much smarter idea but then what he would do is suture either side and I actually forget whether he used a semi-rigid splint he may have just relied on suturing the papilla either side and that keeping it still. Do you think that’s enough? [Peter]A bit like a, it almost looks like a spider web or like a sort of holding it in place and that’s what you see don’t well that’s what I see when when you’re looking at these ortho transplantation cases where they’re pulling out a I don’t know partly partly formed eight to put it into the say the you know a socket of a knocked out front tooth or whatever something maybe a bad example but yeah you’ve seen them stabilized with sutures but no I’ve and funnily enough one of the papers in the journal of endodontics recently Cho was the..C-H-O Intentional replantation. She was doing it with forceps and the interesting point was in the majority of cases there was no splinting whatsoever it was a snug fit yeah you’d be surprised yeah just a small fit. I haven’t tried that I’ve just are pretty dogmatic I’ve stuck to this fishing wire and composites and I’ve found that when I left it six weeks the teeth would come back rock solid but with no evidence that I’d ever put my splinting in the first place it had been chipped and broken away much to my embarrassment but the teeth without fail rock solid not bad rock solid not ankylosed rock solid but just what incredible-ly, beautifully as they should be with all that ferrule and everything’s nice and pink and healed. But I’m nibbling away at that because you know in the sort of private density world patients want you know done already and the trauma guidelines are four avulsed teeth two weeks semi-rigid and my splints aren’t lasting so I’ve moved towards two weeks and I would say that I’m finding my splints are there more often but the teeth are a little bit wobbly. So again my beginner’s top tip would be to start their first couple of cases would wanna be probably about a four week review, remove the splint I would say four weeks later because I’m convinced they will find the teeth to be unequivocally rock solid and it will absolutely be very quick proof of concept. [Jaz]I think the first time you probably see that after doing this the first time you see it come back rock solid you’re probably like whoa it actually worked right? So that’s crazy and the second thing is I just want to know- [Peter]They say there’s nothing new under the sun. We’re effectively talking about replanting avulsed teeth but I feel like I’m almost what’s the word privy to a secret that no one else knows about I’m banging on about it but I just feel yeah ultimately we’re talking about avulsed teeth and putting them back in again and then being amazed that they last even though we’ve been telling school mums to do it forever but yeah it really does work and it’s so atraumatic that you know it you we shouldn’t be surprised but- [Jaz]It’s a very very valid point. One idea I just had, just speaking to you the restorative dentist in me is just thinking right? Because you said in private practice you know patience don’t want to have a gap so if someone’s broken their fore and likes to quickly do something and you’re like well I kind of have to splodge it out a little bit and then you have to be semi-toothless for four weeks or whatever. When you’re doing your splint, how about doing your split and then just building the tooth up in a massive blob of composite at the same time just shy of any sort of occlusion but then also telling the patient, ‘do not chew on this tooth at all.’ Have you tried that? Is that something that’s worth trying? [Peter]Yeah well now I’ve shaving down the period to two weeks is okay. The patients are generally delighted and a little bit more forgiving. I’m sure that’ll wear off as it becomes more old hat but I have found that they will generally go from a decoronated gap like I mean actual gap and suddenly you’re filling two thirds of that gap with tooth colored tooth structure and you’re right the whitish composite that I went into endo because of a lack of interest or ability with cosmetics. So I imagine your hunch is accurate but I couldn’t say that. [Jaz]It’s just something I probably will try when the right case comes along. Let’s talk about longevity. What does the evidence say? Tell us, share with us, what is the existing evidence base for this and what can we learn from the evidence based? [Peter]Yeah so the.. I’ll go with this CHO paper because it’s high imp it’s in a proper journal, it’s recent peer reviewed and so with forceps extraction they found that or their hunch or their stat, their statistical thing was for 12 years. Odds of 12 year retention and 93% spectacular right? 20 odds of it still being there 12 years later, 93% and that was with forceps removal so I’d argue that the benex only stands to last longer when it comes to the things we’re worried about is his ankylosis I guess. So I would say the way we’re handling this too gently and we’re putting it back in quickly those figures didn’t surprise me. Now things like endo and endo unraveling it or I get the thing that’s kind of within our remit that’s like off, if that happens it’s kind of my fault if I introduce too aggressive a crown root ratio. So I’m sure there’ll be some mechanical failures perhaps an over-ambitious project as if it were a tooth candidate tooth. But there might be presumably a little bit of ankylosis external replacement resorption. But I would argue that answering questions like very good longevity is what I’m expecting. I’ve found all of them to be rock solid as I’ve seen and I’ve been doing it just over a year and I’ve had a good few I review my under six months so I’ve reviewed I’d say about three of these cases so far and they don’t sound tinny ankylosed, they’re not on mobile or they’re the right mobility and I could see a nice outline of a root on my periapical. So ankylosis is the only thing I’m worried about to date the endo that I’m doing. I feel like a responsibility or I’m able to eradicate the risk of external inflammatory resorption or things like that. So yeah the things that worry me I suppose are ankylosis and I have but I’m really encouraged by the evidence from that paper in the JOE, in journal of endodontics but this technique has been published in the BDJ by Thomas Dietrich, the professor of oral surgery at Birmingham dental school. It wasn’t kind of a longevity thing but yeah it’s not as once you scratch the surface of pubmed it’s not as novel as you would both think it is. [Jaz]Well I’m glad you shared those with me in an email exchange so I’ll put them on the Protrusive dental community facebook group and also on the website on the show notes and prior to you sending me all that. I only knew of the 14 year case report by presented by that gentleman who presented and he said some great things an interesting question I asked him in the audience actually and for asking the the best question that I won a RelyX Fiber Post but thank you nick sethi and the bard team. But the question I asked was in the trauma guidelines at the time I believe an avulsion of any sort I think they said antibiotics is a good idea and I sort of said hey do you think antibiotics would help? And the guy was like no we don’t think so. And would you agree with that? [Peter]I’d agree with them with the lack of a need for antibiotics if I’m honest, I’d because yeah you’re right with trauma guidelines but we talk they’re probably the antitetanus and it is this dirty tooth etc but again I’m encouraged for benex to outlast traumatize in avulsed teeth because there’s nothing atraumatic about an avulsion right? There must be I’m thinking a cricket ball in the mouth, there must be a massive amount of crushing on the palatal aspect of that root and probably a bit of alveolar bone fracture as it’s knocked out intact whereas this can be the benex the winching and it just is like I don’t know shucking watermelon it just comes out. It cleaves out ever so neatly and you can really imagine that not a lot of structures were harmed during the making of this instagram case sort of thing. So you really are bypassing that cemental damage that maybe the alveolar bone fracture the muck, maybe this got into the sulcus and all those things. [Jaz]Quick question actually I just thought of. At the time where you successfully extrude the tooth do you ever get a ruler and quickly put it and measure the working length? [Peter]So because I’ve take, no. [Jaz]Is that a daft idea? [Peter]No. My bruiser ex says trustee for that job later but the the academic that I’ve been bombarding this professor with cases trying to notice me notice me but he said oh look oh glad to hear someone else loves it like I do. And he’s asking me to maybe keep some sort of you know formal of how much I’m you know so there might be a bit of measuring he wants to know how much I’m extruding it and all but so far I’m just kind of doing it by eye and I’m getting everything supragingival. [Jaz]Which is your bread and butter. You’re an endodontist; this is something you do day in day out. Amazing. I think we’ve covered well what the technique is, some of the nuances of it before I get to kindly share a case for those who will come on later to on dentinal tubules, claim cpd, watch the case that sort of stuff. If you can share me myself included I’ll they’ll come to a time then the reason I haven’t done it yet because covid happened and we’re all out of practice and I’ve joined a new practice and I’m waiting for that right case to come along and you being an endodontist you probably see you get much more exposure to this sort of stuff. I’m waiting for the right case to do it. I’m more than happy to give it a go, it’d be nice to have a benex so I would feel much more confident with the benex than current situation I’m probably using the the finest luxator with care like Dr Bachiani did but ideally with the benex but what advice would you give someone like me, you already gave a few little nuggets about the you know pre-etching, pre-bonding any other advice to a first timer? [Peter]Let me think, so yeah the benex kit it’s expensive but so it’s weight surprise is just more than one thousand pounds all said and done. [Jaz]I think that’s great because an implantologist because I think implantologists can use it, the endo when you’re doing Endodontics and in this way partial extrusion or surgical extrusion I think the application is brilliant but I’m sure even with the tricky extraction you can just set this on and then let it help you as well. [Peter]Yeah absolutely so on the course the implant dentists were learning about sectioning let’s say an upper molar into the three roots and taking them out individually but yeah so if you want to get benex about this atraumatic extraction then yeah you’re sectioning the root but it’s a thousand pounds so yeah you’d be pre-bonding the tooth either side so I would have my lumps of composite either side you don’t want to be doing your first etching and bonding when there’s blood around. An ideal tooth would be probably a five because there isn’t the burden for the aesthetic you can more easily persuade someone who’s effectively not got a five so you don’t have to go to the ends of the earth to give them two weeks worth of some sort of cobbled together aesthetic thing there. I would also suggest that and I’ve stuck to what I learned on the course. I’m splitting my involvement into two visits because if the tooth is cracked or perforated or I’ve perforated it or yeah, you wouldn’t want to have spent so much time on it so by that I mean I am on visit one I’m extruding the tooth and bonding it yeah splinting it. And two weeks later I am doing the root canal treatment but clearly that second appointment goes by the wayside doesn’t happen if the tooth was two weeks earlier split cracked perforated or whatever or just proven to be unrestorable. So you wouldn’t want to let’s say quote or promise or charge or set aside the chair time for the whole thing in one go you’re sort of extruding it and then two weeks later you might get reception to call the late the person two days before is the tooth still there, our appointment in two days time you know you don’t want that wasted chair time for them to bring in the tooth in there in a little ziploc bag. So you’re sort of splitting treatment into two weeks apart. Let me see. So I’d recommend some stiff putty one of my lab, one of my clinical dental technician buddies put me onto some lab putty which is very hard I think sure hardness is the scale and the bigger the number the better. In the case that I sent you with the blow by blow steps and stages, you’ll see that you you sort of put a sectional impression tray full of silicon onto the tooth and that and one either side and it acts like a little bit of a buffer or a bumper or a barrier as you start to apply this pressure because as you know newton’s laws the tooth getting yanked up there’s a fair bit of pressure intruding so to speak those teeth either side and I don’t think you’d want to have something very soft. It’d be a bit bouncy and teary you want something a stiff silicon. [Jaz]And that’s specifically to do with the benex technique obviously? [Peter]It would be. Beyond that- [Jaz]I think those are some great gems there so Peter can you show us a case so that those people who once they’re off the podcast and they want to go home and catch it there’s some visuals they can check that out as well just share with us a case that you have. [Peter]Lateral incisor, post crown decoronated unrestored teeth either side. A little bit of a prominent lower incisor with a wear facet on it which okay so that’s tough enough and pre-operatively we involved a prosthodontist in this about could we you know would an implant work and all because I assumed that this crown gave up the cusp after the proclamation of that lower incisor bashing on it but not a lot of ferrule I hope would agree the the gingival margin wouldn’t afford in my view to go very far north relative to the teeth either side not you can see it in all but you you could you would maybe image two can you see this? There? I’ve taken away the temporary filling and again there are not a lot of two structures left, that’s all. Next picture. The tooth out so uh a lot of root there which is the whole point right a lot of root nothing supragingival but a big long root was sat in there this is my sort of stick as it were and I’m pleased to say that’s nicely parallel with the long axis of the tooth and there was no metal glinting out the side I was pleased to say because before I put my ParaPost style benex drill down the canal I’d flared it a little bit with let’s say a gates glidden or an orifice flare that meant I felt that my benex drill preferentially fell down the canal rather than created its own path with a little bit of apical pressure it. Wanted to stay centered in the canal that I’ve done a little bit of flaring of more so than it wanted to wander off into a perforation. [Jaz]Brilliant. [Peter]Next up I hope was six weeks later and subtle but that’s the yeah it’s just nice pink gum and I’d say a crucial bit of ferrule there. I won’t dwell on it, I’ll just bring up the next image. [Jaz]I mean no but that’s great because if you’ve gone for a surgical crown lengthening there as you said you’re changing yes this might be a low lip line patient but imagine when it’s a high lip line patient or a medium lip line patient then you’re changing the gingival zenith on the central tooth incisors you want as much symmetry as possible so that is phenomenal you maintain the exact gingival symmetry to the adjacent tooth that’s amazing. [Peter]And I couldn’t as you can see, I couldn’t have excluded it more in terms of it bashing off that lower front tooth. It couldn’t really have come out more now the restoring dentist has got a job on his hands but we sort of agreed pre-op and again here’s the x-ray long root. In terms of trying to justify this you could maybe see the size of that little black triangle pre-operatively was more or less well tiny and I’m sure that this last image in this particular whatever will show it. This is a post-op and it’s a nice big long triangle idea I guess just of a decent amount of ferrule dentine there. So an implant my understanding of implants is that they’re not a walk in the park when there’s going to be from that lower incisor a lot of loading on it, it was enough loading to knock out that post crown after all. Resin bonded bridge likely go the same way so even though the restoring dentist has got a job in his hands I think having you know a pretty decent bulk of natural dentine will be the least bad option that was our thing. [Jaz]Fantastic. No, I really enjoyed that case and if you don’t, would you be happy for me to share that with the listeners, do you mind sending me the image because I want in my introduction I want to say hey look at this radiograph that this tooth is unrestorable right? But then look what yeah the likes of peter could do. [Peter]Yeah and what’s the word ready presentable images? [Jaz]No, that was all fantastic- [Peter]And that was an ideal one because it was a bloke you could probably tell and he didn’t mind the gap and there was no carries, no resorption, a nice long root. There was no crown root ratio for me to worry about and there were natural teeth either side so my etching and bonding to enamel is ideal. That was perfect. [Jaz]It’s like a unicorn patient minus the cluster div two but otherwise it was a pretty perfect patient Excellent. [Peter]So yeah, banging on about it a lot I think it’s great. Yeah don’t forget we’re just talking about putting avulsed teeth. An avulsed tooth for two minutes and putting them back in again but I’m just crazy infused about it. I just find that I’m saying to less people less patience and less dentists I can’t help which is good. [Jaz]I think it’s amazing and I’m so glad you’ve introduced this technique to people listening and watching and you have definitely deepened my understanding of the technique and I just love the benex device as well for it. I just think it’s very admirable what you’re doing to try and save these teeth I mean but we have to accept that some keep implant placing dentists will watch this and and they will spit their coffee out because they were like what the hell is this you might as well have an implant but it just depends on your mindset where you come from and I always say and this is nothing against implant blazing dentist but sometimes when all you have is a hammer everything looks like a screw but I just think it’s great that you’re doing that so thank you so much for coming on podcast to share that technique with us. [Peter]Yeah no problem, yes funny so something I should have mentioned right the beginning was that remember on the podcast which was your 2019’s most listened to podcast I think you’d even said ‘I don’t think this extraction and put it back in again’ that you’d seen was being done much in the UK and you said if anyone is get in touch and you know lo and behold you know here we are how funny. [Jaz]That is amazing, that is so good and thank you to was it to David? [Peter]Turned me onto it and a little community, the Portsmouth dental academy gang yeah. [Peter]Thank you so much David. Now the protruserati and thank you for recommending Peter to listen and then eventually you got in touch now I always say there’s never been a better time to be a dentist because now we’re so connected we can learn we can share techniques there’s never been a better time so with all the doom and gloom I hope to bring some positivity and thank you for joining me in that today. Thank you so much. [Peter]Yep, my pleasure. Good luck, nice to meet you virtually, I’ll look you up with a conference to show and that sort of thing. I can’t wait. [Jaz]Brilliant. So there we have it, the surgical extrusion technique or the partial exodontic technique isn’t that fascinating right? I mean something that you would think is innately a bad idea. It just seems too good to be true and it’s just fascinating. I think the true secret I guess is case selection like with anything like any technique. Case selection is always the key so choose your cases wisely and I really do think having something like a benex device if you’ve got access to a benex device wow. I mean you mean that’s half the battle, that’s more than half the battle I think because if you’re relying on luxators then things can chip and break and it may not be possible with this technique. So those are benex wow you’ve definitely got one leg up totally but I really thank doctor Raftery for coming and sharing his passion for saving hopeless teeth. So I hope you enjoy that episode and I’ll catch you in the next installment of the Protrusive Dental podcast. Thank you to all the Protruserati out there.

I recorded an Instagram Live with Dr Prateek Biyani of The Dental Notebook to answer a question sent in from the Protruserati: Hi Jaz, I hope you are well. I’m working as a NHS associate for nearly 3 years and I was thinking whether it’s worth doing DCT training or if it’s better to keep up with private courses to improve skills? Anonymous question from a fellow listener https://www.instagram.com/tv/CKRxwRGJv6H/?utm_source=ig_web_copy_link Full IGTV Video Listen to find out what me and Prateek recommended! Need to Read it? Check out the Full Episode Transcript below! Check out Prateek’s new book, Single Best Answer Questions for Dentistry! If you enjoyed this episode, you might also like Making your Dental Portfolio by Jaz Click below for full episode transcript: Opening Snippet: Welcome to group function where the Protruserati work together to find good solutions to worthy problems in dentistry with your host, Jaz Gulati... Jaz’s Introduction: Hi guys, if you’ve ever wondered about doing a residency post or a senior house officer or just a year in hospital, then this episode is to help you whether you’re newly qualified and you’re looking for that next step, or like the question that was sent in for this group function if you’re a couple years qualified and you’re still considering having that year in hospital, is it worth it for you? But as you may gather this was done live on Instagram so do excuse the live shoutouts but I’m still hoping there’s a lot of value in you listening today. So thank you Protruserati, hope you enjoy. So guys, I’m not gonna waste time because this is a group function is another one the arms of the protrusive dental podcast and someone has sent in a question and would answer it in the best person I have to answer it is Prateek Biyani, aka the dental notebook. He makes some fantastic content around this very topic. Hello, dental bro. Thanks so much for joining. Hi, Andy. I’m going to speak to you in about 45 minutes, I think what meeting? Hello, Chris. Nice to see you, buddy. So yeah, thanks for for joining me guys. This is mostly for someone who is stuck as an associate and they’re considering further training. Hello, amen. Hey, guys, Alex. Hey, everyone. So the question that was sent in I’m gonna get Prateek in a moment is a question that was sent in was “Hi, Jaz, have been an NHS associate for three years, it’s been an associate for three years, I was wondering if DCT training is worth it? Or is it better to keep up with private courses to improve skills?” So basically, three years qualified, NHS associate full time I imagine. Should I do DCT now, or private courses? So let’s get. Hi Haley. Hey, everyone. Let’s get Prateek. Main Interview: [Jaz]Hey, buddy. How you doing, man? I’m good. How are you? I’m good. Do I look fat now? Like, you know the camera adds 10 pounds, right? You have a little bit, that’s how much it’s fine. The camera really does add 10 pounds. Look at that. So at the bottom, I’m reading the comments, Ali. Oh, man, Ali, I love your work. Manual photography, your flow is awesome. And you said you love DCT. I also had a very positive well, mostly positive DCT experience. One of my posts was phenomenal in Sheffield, the other one in Guys was a bit, half and half. But we can we can touch on that in this episode. But listen, this is a group function. So it has to be time efficient, right? So I’m not going to make it a full one hour long. It’s going to be a 10 minute 15 Minute. So Prateek, I’m going to say the question again, for those who just joined us and for you again. “Hi, Jaz I’m an NHS associate. I’ve been qualified three years. I was wondering Should I do DCT? Is it worth it now? Or should I continue to invest in private courses to improve my skills?” So the first thing I’m thinking Prateek before you jump in is like why do anything? What’s the purpose? Right? And I think the very end of her question is to improve my skills. So let’s go on that basis first. So I’m gonna pass it over to you, Prateek. What do you think? Ultimately, I guess the bottom line is, what do you want to do a bit longer term. [Jaz]Improve skills. Yes, let’s go with that. [Prateek]So DCT is an excellent way to improve skills and the opportunities you’re likely to get, as you will have seen at Sheffield and teaching hospitals, the opportunities you’re going to get in those types of environments are far greater than you’re probably going to get. At this point in your career. In practice, you’re going to be exposed to a lot of different things whether depending on which specialty you choose, and these days, we’ve got dental core training PERS, where you can do multiple specialties. So in that short burst of a year, you can cover a lot more and enhance a greater number of skills, as well as going on courses included in study budgets to get the most from a year that potentially, you know, investing yourself privately is going to be far far more than you’re getting from core training. [Jaz]Buddy, I’m gonna agree and I’m gonna disagree with you. I think you mentioned some good points that I think you said Yeah, fine. The exposure that you get is awesome. Like Firstly, if you’re someone who wants to improve your skills, because you want to have a registrar post or something like a specialty pathway, then for sure that there’s no point having a 10 minute video on this right like it’s a yes, no brainer. Do it even if you’re three years qualified. But if it’s purely to improve skills, I didn’t know, I’m gonna just on the whim say that 70% of all DCT posts in the country. Just me I made it up. Okay. Are you much of a pen pusher? You’re not going to do much? Yes. Maybe you get to watch and I think there are a lot of posts that will let people down especially once you’ve been in and associate, your an associate pay and to take that massive pay cut. And then to be in a role where you think oh, I’m gonna upskill I’m gonna do wisdom teeth. I’m gonna do rehabs and suddenly you’re just making complete dentures and you’re doing sush in someone’s face. Then you know that leave a bitter taste. Hi, everyone. Hi, Nina. Currently, what do you think about that? [Prateek]So I think one thing too that I did this recently one of my videos completely agree, the pick, what you’re going to take is something that especially if you’re three years into your career, life also is going on to how you have to factor that into the decision you’re making. For me from the person that I did, I guess I did a bit of research before choosing those posts, and I had quite good feedback from those locations. And I knew that when I was going to go there, I was going to get the opportunities to do what I wanted to get from that year. And I had very specific things from the two years that I did, of what I wanted to achieve. So there is a degree of and I completely agreed, some of my colleagues have been to other places and done DCT post and not got anything out of them. But I think if you’ve got a mindset of what skills you want to improve, if you do some research beforehand, do you think actually some well, is going to match the criteria, we can never guarantee anything. But if you think someone’s going to match that criteria, then I’d say it’s a very good opportunity to at least apply for you got nothing to lose by applying. [Jaz]And then even after three years of practice? [Jaz]I know. [Prateek]I know quite a few people I know of one person who was five years associate work and then just got bored, and wanted something different to challenge their skills. So they came back into DCT. And they just did one year and then went back to practice. But it’s something that they took something, you know, they got stuff from it. And they went back refreshed and took on new challenges, because they hadn’t some new skills. But a lot of it. I know he said improving skills, but it ultimately is which skills do you want to improve? And where do you want those skills to take you as well? Like you mentioned, do you want to be a consultant? Do you want to just be really good at doing private composites? Yeah, that would also impact I guess your decision. [Jaz]If I had to really push you and say, yes, you have to tell this dentist Yes or no? Like, yes. Do it. No, don’t do it without any sort of beating around the bush. What’s your final answer? And why? I would say yes. Three years, three years full time NHS dentist wants to improve skills? [Prateek]Yeah, I would say yes. Again, depending on which skills? I personally would say yes. Because my experience has been very good. I’ve taken a lot from that core training year. Yes, salary may go down a little bit. But I guess if you do on calls, things like that, you may get a similar ish salary, depending on what you’re earning. So I would say yeah, if you’re thinking about it, no harm in applying and seeing what you get, and going for it. [Jaz]Okay, so I’m going to say no, so it’s totally cool that we disagree. But that’s the beauty of it. Right? So I’m gonna say no, and I’m gonna say to this dentist, because you should be watching this later. Or maybe she’s like, now I’m not gonna say I promise it’ll be anonymous. I’m gonna say, here’s how I would do it. Now, if I was three years qualified, and I hadn’t done DCT, right? And I was in NHS practice. I think the reason she wants to do something different, and she’s identified that she needs to improve her skills. And maybe I’m just maybe assuming here that she wants to move away from NHS practice and goes private, I’m just assuming, okay, so maybe she’s got bored like you said, like other person five years, or maybe she’s frustrated, or maybe she’s fine. Like, she’s, there’s no career development happening. Right? So if I was her, here’s what I would do. The average associate, okay, do you know how much the average associate earns? So that the mass dollar figures, the mass dollar figures suggests 67,000? Okay, let’s go with that. Okay, Hi Shabana. So, let’s go 6 7000. Right. So I would do this, I would, obviously, you’re paying tax on that stuff. But I would, I would live like your DCT salary. I would literally live like a DCT salary, and the extra 15 grand, whatever you are, after tax, I will just pump it into courses, I will do all the courses that I want to do. It’s like a sack of freebies, like just do everything that’s relevant to you that you can apply the next day. And that becomes your DCT, your private DCT. That’s how I would do it. [Prateek]Now, yeah, it comes down to what skills do you want to improve the ultimately, like I said, you know, if you, like you said, if you’re just wanting to improve your private composites, or you’re wanting to do some clear aligner therapy, something like that, then that’s very specific course that you can get done relatively easily on a lower budget without taking a hit financially. So yeah, then that would be potentially a far better way of doing and a far quicker way of doing it [Jaz]Which skill do you think would need DCT and that cannot be fulfilled by private? I think it’s more, a more general kind of overview. [Prateek]I don’t know. Obviously, I haven’t done restorative, I’ve only done maxfacts as my DCT job. So you’ve done the restorative side so you know what that’s like. But a more general overview of everything I’d like to say as part of your because it’s an academic position you’re in, you’ve got a study budget, you’ve got the opportunity of doing courses on top of that year that you’re also gaining experience from so you’re getting it from two sources essentially, unit dependent, etc. But I think you just get a broader overview rather than picking just one specific course. You know if like say if you want to be specific, then fine. But if you’re wanting a bit of everything or trying to get a bit exposure to a bit of this thing, then a DCT post may be better, depending on the use, they can offer you. [Jaz]I think Angie has made a great point said home into exactly what skills you want to develop. And I think once this young dentist identifies exactly which skills, I think the answer will just come from that because she left it very generic, I want to improve my skills and improve myself. And that could be done both routes. So you would say yes, to DCT, I would say do it private way. But like Angela said, it really depends on exactly what she wants to improve. So that’s that I mean, even nowadays, Oral Surgery. I think Oral Surgery is one of those things that you want, like over the shoulder training, you want your consultant or someone there over the shoulder. Whereas if it’s private composites, then there’s nothing better than you doing a composite, taking photos and having that in the court. So everything’s different, or if you’re in a practice and you have and you’ve got a great mentor who’s awesome at Oral Surgery, do the joint cases together, then I’d say you know who needs DCT then? But who? Who, you know, how can you make time for that in a busy practicing moment, right? It just doesn’t work. So I’m hoping that will help some people. So that’s group function done. I hope that helps you to who asked that question. Right. Final things in particular is I just want to tell you one about your book, because I think it’s amazing. We’ve done just tell people what you’ve just done in terms of the book and how long it took you, man, I’m just taking so long. [Prateek]Yeah, so it’s been going on for, I think, a year and a half, nearly two years now. So single best answer questions for dentistry, which is basically 280 ish, single best answer questions targeted at undergraduate dental students, anyone sitting there mfds, MDF ore exams, over 10 topics in dentistry and just with explanations, good radiographs, images, everything to kind of give a more holistic revision resource basically. So a lot of work has gone into it and it will be on sale next month. You can preorder it now on the website or on Amazon or anywhere basically. [Jaz]Check out dental noble guys follow them, follow Prateek even, but Boston has asked a good question. So what about if you want to do an MSC or a diploma? Would a DCT be worth it? I’m going to say maybe? Depends on what post like I look at the Guys hospital post I did the six months restorative, it is rubbish. The oral surgeon was okay. in Sheffield, the restorative was phenomenal. So I just think man depends on your posts. Whereas an MSC of taught postgraduate MSC program? Yes, there’s a lot of research. There’s a lot of critiquing papers and stuff. But if you actually in clinics and getting hands on or you’re able to apply that in practice, then it’s good. You don’t necessarily need DCT, What do you think? [Prateek]Yeah, I think I agree. There’s so many variables of play. And yet like say the environment is different. What you ultimately wanting to gain from it is so different for everyone. And I think, a couple of people as Drew’s mentioned that as well. You’ve got to decide yourself what you want to gain from it. And do you think that one year or however many years decide to do is actually going to contribute to your journey if you’ve decided, ultimately you want to go and do an MSC and you met the criteria to get on do it then is that extra year going to add anything? Or do you want to just skip and crack on with the rest of it? [Jaz]So it’s a rush me you can just crack on and go for an MSC? If you want. You don’t have to do this. See, I think you’re in df One moment, I hope it’s going well. I know you’re very reflective practitioner, which is awesome. So I think we’re gonna wrap up that for a group function. I’m gonna say to everyone, I think tonight or tomorrow, the next episode of the podcast coming out, it’s going to be six signs that you are a comprehensive dentist or the six struggles of a comprehensive dentist, which I really enjoy making a 15 minute video. Hi Jake. Hope you doing well, buddy. Jaz’s Outro: So I hope you guys enjoy that if you haven’t already go on protrusive.co.uk sign up for our newsletter. So when the episodes come out, you can get them and I think you have a newsletter function as well on your website. So yeah, yeah, exactly the same. Yeah. Thanks so much. No problem. Thanks for having me. Bye, everyone.

The ORE exam to practice Dentistry in the UK is not easy – listen to Yazan Duedari’s top tips to pass this gruelling 2-part exam and find out what the ORE Exam has in common with a Beyoncé concert! https://youtu.be/qCPUsqPmino Dr Yazan Douedari gives away all the secrets! Need to Read it? Check out the Full Episode Transcript below! Dr Yazan Douedari reached out to me as he was a student of the Resin Bonded Bridges Masterclass. I loved connecting with Yazan. He had so much in common (we are both Refugee’s who came to the UK and are grateful for the opportunities) and listening to his hardships and struggles with the ORE process and how he triumphantly overcame it was very inspirational. There is so much hardship and sacrifice associated with the ORE Parts 1 and 2 – imagine having no income, studying several hours per day and supporting a family at the same time. To top it all off, even once you PASS the ORE Part 2 – how will you find a job? https://youtu.be/sc6HnlsyccY Don’t stress – it will not help you! Yazan shares everything: Step by Step application process How to get your GDC paperwork in order How long to study for each part of the ORE Revision tips How much does the ORE UK process end up costing you? How he failed Part 2 How he overcame Part 2! How he found a job in Private Practice I am so grateful to Yazan who shared his successes and failures in such a humble fashion. He also shared some good ORE resources: ORE Part 1 Facebook Group ORE Part 2 Groups: https://www.facebook.com/groups/645587355509380/ https://www.facebook.com/groups/161356114038001/ https://www.facebook.com/groups/orepart2/ https://www.facebook.com/groups/498077606922801/ Companies to buy materials and equipment from: https://www.mrdental.co.uk/https://www.dentalzonetrade.com/store/ Some thoughts from Yazan on MFDS Exam – is it worth it?: Actually, I wanted to mention MFDS & MJDF during the episode saying it would be good for those doing ORE to do one of these exams DURING their ORE journey (not after) as there are a lot of similarities and require minimum extra preparation. I have done MJDF while I was doing my ORE, I prepared for 1 week for part 1 and 5 days for part 2 and was able to pass from the first time. The drawback is that you need to spend extra money on exam costs (around £1000), but the benefit that you get a diploma degree with a few extra days of preparation.  Now to answer your question, MFDS/MJDF do not add much (or anything!) to your information or skills if you’re doing ORE. The only benefit is to improve your CV generally and esp if you are considering applying for further education degrees in the future, it ould be an asset. Additionally, in my case, my dentistry CV was very weak, so I felt having this extra degree in my CV would help me get a job and would give me some advantage over others.  Yazan on MFDS Exam Some thoughts from Yazan on the LDS Exam vs ORE Exam: One last thing I just remembered and I think it would be useful to mention in the episode is LDS, which is another exam one can take to be able to work in the UK. It is almost identical to ORE, however, it is less frequent (part 1 once a year, part 2 twice a year) and considered slightly easier than ORE, esp part 2. Dr Yazan If you enjoyed this episode, why not check out the advice on Finding an Associate Dentist position! Click below for full episode transcript: Opening Snippet: 've never fainted or almost fainted in my life although like I was near death several times in my life because of the war I was close to getting kidnapped maybe two or three times, isis like I've been through many things but they didn't scare me as much as this Exam... Jaz’s Introduction:Imagine coming to a new country and you’re learning a new language, a new way of life maybe you have your family with you, maybe you’ve got a spouse, a child to support but you can’t work. You can’t work until you sit possibly the most difficult professional exam of your lifetime and your entire family depends and relies on you passing this exam. Protruserati, this is a reality that a lot of people face is that people who come from other countries to practice dentistry in the UK for example. Now this could apply to any country whereby they have entrance exams right? So what I’m referring to is the overseas registration exams which in the UK are required for people of certain countries because their dental degrees are not valid right? It’s the same where for example if I was to go to the USA, I’d have to sit their exams right? And essentially in the USA I’d have to go to dental school again or the equivalent.You can listen to episode 2 with Kristina Gauchan, if you’re interested in the USA but essentially these exams can be very tough even the ones in the USA and we talked about that. Now the purpose of this episode and joining me today is Dr Yazan Duedari, who is from Syria and he completed his ORE but he’s got a very unique story as though he actually came as a refugee and that really resonated with me for many reasons and will explain the podcast but wow to learn about the hardships and the challenges you have to go through to be able to practice dentistry in another country especially like in the UK it’s just crazy. Like did you know that when they open the examination process like the online booking process for the exam goes so fast as though it’s like a massive celebrity concert like a Beyonce concert right? You log in and you’re there ready to buy your Beyonce tickets and like within five seconds they’re gone. Well ORE exams just sit the damn exam that’s the situation they face. So there’s I mean there were so many different layers of complexity that I learned about from speaking to Yazan today so I’m so honored that he gave his time and his energy and his mistakes and his advice. It’s full of absolute gold so this episode really is for those people who are looking to come to the UK or move to any country where they have an entrance exam. You will definitely learn something from this episode. If you’re from the UK and you want to understand the challenges or from the USA, you understand the challenges of a foreign dentist then fine listen to it but this is more for those people who are about to sit the ORE exam we do, we do go into the very nitty gritty of the ORE exam, the different stages, how much it costs, what’s the pass rate, what are the different challenges people face I mean it’s just amazing to think that the process can be incredibly slow and incredibly difficult for no reason at all. So wow I mean even when you finish the ORE to actually find a job is just a whole challenge in itself. So I hope this episode will inspire and help many of you out there. Protrusive Dental PearlSo the Protrusive Dental Pearl I have for anyone who’s looking to sit an exam in a different country to register as a dentist there is this, it’s a quote you may know who it’s by and the quote is “It always seems impossible until it’s done.” It always seems impossible until it’s done the quote of course is by Nelson Mandela and I kid you not when you listen to this episode and you listen to Yazan’s story and some of the stories that I know about like I know I’ve got some close friends who have done the ORE exam and I know what a grueling process it is. I’ve got a friend in Korea right now who’s looking to sit the Korean exams and that’s a massive challenge. I have so much respect for the people who go to the USA and this and they pretty much go through dental school again like wow I have crazy amounts of respect for these people but it always, always, just like when you were like sitting your finals exam to become a dentist like how impossible did it seem? Can you like tap into that moment where you’re about to sit your finals exam like it seems impossible until it’s done. So keep going, keep that faith and I really hope you gain a lot from this episode so we’re going to dive right in with the chat with Dr Yazan Duedari for anyone who is interested in the ORE exam or any exam for that matter. Main Episode:Yazan Duedari, welcome to Protrusive Dental podcast. How are you my friend? ​​[Yazan]I’m good and I’m very honored to be on my favorite podcast ​​[Jaz]Oh you’re too kind, your flattery will get you right very far, Yazan. So Yazan I’ve got you on here for a mission okay? Your mission is to help people okay and let’s be really realistic because there’s ups and downs but it’s to do with the ORE exam and someone’s listening and they have no idea what ORE is that if you want to come to the UK from certain countries then you need to do the overseas registration exam to be able to work in the UK, right? And from what I’ve heard it’s a really tough exam, I’ve had loads of friends who’ve done it and I just want to look at the challenges, the benefits, the risks, the rewards I really want to dissect it. But I also want to learn about you Yazan because you email me because you kindly did my resin bonded bridge master class and you emailed me some kind words you said hey how can I find more courses like this and we were discussing and then I found out a little bit about you. But can you just tell me roll back the years ,go back to your childhood because something very interesting I want to highlight because wow what a story you have just tell everyone a little bit about yourself, childhood and then what you do now as well. ​​[Yazan]Yeah so I’m from Syria and I grew up in a small city called Idlib which is now famous or infamous for war unfortunately. And I studied in Haripur University, graduated from dental school in 2011 and that was the year when the war started and I stayed there for one year, left for Egypt for one year and didn’t stay in Egypt for longer than that. Went to Turkey for two years again and then came here to the UK in 2015 and after arriving here I claimed asylum so I am currently a refugee here in the UK. And I had to go through the process of the ORE to be able to practice again as a dentist, that’s very briefly. ​​[Jaz]No but I like that and I’m delving deeper into it and the reason why that story resonates with me so much is because I came to the country when I was six years old from Afghanistan and I’ve been through a process of claiming for asylum and I’m so grateful to receive a British education and I’m absolutely indebted to this country but like yours is a little bit different that you came later in life but the challenges are definitely there and would you consider yourself lucky that you are here today? ​​[Yazan]Yes definitely like I mean yes being a refugee is not fun. It’s not easy but at the same time unfortunately being a refugee in the UK it’s better than the alternatives for me so yes I consider myself lucky that I was able to come here. My asylum request was accepted and I’m surrounded by really amazing people in this country like British and non-British resident of this country are really really amazing. And yeah I’m also lucky to have came here in a relatively young age. I’m 32 but yeah I’m like it’s not too advanced in life and I’m now done with the difficult part. There are more difficult parts to come but it’s good to be done with some of it. ​​[Jaz]Well I also want to say we had a little chat earlier before we started before I hit the record button so congratulations for your newborn son, Hassan, three months old. It sounds amazing and also recently you started a new associate position in Chelmsford right? ​​[Yazan]Yes, right. ​​[Jaz]That’s the one fantastic and you’ve been telling me good things about that how you’re enjoying the position but now before we get to this place where actually now you’re working in an environment that you like and although you have a significant commute you’re still happy. We need to tackle the elephant in the room which is that mammoth of an ORE exam I mean what did you- why did you move from turkey to the UK? What did you expect in terms of- what did you know already about the ORE? Did you have people to help you? Tell us a little about what you expected before you came and then when you came we’ll start from there I suppose? ​​[Yazan]Yeah so actually just to highlight I came to the UK for a scholarship and it’s basically the foreign commonwealth office scholarship. I did a masters in public health and after that I worked in a few non-dentistry jobs and after that I thought I should really get back to my career and it’s just that it’s worth the investment in time and money to just do this scary exam that everyone talks about. And basically I did have some help from people from my country who passed the exam before but the actual that like the more important help you can get is from people who are doing the exam at the same time or who have recently passed the exams because my friends have passed exams like three years ago, four years ago so they would forget about the nitty gritty details and even the exam sometimes they changed over the years. So yeah it’s I had some great support from great people throughout this journey and the support was mutual like we were supporting each other, we were complementing each other. ​​[Jaz]Well, tell us about for those people who are maybe considering doing the ORE and coming to the UK for example or anyone who’s about to start that journey. What’s the first part? What’s the second part? How much does it cost? What’s the pass rate? What’s the failure rate? And then we’ll get into what it actually involves and I can tell you some stories I’ve heard from friends who’ve done ORE as well but tell us how many parts are there how many years does it take on average? ​​[Yazan]Yeah so I will start like maybe with a general description and then we will delve into the details. So basically the ORE is two parts and in terms of time commitment because this is the first thing that comes into mind like will I spend like five years doing this or is it just few months. Basically in terms of studying I wouldn’t say it needs more than one year of full-time if you’re like dedicating yourself five days a week to studying. Then one year is enough but there are some logistical challenges that I will come into it so you should expect to spend one to two years on average to finish this exam. It might be longer but ideally I think for the majority of people they are all able to finish it in two years. In terms of money, the money part is very important because not many people would know how expensive it is. I would estimate it to be between 10 000 pounds to 15 000 pounds and this is I’m only talking about the exam costs and the material cost, the courses that you have to do. I’m not mentioning the living cost because the living cost it’s going to be large. ​​[Jaz]That’s variable but that’s significant as well so you raise a good point there’s the examination fees and everything around it but then the longer it takes you to pass this exam to be able to earn an income from dentistry and then there’s a longer you’re supporting a family, potentially and supporting yourself, rent you name it that sort of stuff so I completely appreciate that so what else do you want to add to that? Sorry. ​​[Yazan]So yeah actually on top of that even this is something that people rarely mention after finishing the ORE which I will also touch upon later but it also takes like maybe six months sometimes paperwork. And sometimes finding a job could also take a few extra months so you could also consider maybe an extra six to 12 months after passing the ORE to start earning money. So this is a very broad picture for anyone considering doing the ORE, you have to have these commitments in place. Financial commitment, time commitment and the effort of course and the mentality to do this. ​​[Jaz]That’s crazy yes and that’s crazy because I know of people who’ve done the ORE and their whole life is consumed by this exam. I need to pass this exam and now you’re saying that hey even after you pass the exam there’s so many more hurdles at that point as well. So naturally my next question is, is the juice worth the squeeze? ​​[Yazan]I never really thought about it because in to me it wasn’t really a choice like for me doing the ORE it’s not about being a dentist in the UK, it’s about being a dentist everywhere, anywhere, because basically I can’t go back to my country and I can’t is like I can’t go out from here like I’m a refugee here even if I wanted to go back to the countries that I lived in like Egypt and Turkey now I need a visa and they’re not really granted visas so it’s about me being a dentist. So I didn’t really have another choice but now that I’m thinking about it after having gone through it, it’s definitely worth it. It’s difficult, it’s time consuming but once you’ve done it like yeah it’s just maybe one or two years and that’s it. It’s done and it’s not a horrible two years. You enjoy many parts of it, you hate some parts of it but it’s a journey like any other journey. ​​[Jaz]Did you enjoy the learning, the re-learning? Did you enjoy that? ​​[Yazan]Weirdly, yes I did and I learned many new things. I enhanced for example my communication skills massively during the ORE even my hand skills. Like I used to have like good hand skills but I can’t say that I significantly enhanced my hand skills like practicing on the mannequin, on fake teeth even I learned the indirect vision technique so just like working looking at the mirror only this is something that we don’t really do it much in Syria or it’s not at least it’s not taught in our universities. So I learned that here I’m very happy that I’m able to do this now very comfortably I mean. ​​[Jaz]For someone listening right now and they know about the ORE already and they know about people who sat there ORE. None of what you said the last 30 40 seconds will be surprising to them but in case someone’s listening right now and you already have a BDS from a uk university or us or whatever and you’re listening and you’re talking about mannequins maybe they haven’t appreciated the following which is the number of people who do the ORE they actually here, they source and they buy their own mannequin head and a motor and a handpiece and they’re there like in their garage like practicing and stuff for hours and hours and hours for the practical element of the exam. So you guys pretty much yeah you do really delve deep into the clinical hand skills the repetition and I can see why I mean anyone even if I had the opportunity for two three months have a mannequin head some models and just practice preps for three months? Of course you would improve so there is that beauty of it I suppose. Is there anything you want to add to that in terms of any advice you want to give someone already with regards to purchasing a mannequin, where do you even buy one I mean eBay or? ​​[Yazan]No, most people buy used ones and this is what I did because it’s cheaper and you don’t want to spend a lot of money and basically it’s just people passing and then like selling their own but some people would prefer to buy new ones. And if you can comfortably afford new ones it would be definitely better. There are specific companies here that are known that provide specific stuff for ORE so I don’t know if you want me to mention. ​​[Jaz]Yes, mention it because it’s definitely going to help someone. I mean there’s no commercial interest but we can help people. ​​[Yazan]Yeah definitely. There are MR dental for example they are the most famous providers. There was a new company that also started and it’s based in London but I forgot its name. ​​[Jaz]You can email me I’ll put in the show notes yeah because people will so go to protrusive.co.uk/ore and you’ll be able to find all the resources that Yazan can help us with hey was it helpful because I found it helpful to like when I was moving to Singapore for example to find a Facebook group for that or whatever would you, do you guys have like a secret ORE club on Facebook? ​​[Yazan]Yeah we do actually. Yes there is one well there is one big group for part one I think it has like 8000 members so it’s a huge group and yes people can post questions there you get answers so this one is really helpful. For part two there are few Facebook groups but I don’t know why they’re not that helpful. They have different mentality but- ​​[Jaz]Do you think it’s competitive? Do you think it’s because people are now feeling like they’re competing against each other maybe? ​​[Yazan]I think yeah partly I think that part two groups, Facebook groups, they’re owned by different providers of courses so this is probably why but while the part one group I don’t think I don’t know who owns it I don’t know if really it’s owned by someone. So yeah. ​​[Jaz]Okay that’s very interesting so you must send us this thing so people can join these groups. That’d be amazing again. I’ll stick that on the website. So tell us you apply to your part one. So part one’s purely written break the exams for us. ​​[Yazan]And actually I forgot something because I didn’t really go through it before even part one at part two, there are two small issues. You need an IELTS and you need an overall score of seven and a score of 6.5 in each subsection like reading, writing, listening, speaking. So I know people struggle a lot with this. For me I already have had my IELTS because I came here and studied for a master in public health. It was expired so I just communicated with the GDC telling them like look I have a master from the UK and I have my expired IELTS and they accepted it. They requested some sort of preference but there are some rooms there because I see a lot of questions asked about the Facebook groups, about different people having different things to document that they have really good English. So it is possible sometimes if you have an expired IELTS or maybe. ​​[Jaz]To bypass it? ​​[Yazan]Yeah exactly. So because I know one of my friends, he spent two years to get the ielts degree and then one year for the ORE. So for him the IELTS was more challenging than the ORE itself and I think just getting that specific grade is enchanting, not sure why exactly but there is something in there. So yeah this is something to consider. ​​[Jaz]You know I imagine, Yazan, that the exam is, how do you say this exam, this English exam. How do you say it? What’s it called? ​​[Yazan]The ORE? ​​[Jaz]No the English, the one, how do you spell it? ​​[Yazan]e-i-l-t-s. Okay international English language examination. ​​[Jaz]I’m with you. So I imagine that that’s like it’s not like it’s probably a complexity whereby if the majority of the public in the UK did it a lot of them would probably fail. Like that’s what I can just imagine it being like that because it’s like if someone does a nationality exam like half of the people in the UK probably just fail it because no one knows that stuff unless you’re studying for it but anyway that’s yeah a side thing so yeah it’s a very good point ray so you have that hurdle to cross. What’s the next hurdle? ​​[Yazan]A very small one but you also need to send your documents to the GDC and this could take basically, it shouldn’t take much. It should take like once you send your documents to the GDC, the general development council, they come back within like a month or two but sometimes people struggle with the paperwork. It takes them several months to prepare the paper works. But in my opinion there aren’t many like a huge amount of paperwork, just the reasonable ones and then the logistics for example part one, it’s run, well pre-covid it was run twice a year. Once in April and once in august and the opening to register to the exam and the registration open eight weeks before or two months before the exam date. So you have a really small window. You have to have your papers ready for your IELTS ready everything, ready before the opening of the exam. And for example if you miss the august one, the next one is in April the next year so that’s almost eight months of waiting. So it’s something also to consider. ​​[Jaz]And so this is once you apply and you do it and you’ve got eight weeks left until your exam and you’re studying and this is a purely written exam? ​​[Yazan]So part one it’s mcq, so multiple choice questions. So you don’t really write anything. There is a computer that you just read the question and you read the answers and you choose one answer, sometimes you might need to choose more than one answer for some questions but yeah that’s basically it runs over two days. It has paper A and paper B and you need to pass both. Well, paper A is more focused on what we called applied, applied science something like anatomy and physiology, the basic science while the paper B, it’s more focused around the clinical like for example prostho, perio, endo questions. But you might get like anatomic questions and paper B and it’s not really like a clear cut in there and you have one day break between the two papers and you need to pass both papers but passing like to pass part one you need to answer 50 of the questions correctly so I would say that’s easy one. Like if you have prepared for the exam just to get 50 of the questions that’s really not difficult. For me I prepared for four months and it was enough for me. It doesn’t need to be like I see people would like to spend one year preparing for part one because it’s a huge like if you think about everything we learned in dental school over the five years. It’s a huge amount. If you want to perfect it, yes you need maybe one year or two years but you don’t really need to perfect it you just need to study the popular topics. So I would advise people not to overdo it with part one. ​​[Jaz]So maybe practical advice there is if someone’s thinking hey you know what I don’t feel ready for part one but they’re a dentist, they’ve got their degree from India or Pakistan or Syria or some of that and so they’re a dentist but they don’t feel confident your advice is just do it. ​​[Yazan]Yeah exactly. At the same time I see people who would like to study at the night of the exam and go to the exam and I would really advise against that. I’ve heard of people passing, doing that but think of the time investment, the money investment because of the part one it’s like 900 pounds, it’s a lot of money and you will need that money believe me. Even if you fail then you have to wait several more months to just do it again. So wire is to prepare I would say at least three months and in my opinion a maximum of six months would be enough for this exam and to know what to study because it’s very broad but at the same time there are known topics that they’re kind of repeat or they’re kind of. ​​[Jaz]Recurring themes. ​​[Yazan]Yeah exactly and the things that you’re not very strong of, for example if you had an endo question like most of us are likely to answer it correctly without really studying anything but for example if you ask me now about anatomy I might not be able to answer this question without revision. ​​[Jaz]You mean like kidney function and it could be liver function and it could be like that sort of stuff as well okay interesting so very important. So okay let’s move on you’ve passed part one hooray. You celebrate, you call your family this has happened. It’s very good. What’s next? ​​[Yazan]Okay now the serious bit starts well, the good thing is that you’re halfway through. You finished like a huge part of the exam now just the final step is remaining but it’s a difficult step. It’s where you spend most of your money, most of your energy and also it could be when you spend most of your time as well. For part two basically it’s four exams in one exam. The first it’s called the OSCE. I think it’s an abbreviation for can you help me with that? ​​[Jaz]It’s an objective structured clinical examination. ​​[Yazan]Yes, so it’s basically a test of your communication skills. Well it has many parts but most of it, it’s an actor sitting in a room acting like they are the patient and you need to enter the room and to speak to them for example ask them questions to diagnose a problem or even explain a diagnosis or explain a treatment plan and then. ​​[Jaz]It sounds like mfds. Like we, well I’ve done mfds and we had OSCEs and it was all pretty much a communication from one I remember from the mfds part two. So is it the all ten stations or how many of the stations there are? They’re all communication based? ​​[Yazan]Yeah 20 I think but some of them would be written and some of them would be skilled OSCE. So for example to do a suture or to place a rubber dumb and so there are like different pieces. The second part, it’s called the diagnosis. ​​[Jaz]I just want to ask you before we move on to each because I like this format that you’re going through each part. So out of difficulty, how difficult do you think the OSCE is? ​​[Yazan]Well I think it’s medium difficulty and mostly because many people would fail the OSCE and this is partly because of the way some people prepare for it. It has to be spontaneous, you need to really communicate with the patient or with the actor, you need to actually forget that they are actors you need to think of them you just- ​​[Jaz]And that’s what you just said you forgot you’re in the zone. This is why you pass exactly. ​​[Yazan]I’ve seen people just focusing on the information and what they need to tell the patient and just memorizing what they need to say to the patient before entering and it doesn’t really work like this. It doesn’t really matter like no it matters what you say but I mean what matters most is how you say it, how you explain it. Is it simple to understand, are you just constantly speaking and explaining things like yeah the actor will not really appreciate that. So just forget about everything. If you’re in the exam forget about everything you learned and just enter the room, communicate with the person in front of you because they might tell you different things, they might tell you weird things. It doesn’t really matter, just communicate with them and make them feel appreciated and listen to them and- ​​[Jaz]It’s a good tip. ​​[Yazan]Then I’m sure you would pass these stations. ​​[Jaz]Brilliant. So then that’s on day one for example or is it half the morning or like half a day or a whole day okay? Then what’s next? ​​[Yazan]Maybe two hours I think they will feel like five minutes but it’s two hours. ​​[Jaz]Definitely been there. ​​[Yazan]The next day it’s the mannequin, which is the money cutting exam which is the most difficult example and basically in this exam you have to do three tasks. One is made sorry…Two is made considered major and one is considered minor and you need to pass each one of them to be able to pass the manika. And so for a major for example to prepare a crown and you need to do this indirect vision technique so you can’t like clean and look. No, you have to all the time just look in the mirror and just prepare it and even for one second leaning is not really acceptable so no direct. I mean yes you can do direct vision if you can see like this but you can’t lean forward. Another major exercise is also to prepare for class two. This is a very common class two cavity and does an amalgam filling on a different tooth. A minor exercise could be something simple like take an impression or do an access cavity. So things that are simple but the tricky part in the mannequin is that they don’t evaluate your whole performance. They evaluate each like if you do a cavity they will evaluate this cavity if you fail in that cavity you fail in the whole exam in the whole world. So that’s the difficulty. ​​[Jaz]The stakes are high. ​​[Yazan]And the other difficulty is the stress. This is the most important factor you need to manage, your stress and I failed my first attempt in the part two because of this and I just got so stressed that I almost fainted and I’ve never fainted or almost fainted in my life. Although like I was near death several times in my life because of the war. I was close to getting kidnapped maybe two or three times, isis like I’ve been through many things but they didn’t scare me as much as this exam. It’s really scary, it’s really stressful. It was difficult and I knew that beforehand I knew that I had to manage my stress. I didn’t really do that very well but in my second attempt I just entered the exam. I said you know what I really don’t care anymore. I’m just tired of those whole exams. If I fail that’s fine I’ll try again. A third attempt in January and we’ll see how it goes but I’m just tired of stressing out. ​​[Jaz]So that’s fantastic advice I think because if someone can listen to this and then just learn from, I hope you don’t mind me saying this learn from your mistake because or learn from, you not passing the first time around and just learn from that and remember that hey you know what Yazan said in that podcast not to stress because stress will put my body in not the right state to pass the exam. So it’s very honest of you to say that. So I really appreciate you sharing that with us all. So you think, you believe that the stress was a major reason and was it like a major or a minor one of the clinicals that you failed because of the stress? ​​[Yazan]I’m not sure why, like I’m not quite sure why I felt to be honest but generally my preparation on that day wasn’t as good as I usually prepare it wasn’t horrendous but it wasn’t perfect. They look for perfection. That’s the thing I might have made few minor mistakes but generally my preparation was a bit not as good as I usually do and another actually factor that is really important is we practice at home on our mannequin, on our motor, on our handpiece for like six months then we go to the exam and the settings are slightly different that when you press the pedal the speed is different, the cutting speed it’s really different though the way the teeth even respond to the handpiece, they are different. So that was also a little bit shocking to me so that helped me in my second attempt to know what to expect. My advice is in part two you will be doing mock exams for the manika. Try to go to different places for the mock exam. Try to be out of your comfort zone because I noticed myself doing amazing preparation at home but when I go somewhere else for a mock exam for example it’s not as good, it’s still good but it’s different because the setting is different an- ​​[Jaz]Environment will be different. ​​[Yazan]Yeah and some of the mock exam providers have equipment which are very similar to the exam and equipment so try also to make sure you go to these ones so you can test because in exam it’s usually the cutting speed is usually more it’s usually faster than what we use at home. Even for the slow handpiece they really cut in at a very slow speed but it’s much more cutting so- ​​[Jaz]I can definitely use one of those at work right now. I think that would be good. That sounds very good to me actually I quite like the sound of that hand piece. But no you’re right to have a more familiar setting would really help you. I can totally appreciate that. So the second time around you passed the sort of the mannequin challenge mannequin challenge, I don’t mean to say mannequin challenge obviously you can call it the mannequin challenge. What’s after that? ​​[Yazan]So that’s on the second day. Now the third day you have two exams at the same time one is called diagnosis and treatment planning, where you also it’s from the name you have a patient, you enter the room, you need to communicate with them like taking medical history, social history, dental history and of course their chief complaint and you only have 10 minutes for all of this and you need to write it down at the same time you need to be as comprehensive as possible but at the same time need to be reasonable with the time like I saw many people try to ask all the questions that they have to ask and it doesn’t really work like this for example for the pain questions there’s subcrates- ​​[Jaz]Subcrates. ​​[Yazan]Yes exactly. Some people would go to the room and they try to ask every single question and in my personal opinion it doesn’t really work like this. Like if you ask a few questions and you’re able to diagnose that it’s an irreversible pulpitis let’s just move on. It doesn’t really matter if you cover the whole questions and yeah basically part of it is communication with the patient. Part of it is actually diagnosing and putting a very comprehensive treatment plan for the immediate term and long term and after that to communicate this to the patient and convince them of the treatment that they have to go through. That exam, it’s actually on one hand, it’s difficult because it’s one hour it’s actually 54 minutes but you get a lot of information from the actor who will tell you a lot of information so we don’t have enough time to deal with it. So most of it is about time management but in my personal opinion the marking it’s not that tough it’s easy to pass it. I would say don’t worry it sounds intense but it sounds like it’s still possible. ​​[Jaz]But it sounds very intense though yes it sounds like the main power there is manage your time and be efficient instead of instead of going through the entire Socrates going all the way to the e to the s at the end to once you get your diagnosis be a good communicator and then get the mark, get the past that station and move on. ​​[Yazan]Yeah again and similar to OSCE, just communicate with a person in front of you like you don’t need to cover all, you need don’t need to tick all the boxes but what you need to do is to have an actual conversation with a person in front of you because these I think are valued very much by the examiners because all of us can diagnose, all of us can write treatment plans but the tricky thing is to communicate. ​​[Jaz]Okay so you’ve got that one and what’s next? That was the third one? ​​[Yazan]Yes the third one and on the same day the fourth one which are mythical emergencies. This one is relatively easy because you don’t have anything like it’s known that medical emergencies you have heart attack, asthma attack. ​​[Jaz]I think as long as you learn the recess document that’s it right? If you just learn that research documentary inside out. ​​[Yazan]Exactly so you have to really know it by heart and not just do it for the exam, for real life because you might have someone in the clinic fainting and you need to deal with their life threatening condition. So it’s worth the investment in time. The good thing about this exam is that, like you know what to study, it’s limited. They will ask about these things and that’s it. So if you know it you will easily pass it. But it’s not like yeah the questions sometimes could be tricky so you need to really- ​​[Jaz]It’s a written exam? ​​[Yazan]No it’s like an interview okay and some of it you need to give CPR. ​​[Jaz]Okay yeah. ​​[Yazan]And the other tricky thing about the ORE is basically you need to pass all four exams. To pass the part two so if you for example pass everything and you fail manika like I did you need to redo the whole thing again and I’ve seen people sometimes like maybe I heard about a few cases people like for example failing their market in the first time and then in the second time they passed. Everybody came but they felt they’re asking so it’s like they failed again but for a different reason so you need to make sure that you pass the four elements to be able to pass part two. ​​[Yazan]How long after you sit the fourth and final exam do you get your result? ​​[Yazan]It takes four weeks. ​​[Yazan]Oh my goodness oh my god four weeks. That was the most painful four weeks ever but we the four weeks is stressed but like it’s out of your way but we all remember passing dental school and that wait until they until you get find out until you know you get your finals results or whatever so I can sort of empathize with you in that sense yeah. Four weeks is massive. They just do it to tease you, they just do it to tease you they already know by day two. It’s all electronic, they’re done already, they just say how did you feel 28 days. ​​[Yazan]They actually put the marking on the day so I don’t know what takes them four weeks it’s same for part one actually they take it takes them four weeks although it’s all on the computer like we press the answer on the computer and then it like they can immediately. ​​[Jaz]They’re just trying to delay you, they’re just trying to delay that’s the only causal explanation. I’m sorry to hear that but let’s get, so amazing you’ve mentored someone through this journey, they’ve passed the ORE something that’s been consuming their entire life. They’ve spent all their time, money, energy, livelihood, thinking, practicing, learning for this exam but then the struggle is not over. This is why I admire you and anyone who’s been through ORE so much because I really admire the hard work that it takes and it the journey continues so hopefully you get the result that you want and you passed. But then there are some more challenges so just next the final part of the podcast tell us what challenges can you expect once you pass the ORE finally? ​​[Yazan]Yeah so that’s the thing that you don’t, you’re not done by passing the ORE but of course you’re done with it with the difficult part but before moving to that I just want to highlight another thing that I think is really important to highlight some logistical challenges with the ORE is booking the exam. I would say this is the worst thing about the exam because basically spaces are limited and there are many people who want to apply for the ORE and as I mentioned there are only for part one there are only two settings per year. So what is actually happening and what has been happening for the past few years, maybe three or four years, is that the exam opens usually on a certain day 2:30 p.m. 2:31 or 2:30 and maybe in two seconds it’s fully booked so- ​​[Jaz]Oh my god. ​​[Yazan]Yes so basically you need to refresh the page at 2:30 exactly and what happens with many people is that the screen will show no exam to book or exam hasn’t opened yet they refresh the page and it says exam fully booked. ​​[Jaz]That is terrible! ​​[Yazan]That’s true. ​​[Jaz]I mean this is like a Beyonce concert, they you hear like in seven seconds it goes this is like oh my goodness I never knew that you don’t even think as an outsider that this applies but this is so disheartening. This is like you’ve been preparing for this exam your whole family. Your livelihood depends on it and you have to there’s this extra dimension of pressure. ​​[Yazan]This is the worst. I would say this is the worst because this is something that you can’t really control at all and it’s not within your hands you’re just sitting there and trying to refresh and hope for the best. And I know people who like this are extreme but I know someone who maybe spent two years waiting so that’s horrible. So yeah that’s even for part one and part two. So this is something also to factor in your calculation expect that there might be delays outside of your control and just have a plan B for example if you can’t book the exam just know what to do in this extra time. ​​[Jaz]That’s a very fantastic point you made because I had no idea about that. I mean I’ve heard of so many different challenges and obviously the challenge we’re going to come on to now and shortly about how to find your job and stuff but sorry you’re going to say something? ​​[Yazan]Yeah and I mean we tried to just want to highlight that we tried to sign petitions and communicate with the GDC but unfortunately they were saying it’s first come first serve but it can’t be first come first serve when it’s like he didn’t get the chance to click a stupid button like that’s not so if anyone out there who can like help with solving this issue please do because this is just so horrible. ​​[Jaz]I 100% agree with you man. I 100% agree with you and hopefully someone will listen and do something who knows you never know okay you never know so I appreciate that so wow what a challenge you just told me about there. So you’ve passed your ORE after the vigorous process of even getting a damn place on the exam like a Beyonce concert and now this added challenge of actually getting work, finding work. So what’s the requirement like what’s the rules? ​​[Yazan]So before even getting to that you also need to again send your papers to the GDC. It’s actually the same papers that you said the first time but they requested again. ​​[Jaz]How can we delay these guys even more? ​​[Yazan]I don’t know even the ielts they requested again and there are some few extra bits and pieces that you need to do not necessarily related to your registration the GDC for example to make sure that you have vaccinations. So blood tests for example to have a CPR course for example like yeah there are so many different bits and pieces that yes basically it takes several months just to be done with the paperwork and yeah some people would take them like a very lengthy process like six months some people will finish it within like few weeks. So I heard my friend finished it in like I think 10 days and that was it so it’s different from what the person told me. ​​[Jaz]That’s like the GDC clearance of the ielts and the paperwork and everything like that and so that’s an extreme example of but you as you said it can take up to six months to just get your paperwork in order and all that stuff. ​​[Yazan]Yeah exactly and after that you have to apply for work and again it’s very difficult because well basically you have two options, you can either go to the NHS or go to private. Now many dentists who pass the ORE would prefer to go to work with nhs but there are reasons- ​​[Jaz]Why, Yazan? I don’t understand what’s this attraction to the NHS why I don’t see it? ​​[Yazan]I don’t think it’s really attraction I think it’s- ​​[Jaz]Maybe not feeling? Is that what it is? ​​[Yazan]I mean going through the ore it’s mentally difficult because you are a dentist you have several years of experience but someone out there is telling you no you’re not worthy you need to go over through this lengthy process and they challenge you and they put you through like very difficult experience so I think what happens to most of us including myself that we start to doubt ourselves, we feel that we’re not worthy of private we’re not good enough, so it’s just it feels safer to go to nhs I think this is what’s happening. But there’s also another difficulty like even like going to nhs like doing the door it will take you maybe two years at least sometimes three four years like in my situation yes for going through the whole process maybe took one year and a half till I passed not till I finished my paperwork but maybe two years with the paperworks but before that I had to come here to the okay I had to settle, I had to earn some money, some income to be able to go through the ORE so basically this whole process took me around four years so this means that I have four years gap, four years of not touching a patient. So it’s really difficult for employers to employ you in a private practice where you have this lengthy gap. So that’s also another factor and even yourself like you feel that yes I have good hand skills now. I worked in Dominican for several months but I haven’t touched a patient in several years and it’s difficult. But my advice is don’t really doubt yourself it’s fine you are a dentist you have experience yes you might do stupid things at the beginning like yes for me the first patient that I touched I was just retracting the jig so hard because I’m used to the mannequin cheek and it’s rubber and I need to drive to dreary heart so it’s like the lady just told me like you’re attracting my cheek so hard I just realized that I said oh sorry but that was it you know yes it’s fine we’re humans we make simply click exactly right? Not a big deal. So wow this is in terms of the private. Now the other option is to go to the nhs but to do the what is called the VTE or vocational training or now it’s called PLVE they keep changing the names but now there’s a new rule that if you want to go and do that well if you want to work in nhs you need to do the plve or the vte but in order to do that you should have at least three months experience in the past two years. ​​[Jaz]That doesn’t make sense because you just told me that the average person will take two years maybe longer to even get the damn exam passed, paperwork and stuff and you’re not allowed to work as a dentist during that time but then they suddenly say hey you know what we also want you to have experience how? ​​[Yazan]Well yeah many of my friends finish the exams and they wanted to go to nhs but so far I think nobody was able to do that since they passed this new law it’s just becoming impossible so the what some people are suggesting I saw that on WhatsApp group is to go back to your home country and spend their three months practicing dentistry and then come back. But first this is like after going through all of this you need us to go back to our country and to practice. Second this option is not really available for everyone my personal estimation is half of the people doing the ORE refugees. So for me like I can’t go back to Syria of course. ​​[Jaz]Oh my goodness please don’t. I’ll let you take a tooth out of me. I’d rather you do that than to go back to Syria, my friend. ​​[Yazan]Yeah exactly this is not an option actually for many of us so for me it was like impossible to go to the nation. So I had to go work in private but after working in private for three months like I mean yeah I have a job why would I leave it to go and work in NHS like yes it would be great but I already have a job I’ve committed I signed a contract so it’s like it’s a bit weird and the reason behind it is that it’s about the safety of the nhs patients which is also doesn’t really make sense how about the safety of the private patients and also does it mean that the ore is not good enough like why did we have to do it then like it the whole thing it really doesn’t make any sense. ​​[Jaz]You raised a fantastic point there. When did this law come in or when did this rule come in that you had to have this, do you know when it came in? ​​[Yazan]I think 2019, maybe 2019 like 2019. No I think it’s yeah late 2019 or beginning 2020. ​​[Jaz]2020 has everything bad that can happen even to ORE people 2020, covid throw in this three-month rule everything oh my goodness. So are you also subject to this three-month rule or not? ​​[Yazan]Yes of course but for me I wasn’t seriously considering the nhs but I did think about it but it wasn’t really an option so I just rolled it out but even if you have this the the process to apply for the plve/vte position it’s very lengthy. It’s very tedious process it takes between six to 12 months to apply it for to start working so what happens to people that they finish the ORE and they spent another year just either paper works or applying for vte position and like we need money we need livelihood, we have families and it’s just horrible. What most people do is they work as hygienists which is rewarding financially but after having gone through all of this tedious process is just yeah it’s just another unjustifiable hurdle. ​​[Jaz]I’m completely with you. I just want to say wow like just wow just hearing that I mean the reason I got you on and the reason I’m choosing to shout about this topic and help people is because I know people like you and shout out to my good buddy Chanted who’s now working in the northeast he’s been through this grueling process. So I’ve always appreciated how difficult it must be but you know what you told me today has just increased my level of respect for you guys like even more like it’s just amazing I salute you. So well done. But just so I think people are listening to this and people maybe if you’ve listened all the way this far into the episode you’re probably about to do your ORE or you’re doing your ORE or you’re going to do your ORE. They want to know what’s on everyone’s mind at the moment is how did you get a private job? ​​[Yazan]I don’t know. I think I was lucky. And seriously, I was lucky. And I was a bit bold. I think I just applied to jobs while I was preparing my paperwork and I actually got an interview and I was like I almost didn’t go because I seriously didn’t think that I would get it but the reason that I went I hope my employer doesn’t listen to this. The reason that I went is that I wanted to practice interviews. I never ever thought that they would grant me the job so it’s so yeah I was lucky enough to get this job. The thing is it was a practice that was newly opened so this is also a small tip for new practices there. There usually aren’t many patients, they’re not usually fully booked so that would be an easier access for us who finished ORE and it’s also give us time to get back to work like you get to take extra time dealing with patients. So that’s a really good start. ​​[Jaz]I would say I agree that sounds like a good scenario so it’s a win-win. You said you were lucky. I disagree with you. I mean you make your own luck right? You made the decision to be bold enough and being brave enough to apply. Yes you went for the interview experience but they obviously liked you for who you were competitive delegates so I wanted to say it’s not luck it’s you but I think the take-home point from that is don’t. Stop doubting yourself, stop doubting yourself apply for the private positions if you can do and a great pearl you shared is to maybe go for a squat practice a brand new practice that maybe your income will not be so high initially or because your patients will not be there but that suits you perfectly because you can spend a bit more time extra 15 20 minutes here and there will mean so much when you’re coming out of ORE and you’re practicing on patience again. ​​[Yazan]Exactly, it helps a lot. ​​[Jaz]Amazing I think we’ve covered. I didn’t have to look at my questions even once because it was just a flowing conversation and I didn’t have to look at my questions at all. So wow you did everything in which case my last thing to ask you is the microphone is yours my friend. What do you want to say to the people who are obviously very interested in this topic because they’ve listened all the way to this point, what do you want to say to them? ​​[Yazan]And if you are preparing for the ORE. It’s very doable. It’s very difficult but again it’s very doable just know how much commitment it needs in terms of finance, in terms of money, in terms of even like mentally and psychologically. It’s not easy for example not to be able to the exam or to fail the exam that for me that was the first thing I ever failed in my life but it made me stronger in a way and it’s fine to fail like many people don’t really pass it from the first time it’s completely fine and don’t over stress about passing from the first time and except that it is what it is and just do it and advice for.. sorry you wanted to comment? ​​[Jaz]I just wanted to say what so I never asked you what’s the percentage pass rate? ​​[Yazan]For part one I would say it’s relatively high. I think it’s maybe 60-70 percent. I forgot exactly how much but also take into consideration that many people, not many people but some people who apply for part one they’re not really preparing for it so it’s actually for those who prepare I would say it’s much higher if you prepare really well. Your chances are almost certain in passing the part one. The part two ranges between it’s different from exam to exam but it’s around I think 35 to 50% so not as high but if you take the higher number 50 percent it’s not horrible. It was in certain years maybe 10 years ago because I looked at the statistics and it was as low as nine percent. One year it was 90% and I think at that time the highest passing rate was 20 percent. So now people are able to pass but maybe 10 years from 10 years ago it was much even more difficult so it is becoming more and more doable. ​​[Jaz]Fantastic. Brilliant. One more thing. Please share with us. ​​[Yazan]Yeah my other thing is for those who are listening to us and who haven’t gone through the ORE, if you are in an employer or if even if you’re not an employer don’t look down for those who have done the ORE like I might sometimes say stupid things I might forget some things like for example I studied dentistry in Arabic so sometimes I just forget the names of things and I just say like you know calcium hydroxide but I don’t really remember the brand name that is used in this country. ​​[Jaz]Yes I did the same thing today. Listen, I’m UK trained. You know what I did okay I can’t believe you’re saying this because the same thing happened to me today. So my nurse Zoe she’s probably watching this actually if it comes up on instagram hi Zoe. So Zoe, what I did today was I was about to fill the canal with the non-setting calcium hydroxide I said can I get some non-setting calcium hydroxide and she looked at me blank and I was like crap are we finished? I was like okay I have to use Ledermix then right? I’ll say if you don’t have that. Can I have ledermix. She goes do you mean Hypo-cal? Yes I mean hypo-cal yes and even I did the same thing my friend. So don’t worry man. ​​[Yazan]Yeah so it happens and we’re not perfect but we are like colleagues, we are dentists and we’re not listed. We might not know certain things in this country, we might not fully know all the regulations but we are good enough to hire. ​​[Jaz]You 100% are and you guys are you know you are human you are you’ve been through such a grueling process I mean it’d be interesting to experiment one day like imagine we took a dentist the average dentist in UK and we just said hey you’re going to sit ore exam today I would be fascinated to know how many of us would even pass because it’s a serious examination I mean you go to labs and look at the preps that go in you can look at my own prep they’re not amazing to be honest with you. I bet your preps are better than mine she wants to do because of the practice that you get so I think it’s a grueling exam and I definitely echo your sentiments that if you’re listening somehow and you are in a position to hire someone don’t look down on the ORE grad give them kudos for passing such a crazy exam and help them out in that way. If you feel as though they are good enough don’t say that hey they’re the best candidate but I’d rather take someone with BDS or whatever look at them as an individual. ​​[Yazan]Yeah and also if you can’t think of anything else to support I know some people are considering some training programs or whatever anything that you can support it would be greatly appreciated and it is much needed because there isn’t much support out there. ​​[Jaz]That was very useful, yes and I hope you feel that as well that the information that you shared today had you had access to this two years ago I’m hoping that you would have gained from that. So thank you for spending time away from your wife and from Hasan to spend this evening with me to help people. I really do think you’ve helped people a lot so keep doing what you’re doing I wish you all the best success in our country and you are one of us and we are grateful that you came and you can now share your expertise and look after the patients in the best way you can so thank you so so so much, Yazan. ​​[Yazan]Thank you for hosting me. It’s been a pleasure. Jaz’s Outro:Well there we have it such a fantastic guy Yazan is such a sweet guy I mean he was a joy to interview and joy to speak to I really loved his story and his drive and I’m so happy he was able to find a private job like wow I mean I’m so pleased for him so well done Yazan. You really gave so much knowledge away I’m sure you’re going to help hundreds if not thousands of dentists who may be sitting registration exams for other registration bodies around the world. If you want to download any of the resources or find out the different Facebook groups or different courses there are supporting people who want to see the ore exam then just go to the show notes on protrusive.co.uk/ore and you would find everything there and again subscribe to the newsletter if you found value from this share it to someone who may be sitting the ore or is even thinking about it let them learn the journey the best thing to do is share this episode with them so I really appreciate all your support guys thank you for listening again all the way to the end I’ll catch you in the next one.

Move over, traditional crowns! These ceramic onlays are way more conservative and just downright sexier. But let’s not go crazy – like with all aspects of Dentistry, case selection is key. https://youtu.be/Rl9BF-sIHqI This is going to number 1 for 2021 – it HAS to! Need to Read it? Check out the Full Episode Transcript below! This episode is one for true Dental Geeks. Nik Sethi will adhesively blow your mind (wait….what did I just say?) Imagine a 1 hour podcast episode after which you will improve your Onlays like never before – THIS is that episode. From the painful temporisation of onlays to the delicate bonding procedure, Nik leaves no stone unturned. Grab a pen and paper! Protrusive Dental Pearl – use air abrasion on your Tanner/Michigan splints to help to see articulating paper marks more easily. Also it can be used to test compliance of your patients, as they will polish/grind away the abraded surface. Thank you Dr Tilly Houston for sending that one in! In this episode we cover: When to place large composites vs opting for indirect ceramic restorations How to incorporate Immediate Dentine Sealing in to your workflow without feeling you have done anything different or additional How to become more efficient with your adhesive onlay preps When to start overlaying cusps, and when to leave them be (the answer may surprise you…) The full bonding protocol with heated composite (etch and all!) HOW TO TEMPORISE THE BLOODY THINGS When to shoulder….when to bevel? Nik was really great – my only contribution to the show was the term ‘Vonlay’. You’re welcome, everyone! If you loved Nik’s down-to-earth style of teaching, do check out their courses: Elevate 6 – Elevate Dentistry (elevate-dent.com) By very popular demand Riaz and Niks hands on 2 day course covering their FIPO protocol: Leeds 12th & 13th March 2021 London 9th & 10th April 2021 London 23rd & 24th April 2021 Leeds 7th 8th May 2021  Leeds venue- Optident, Valley Drive, Ilkley, LS29 8AL London venue- Blue room venue 220, Headstone Lane, HA2 6LY 2 Day – FIPO – Elevate Dentistry (elevate-dent.com) Finally their pride and joy: Advanced Aesthetic Diploma. Diploma – Elevate Dentistry (elevate-dent.com) If you enjoyed this episode, you will love Emax Onlays and Vertipreps with Jason Smithson! Click below for full episode transcript: Opening Snippet: This episode will improve your ceramic onlays from that painful, temporarisation stage, which everyone worries about to the full bonding protocol with Nik Sethi... Jaz’s Introduction: Hello, Protruserati and welcome to Episode 59 of the Protrusive Dental podcast. Thank you so much for joining me. As always, this episode is wow like so jam packed. Like every sentence like you’ll have to definitely grab a pen and paper for this one is one of those crazy ones. And I know you will love it so much and I’m so excited to share it with you. Before we get to that I have some cool news. I’ve done a few extra videos I have one on YouTube on how to take occlusal photographs which you can just search for it. But recently one of my buddies [name], he asked me can you make one on how to take posterior quadrant photographs. So I show how to use the long buccal mirror and that’s all on the website also on YouTube. So check out my channel if you’re interested in how to take photos for posterior quadrant dentistry. I want to say a warm welcome to all the new members of the Protrusive Dental community. Thanks so much for joining guys really appreciate it. If you haven’t checked out the Facebook group, it’s called Protrusive Dental community and one of the listeners, one of the Protruserati, shall I say message on that asked if we have a whatsapp group. We don’t but now because of the demand like that thread has got like 80 plus comments of dentists of the Protruserati who wants a whatsapp group. So it’s coming soon guys, as soon as the splint course is done, and out and ready, and I’ve done the whole launch has been taking up all my time at the moment. So once that is done, then we will have a whatsapp group just to Protruserati. I want to give four more shoutouts before the Protrusive Dental Pearl and then we will have this epic episode with Nik Sethi. So the first Shoutout is for Sai Mehta, who is a great young dentist, buddy, thank you so much for all your support, also to Taha Adamji, who has made some phenomenal notes on those episodes with Zak Kara, Episode 10 and Episode 40 something on comprehensive dentistry and treament planning, you have done a wonderful job of making notes, which I’ll be sharing on the Protrusive Dental community as a PDF download. So thank you for taking the time to do that. And if anyone else because I know some of you guys take notes on the episodes, if you can just email me those notes and I can share them with the community. That would be amazing. Shout out also to Jenny from snowy Norway. Thanks so much for tuning in from Scandinavia. And last but not least, I’m going to read out an email that I got, which is just, you know, one of those moments where you think wow, just Wow, what an impact. And it made me so grateful to be able to have this platform with you guys. I really appreciate you guys listening and his emails like this and that which really just validate and keep me going and keep me podcasting. Right? So thanks so much. I’m gonna read out. I’m not gonna read out your full name because I don’t wanna embarrass you in any way. So it’s from Adam says, “Hi Jaz. I just want to reach out to say what a fantastic job you’re doing with the podcast.” – Thank you, buddy. “I’m a 40 year old GDP working in a city I won’t name and up until have felt stuck in a rut and had become a bit despondent with dentistry. Your infectious enthusiasm that you show your podcasts and your YouTube videos has really helped me reignite my passion for dentistry and I’m really enjoying learning then. The guests you have on the show are so interesting and so knowledgeable. I particularly enjoyed listening to the master that is Finley Sutton. I could listen to him talk about dentures all day.” I think we all can, Adam. “I’m enjoying my job so much more now. And you have even started a distance learning MSC program. I won’t which uni and I’m doing that alongside my job. Keep up the great work. It’s always great when you have one your new episodes drop and I can listen to them on the way home from work. Myself and many others out there. I’m so grateful for the work you put in. With all the negativity in the world right now. I still feel feels important to give people some positive feedback and praise where it’s due. Thanks again Jaz, Adam.” Adam, honestly, what can I say you have made my day, month, week, year with that email. That’s one of the sweetest things I’ve ever had. So thank you so much. I’m so so pleased that it’s made you more passionate about dentistry again, which is exactly the mission I’m on now, before it was it was a fluke that I made the podcast but now I feel like I have a purpose which is to help dentists become the best version of themselves. So thank you, Adam, and thank you everyone who have given a shout out to and thank you who’s listening or watching right now for tuning in today. The Protrusive Dental Pearl I have for you is a splint one and is dedicated to Tilly Houston. Tilly, thanks so much for listening to podcasts you sent in a slide from a lecture you went to at Queen Mary’s I believe, and it was about the use of air abrasion or sandblasting on a Michigan splint for a couple of reasons. And the reason why you would do this and typically I would usually do this when I’m checking for compliance. So by air abrading the Michigan or Tanner appliance, when the patient goes home and comes back and when they’ve parafunction on the appliance, you will get these polished areas. So you know they’ve been wearing it, right? And if they’re not wearing it, it still remains sandblasted or that’s how it goes. Now Tilly messaged me about that, “Hey, Jaz, have you heard about this?” But also, she also taught me from what she shared with me was that you can actually use it for getting your contacts as well. So when you’re checking your contacts, it is one of the problems is that when you’re checking with the articulating paper is difficult to get the markings on the polished surface. It’s only after I’ve adjusted it with the acrylic bur that I can see my contacts are much better. So to check your contacts if you actually air abraded or sandblasted the Michigan splint, then your contacts or articulating paper marks will show up much better. So that’s a great pearl. Tilly, thanks so much for sharing that with me. And so guys straight over to the main interview with Nik Sethi. Man, you will love this. Enjoy. Main Interview: [Jaz]Nik Sethi, Welcome to Protrusive Dental podcast. How are you my friend? [Nik]Amazing, mate. Thank you so much for having me on this evening. [Jaz]Dude, I can’t think of anyone else who is so anal about getting their onlays on so beautifully. And every time you blow them you know this, Nik, every time you post a case on Facebook, right? And I was like, Wow, that’s awesome, right? And then you’re like, oh, by the way, this is a temporary and you just crush all our hearts. [Nik]No, that’s that’s definitely not true. My temporaries are okay, but they’re not as well. My brother’s temporaries they are another level. My temporaries are alright. Basil and Sanjay’s temporaries, I can’t touch them there.. [Jaz]We know all about Basil and Sanjay’s temporaries. But not everyone I met. What I meant to say was you know, you could take every photo so well, when you post on and it such a something that you want me now I know your passion about lots of various dentistry but I know a [inaudible] and onlays and stuff, something that you’re quite hot on. And that’s exactly what we’ll be talking about today. And we’re gonna talk about like the really, really big things that comes onlay, that how to make them look invisible, how to temporize. That’s a massive one. That’s a biggest pain that Dentists have right how to temporize. We’re gonna cover that. We’re gonna cover about your learn about your workflow, you know, do you do IDs, do you not? What’s like your workflow? And that’s exactly what I’ve got you on for today. And I know you’re so passionate about it. So I’m really excited to have this chat. But before we do get into that, Nik, tell those people listening all over the world, who don’t know who you are, a little bit about yourself, what drives you, where you work, that kind of stuff. [Nik]So my name is Nik, I’ve been working in private practice in London, a practice called Square Mile Dental Centre for the last 10 years now, I can’t believe I’m already 11 years qualified, it’s crazy. And I did my qualification at Kings and I went back to do a masters in aesthetics at Kings as well. And I work for my brother, who is Sanjay Sethi, and a previous president of the British Academy of aesthetic dentistry for which I’ve just become scientific chairman. So big, big bruise to follow from Rob Oretti and Sanjay and people and so on. And Sanjay from day one, told me one thing that I would never forget. He said, Look, forget all the magazines and the posts you see on work looking pretty. He says, You’ve got the rest of your career to make things look pretty. So make things look beautiful, but if it doesn’t stick, you’ll spend the rest of your career replacing it. And so He hammered me on protocols, Jaz, I mean, literally my nurse Shaz, she’s like a second mom, she was like a spy, the number of times she ratted me out is amazing. His son would be so a naughty I’m so angry. So I know about protocols and adhesion dentist somehow think that we’ve got this right to be scientists, we’re not scientists where the end user of a toy that’s been made by billions of pounds of research by people that are far cleverer than us. So talking about what drives me, what drives me is the inspiration behind the people that made those products and those protocols and the science of how they got to those protocols. How did they develop this chemistry to be able to bond a tooth which is got water in collagen fibrils and provides a restoration that can bond to it and change it to a hybrid layer and make a restoration last 15, 20 years. For me it’s bonkers. [Jaz]That is crazy. [Nik]What breaks my heart is people abuse the protocols. You know what one right didn’t have to abuse those protocols set by the guys that have done so much research. So Sanjay with literally I mentioned this day, at the end of every week. And all I wanted to do at the time was go out and party. You know what it’s like I was 20, 21, 22 and San, he would sit me down on a Friday. I’d have to show him all my before and afters for the week. Every single one on the intraoral. [Jaz]This is you as a student? [Nik]No, this is me when I started working at Square Mile. So they put me through a rigorous six month training program. And he’s done that to every associate to be fair, and we have to show him our photos before and after. And he puts a kitchen timer in every surgery, and the nurse is pressed timeout, press start when you start the etch, and she will not let me wash until it’s hit 30 seconds. And then she was drying until it’s washed for 30 seconds. So from minute one, I didn’t have a chance to fall into bad habits. So I’m very lucky. It’s not because I’ve got a gift or an incredible brain, I’d like to consider myself as fairly academic and I enjoy studying. But when it comes to hand skills, my brother’s the opposite. He may not be as as naturally academic, but I’ve never see well, very few people I’ve seen with natural hand skills like him. So he really whipped me into shape. And that inspired me because I realized in dentistry people are very lonely. They find that very challenging. They’re constantly comparing themselves to this university of Facebook and Instagram. And realistically, you need a mentor, you need a collective of people around you, whether it be an academy such as BARD, PACD, Dentinal Tubules, you need like minded people that you can openly discuss your failures and I’m very lucky to have that. So if I can do my bit to help drive people to say that it’s okay to fail, because Lord knows I’ve failed many times, then that for me to see the light come into someone’s eyes like Sanjay did for me is a lovely thing. [Jaz]That’s brilliant. I can just say I’ve got visions of at the end of the day, Shaz going up to Sanjay was like, he didn’t use the 2% chlorhex rub and he only air abraded the mesial part, but he missed that distal part, or, whatever. [Nik]She’ll kicked me under the chair. If I forget to put a second layer of bond or something, she physically kicked me. [Jaz]That’s fantastic. Well, let’s dive right and ask you, the first clinical question, which is a bit about decision making, right? So every Clinician’s is different. What features of a tooth have a cavity of a fracture or just any toothpaste or a quadrant makes you the more towards an indirect restoration than a direct restoration? So what is your threshold? Is it the same as what the textbook says, you know, more than a third of isthmus, root field, that sort of stuff? Or are there so what’s your sort of decision making process with regards to that? [Nik]It’s a really interesting question. And I think decision making changes all the time over the years. And I always when I start my lectures, I always talk about traditional concepts and minimally invasive and whilst we mustn’t forget the traditional concepts, we also shouldn’t just blindly believe, for minimal invasive dentistry, we’ve got to have some, a lot of Didier Dietschi coins that beautifully minimally hazardous dentistry, you’ve got to appreciate the limits of adhesion, and also move away from heavy preparations where we can so there’s a wonderful article by Marco Veneziani , who spoke at the British Academy a couple of years ago, and it’s an article I recommend everyone to read. And he says that the best way to answer that question that you’ve got general factors and dentists, you know, you’ve got someone comes in and pain or a fractured cast, we’re very quick to just stick an ID block in and crack on. But we’ve got to look at General factors, meaning where’s that tooth in the arch. So I might treat a cracked Upper premolar. I have a patient who’s got canine guidance with no lateral contact differently to how I may treat a lower left seven, with a strong upper medium palatal CUSP with history of fractures, clenching and dietary habits. So the general factors would be the position of the tooth in the arch, the presence or lack of anterior guidance, the depth of occlusal schemes if they’ve got history of fractures or parafunction, and multifaceted issues such as tooth wear, say we’ve got our general facts, of course, but we’ve also got to appreciate the local factors and that’s what all dentists are pretty good at. And essentially, those factors have changed. So traditionally 1/3 or more of the isthmus, but now it’s been shown by Didier Dietschi, Pascal Magne, [inaudible] but on a vital tooth. Even if you’ve got one millimeter of residual cusp width, that’s enough thickness to be able to keep a wall with a good adhesive restoration. You know, today’s restorative composites are fabulous. So I do not take the decision to hack down a cusp lightly with the fact that these composites such as Venus diamond, GCs, G-ænial, ENA HRi , you name it, there’s some fabulous systems on the market. If I’m missing both marginal walls, if I’m a millimeter and an MOD cavity, I’m going to start thinking this is higher risk. Then if you compound that with endodontic treatment, and symptoms, cracks, you’ve got to start thinking. I must admit, I tried to be a bit more of a hero earlier on in my career and try to avoid because I thought I was being minimally invasive, but you’re not really because when that Does fracture, you’ve then got a bigger crime on your hands. So now I’m a lot quicker to decide to partially cuspal coverage doesn’t mean I’m hacking away buccal and lingual, but if I’m worried about one cusp, I will bring that down. Concerning a millimeter, 1.5 millimeters and then overlaying it with composite. And if it’s, I feel that that’s not going to work for that patient, then I’ll weigh up and decide to go indirect, which more often than not, because I don’t have a milling machine, will end up being a lithium silicate restoration. [Jaz]That’s a fantastic. Very comprehensive reply on [inaudible]. And definitely I’ll link to that paper you mentioned, for general reading. So I put it on the website, the show notes and on the Protrusive Dental community where, Nik, you’re welcome to join as well. So we’ll add that paper on, which would be really cool. It’s interesting. So about a millimeter remaining. Let’s say for example, buccally palatally, it makes total sense, because how many massive amalgams Have you seen where the patient comes in, and they’ve broken off the mesial buccal corner? But How long ago was that amalgam restoration placed? It’s been there for 30 years, right? So you’re completely right, with these modern additive systems, then I’m sure that will hopefully surpass it or change the mode of failure in a more favorable way, would you say? [Nik]Definitely, and it’s a fine balance, because dentist has to realize that whilst the adhesive material is getting much better, you can’t deny function. And this is what Riaz is really hammered into my brain. This whole, patients don’t just bite and grind left and right, we chew outside in, we’re hammering these cusps all the time. And if you don’t appreciate that function, and you rely purely on adhesion, you’re gonna lose because the body’s gonna win. But on the other hand, this whole thing of like, you say amalgams that I keep saying to patients, you know, Mr. Smith, we’re gonna have to replace this, but I will let the tooth tell me I went over to, and it’s still there five years later, six years later, it’s it’s amazing. And it’s very much case dependent. [Jaz]I love that what you said that quote, Mr. Smith, I’ll let the tooth tell me, I’m definitely gonna borrow that one. So that’s great. That’s a real gem right there. Next question that Nik is, talk us through your protocol, because I know you’re really hot on protocols, Sanjay has read drill that into you, right? So tell us about specifically, we know that the bond between ceramic to enamel is one of the strongest bonds in dentistry. So tell us you’ve got your rubber dam on, you’re doing a lithium disilicate onlay. And you’re about to fit just to briefly describe your standard adhesive protocol. [Nik]So we’re skipping past the first stage of the prep and IDS where we’re talking about the fit stage, right? [Jaz]You know what I would like your take on, I would love to hear your take on IDS as well. And you know, which global you use, you know, what adhesive system you use that kind of stuff. So if that let’s roll it back a bit, let’s talk about IDS, and then let that lead nicely to the fit appointment. And talk us through your protocol that I think we can learn a lot from that. [Nik]Yeah. So I mean, that’s probably more logical way for me to explain it. So traditionally, what I used to do was, I used to take out my restoration first. I used to build up the tooth with their core filling. And I’ll talk about the adhesive steps in a minute. And then I would prepare the tooth. What I found in my hands is, I found that took quite a long time to build up a core filling wait for you know, cure it layer by layer by layer. I didn’t see the point of it. And if the whole goal was just to block undercuts, then I thought, Well, why don’t I get my prep done first. So I leave my amalgam in, I will do my depth cuts, I will do my reduction, I will do my variable margins, which we can discuss later how I blend in my margins to make the ceramic look not invisible, but as close as I can to the enamel. Once I’ve done my margins, and I’ve done my contacts, and I’ve done my depth cuts, at that point, there’s not much restoration left, I remove the amalgam very carefully or whatever they are caries or composite. And at that point, I don’t have a massive job to do in terms of rebuilding. And with onlays. We’re not trying to rebuild a whole core because we want 2, 3 millimeters for the ceramic, we want the strength of the Emax. And I don’t understand when people are doing these big core fillings and then saying we only do 0.5 or 0.7 millimeter reduction. And I’m thinking is bonkers. It doesn’t make sense. whopping great big restoration in the middle. Why not have a thicker layer of ceramics. And the first thing is I make sure that I don’t even call it a core filling. We call it a mini core. So we’re essentially we’ve got rid of our amalgam. I always use air abrasion with aluminum oxide. And that’s because as you know, when you cut with a diamond bur, what we think looks nice is essentially hundreds and thousands of microcracks. It’s like throwing a stone at your window sale. You get all microcraks. So what an air abrasion system does is, it removes all of that so you get a nice clean surface, but also any oil from the handpiece, any residual biofilm that’s going to massively impact that adhesion is then gone. You don’t have to get a massive expensive unit, I bought a two, two and a half grand prep start unit people buy an aquacare unit and these are great and I’ve worked my way up to be able to afford and by that and save for it. But you can pick up a micro etch for 2, 3 pounds.. [Jaz]The latest trend, Nik, I don’t condone this but the latest trend because I’ve got a few buddies on Instagram who told me this, is their 80 pounds on eBay they go for a [inaudible] I don’t condone it in any way but they’re out there you know we know that [brand] are out there. We know that [brand] any country is over systems of air abrasion but nothing beats the gold standard like what you’re using but yeah, these are their options do exist. [Nik]Okay, perfect. So I said once the air abrasion is done. Then at that point, I’ve got a nice clean surface. And since I’ve been using microscope, honestly, the change is incredible. Even from loops to microscope, the surface you see of air abrasion is just stunning. It just looks like it’s ready to accept resin. It’s lovely. At this point, depending on my goal, my adhesive protocol changes. If I have not got a deep margin, and I’m not planning on doing deep margin elevation, if I’ve got nice supragingival margins, then my only goal is to seal the dentine and block the undercuts. And with flowable and maybe add a touch of composite if it’s too deep, and I don’t want any more than three millimeters of lithium disilicate has been shown by Professor Dr. ArcAngelo. If you’ve got more than three millimeters of lithium disilicate, you’re like your unit struggles to penetrate to cure the cement underneath. So three millimeters are critical level, and that’s quite easily achievable. He just measured to the adjacent marginal Ridge with your IMC probe. And you just build up your core to that point if you overdo it, or you can just trim it back. No big deal, right? So if I’m not going to do deep margin elevation, I’m not really bonding to any enamel. In that case, I generally don’t etch, I will go to a self etch system because I’m purely adding to my dentine. I like to use OptiBond™ XTR, I use a dedicated two bottle system, which is a separate self etch, and then a separate bond. Maybe because I’m pedantic and Sanjay has knocked into me you’ve got fabulous bonds such as G-Premio BOND, CLEARFIL™ Universal Bond and they all have the MDP monomer in, they all have the ability to self etch and I’ve no doubt that’s where we are going and I know I’ve no doubt they work terrifically well, but not having any trudy bonds in the last eight years with this system. It’s difficult for me to change when it’s not taking another 20 seconds right. So I like my water chemistry and I like my dry chemistry separate that’s that’s how I feel. So I do my self etching primer-dry-bond-dry-lightcure. I always light cure my bond for 40 seconds. Again being pedantic. [Jaz]Valo or no Valo? [Nik]Always Valo, man. I can’t do anything without my Valo. And that’s not a [inaudible]. [Jaz]40 seconds of the Valo is like three minutes with a normal life. [Nik]You know, it’s funny because I keep saying it doesn’t work like that. Chemistry is so funny. I remember when I first got it, I was thinking yeah, wicked I can cure this layer in five seconds now. But anyway, we’ll go off topic, but essentially, the power diminishes so quick, every millimeter you move away from the tooth, the almost hard. So essentially, if you’re six, seven millimeters away from the face of that cavity, you’ve got to give it time. And especially if you’re not using a powerful like your unit, if you’re using something that’s under 800 milliwatts per millimeter squared, you’re gonna get poorly cured adhesive. And this is why we see marginal staining, and post op sensitivity on class two composite because we’re not respecting the light. It’s like A Bug’s Life. Don’t look at the light, you know, light. The light is so important. And it’s, I always say to dentists, it’s the easiest part of the whole process. But we don’t give it enough credit. And we’re not light curing, we’re like activating, we’re starting a free radical reaction that will then carry on over the next 24 hours. So once we light cure I then use them flowable composite for the FIPO protocol, we use their G-aenial Flo, which flows really nicely, the universal injectable because it’s not too runny and you don’t want it running off the sides of the tooth. It’s quite nice to handle. If I’ve got dark amalgam stains or residual dark brown color from caries, then with lithium disilicate, if you’re going to use a high translucency block, which we’ll come to later at hiding margin and becoming invisible. Any grayness will show through and it breaks the aesthetics. So you can either use a more opaque block, but then you use that ability to blend. Or you take something like a baseliner from Kulzer, you get the Venus Baseliner, which is literally, I call it dental tip x. And it’s a drop of that, and it just completely masks it. And then I just cover again, with a touch of flow, [inaudible], we’re done. And in most of the time, I don’t even need to then go ahead and put composite on, because I’m usually at that point within three millimeters of the marginal ridge, I don’t need to build any more. If it’s a very deep cavity, I will then use my G-aenial posterior composite to then put a mini layer on to build and then cure it. But essentially, it’s very quick. Rather than rebuilding a core filling, putting matrix bands on and stuff I don’t need to I’m controlling where I put the flow. The whole process of the mini core takes me no longer than about four or five minutes. It’s very quick. [Jaz]I mean, you’ve got your mini core, but that is essentially doubles up as your immediate dentin sealing. Is it fair to say? [Nik]Absolutely. And in fact, one step further than that. There is a problem if you’re just immediate dentin sealing, the layer of bond we use for people that aren’t using a thick bonding agent such as OptiBond™ FL or OptiBond™ XTR, if you’re using one of the older generation, all in one bottles. Then what happens is your adhesive layer’s too thin, and you get an oxygen inhibition. So if you’re light curing, some of the adhesive layer doesn’t actually set. So you still have an uncured resin, which basically means your dentine isn’t sealed. So all the problems, you’re going to get possible sensitivity, poor bonding strength at stage two, these things can be easily over come by just adding a drop of flowable over the top to block that oxygen inhibition layer. And then you get the benefit of curing the adhesive fully because it’s blocked. And you can control the color and undercuts with the flowable. [Jaz]Brilliant. I love that. That’s fantastic. And you’re scanning at the moment, you’re taking What’s your flow at the moment? [Nik]I’ve just been scanning for the last year, we’ve just bought TRIOS 4, 3shape. And it’s lovely. It’s not without its learning curves. It’s not without its problems. So I wouldn’t say I put your impression materials away. It’s a learning curve. Now that I’ve got used to it, I hiked the dream, it’s lovely, because one of the biggest things is you can check your prep, and you can check your clearance immediately. Which for me, me being just the same as any other dentist I do what everyone does, I often used to under prepare the occlusal surface, the mid occlusal. And we used to complain our labs when we get a very thin onlay, but they’ve had no choice, we’re very quick to blame our labs. But if we don’t give the correct space for them, you know, they’re not Harry Potter, we’ve got our way either my lab would phone me in the past and say “oh Nik, there’s not enough space.” Either I’ve got to get the patient back numb up again, take off the temporary re prep or they make me a reduction jig which loses the accuracy of these minimal prep onlays which I don’t like. So with scanning, I can just check my clearance and I can see very quickly where I am. So from that point of view, it’s great, patient comfort wise obviously is through the roof and they love it from a patient perspective. It’s great for a I guess sellings a bad word but it’s from a communication tool. It’s been fabulous and just that digital design, being able to see the wax up design digitally the next day is amazing or no I don’t like this incline I prefer if we can avoid that contact. Normally you just rely on the labs just doing what they do or maybe they show you a day before the appointment you know which is no good. [Jaz]Absolutely and that said that function of checking the clearance has saved me a few times often the functional bevel area buccally where I’ve perhaps underprepared and be able to check out let me go back rub that bit out, prep again a little bit, give that bit of space. It’s just a dream also using the 3shape so that’s been great as well. So you’re now going to come on to the actual fit appointment and the protocol that’s you beautifully described the, your IDS version if you like, blocking the undercuts. [Nik]We forgot about the temporary because that’s not easy, but either. [Jaz]Can we get the temporary at the end because it’s temporary I want to give it a whole section because temporaries are so so I mean, everything is important don’t get me wrong, but temporary is I if you look at the because what I do is I’m wanting to on Facebook, the kind of questions people are asking what not and huge one is how can I get my temporary stick, right? I just wanted on the theme of protocols, I would love to get your the rest of your protocol and that can be chaptered off as the protocols. [Nik]So the one thing I forgot to mention is if I do have a deep margin, which is equigingival or just slightly subgingival then I have to make a decision because too many times I think I managed to isolate that at visit one I’m so good. When you come to Try and isolate a visit two, it’s a whole different ballgame, trying to get a rubber dam around the deep margin is much more difficult than putting a rubber down around the tooth and the margin goes deep. That’s okay, we can handle that. There’s so many times where I’ve been sweating trying to fit in onlay in the past, where I’ve got these deep margins, so at visit one I was giving myself a pat on the back. So just to rewind, if I’m going to be doing a deep cavity which has gone subgingival or a fracture, then I’m going to consider two things, I’m either going to consider crown lengthening, and then putting the rubber dam on immediately, and doing my deep margin elevation. But a lot of the time has been shown by a wonderful paper getsy in 2019 in the European Journal, that we were always taught this thing about biological width, you must have three to four millimeters from the crestal bone to your margin of restoration. And that was true for traditional prosth when you’re cementing a crown. But it’s not true for composite which blends in and you’re polishing the margin to a flush finish with tooth, you don’t have a fit of such you can get within 1 to 1.5 millimeters of crestal bone. And as long as that composite is smooth, the bone tolerates it superbly. So as long as you can isolate it, you can do deep margin elevation, only if I can’t isolate it when I then do crown lengthening. So if I’m doing crown lengthening, I will etch the enamel especially if there’s a little ring going up the walls, I want to make sure I etch that enamel because I will be bonding to enamel so then, there’s no chance I’m going to rely purely on self etch, I’m going to etch. Then we build up the composite for deep margin elevation. The reason being, I want to build up to make my margin supragingival. So that answering the next question, firstly, rubber dam placement is easy as pie. Because that is tricky. So deep margin elevation is a game changer for your second stage protocol. So now we come second stage, we get the onlay back, I check the fit. The nice thing is usually at this stage, I don’t need local anesthetic because I’ve done the mini course sealed all the dentine, generally, there’s no sensitivity. So you know, no one likes to put ID blocks back in for a fit and lots of local a lot of the time I get away without it. Temporary comes off, we clean it with a bit of air abrasion again, I check the fit of my onlay, I check the, lightly check the occlusion, I check the contacts, everything we normally do. And roughly check the aesthetics. Emax will always or lithium disilicate or LiSi whatever you use. With lithium disilicate, will always look brighter before you cement it. Once you cement it really acts as a contact lens that absorbs into the tooth. So at that point, my rubber dam then goes on. The onlay I go through my bonding protocol, we do the porcelain etch, I use the bond from ultradent. We then wash, we dry, I then use the I don’t have an ultrasonic bath yet. But I need to get one because apparently that [inaudible name], he said Nck you have to get a Sonic bath but I’m just using normal phosphoric acid etch after to try and remove the salts, which has proved not to be so effective, but I’m still doing it, then I prefer to use a separate Silane and then apply a bond and then you get these [inaudible]. But I prefer the chemistry to be separate. So we apply the Silane for five minutes, while the silanes going on, my rubber dam is going on. So I’m not wasting time. And I get my nurse to do a bit of this as well. So it helps, she helps me out. [Nik]Once the rubber dam goes on, then my onlay is ready to go in the heater. I put my onlay in the heater. This is a critical step. Because I cement all my onlays, the LiSi onlays that were used, I cement them with heated composite because I find number one, the aesthetics is incredible, which we’ll touch on later. But also the handling. Everyone in this room in this podcast knows how to handle composites, everyone’s struggles to handle luting cement because they go everywhere. And no matter how much you try and clean, you take that by a year later and you just see a bit of extra cement sometimes you think how am I going to get rid of this, then you’re there with scalpel blades, you know, whereas with composite heated composite, it just goes on like butter. So the tooth is ready, I will do a total etch technique this time because there’s no dentine exposed. So etch the whole thing, the enamel, the composite, air abrasion, so my composite is fresh and ready to go. Then use a same bonding agent which contains MDP. But at this point, you could just use a standard universal, 3M Scotchbond™, G-Premio BOND, universal all of these things, because there’s no dentine involved. So now you’re back on Easy Street. You can use whatever you want. Once that’s done, if you talk to the chemist, they say you must secure your bond, because you need to get that bond strength. If you talk to any dentist out there who has done that a couple of times, and you’re onlay then doesn’t fit, you don’t. [Jaz]So you definitely don’t, right? Cuz I was I was thinking, yeah, I’ve read that, you know, some dentists, you know, some instructions say cure, but I’ve made that mistake before and it’s not quite sitting as it should do. So the real world clinical advice is, it’s impossible. [Nik]It’s impossible. Well, it’s not impossible, because I have done it, and it has worked. But I mean, do you really want that to be the step that wrecks your whole, the whole plot of the story, right? You don’t want that. And you know, using a light like a Valo I’m pretty confident this thing is going to get through a brick wall, let alone a thin 1, 2 millimeter onlay. So we don’t cure, we dry, we air thin, and then my onlay comes out, which is warm, and then I apply warm composite, heated composite. Composite is an insulating materials even if you heat it, it loses temperature very quick. So by the time you faff around putting hot composite on a cold onlay, it’s already cooled down, and it’s going to be very stiff. We use the G-aenial because it’s quite nice to handle but previously, I’ve done hundreds with Venus diamond, which is lovely material as well, but it’s very stiff. And if it loses its heat, you’re not sure if it’s fully seated, you press, you remove the access, you press a bit more and more access in thinking calm when it’s going to stop and I have had a couple of incidences where I’ve tried to do a six and seven together, that by the time I get to the seven, if my nurse hasn’t put the composite back in the heater, the seven didn’t fully sit. And I took a post op extracts it didn’t feel right. And you think man nightmare. So a hot onlay. And making sure the composites back in the heater when you’re not using it, is the way to get around it. Composite goes on, I press I use the LM-Arte™ instrument a Fissura, the green Fissura, that we do posterior anatomy with, we remove the excess with that, Elaine taught me that trick actually it’s lovely. We remove the excess, floss the contacts, keep lots of pressure on the tooth. And then we ligth cure it for minimum one minute per surface buccal lingual occlusal. And then I go around another 20 seconds using an air blocks such as Oxyguard or liquid whatever it’s called is this few on the market like light liquid barrier. Then the nice thing about that is because composite drags together, there’s no cleaner, I’m not spending more than literally, the only thing I spend then is adjusting occlusion if I have to, there’s no cleanup as such, because everything’s just dragged away nicely, I might use a composite brush over the margin, just to make sure that as you’re dragging the composite, it doesn’t pull between the composite, between the onlay and tooth, I would use my Fissura and then go over it with a brush. So there’s no dragging. Then we set it and remove it. Check occlusion, adjust. And I have to say it’s the least stressful adhesive cementation technique that I’ve had for years because I used to use you name it Multilink, Panavia flowable composite, a lot. And I never enjoyed it. I’ve never enjoyed cementing with a dual cure composite. I just, I’m a slow dentist, I take my time. And I don’t like the fact that someone’s telling me I’ve got one minute to clean this thing up. It’s a stress I just don’t need in my life, Jaz. And so with a dual cure composite, you know if you’re not quick, and it’s an upper left seven with a patient with difficult access. It’s not fun. It’s really not fun. [Jaz]It’s not fun to use those little interproximal sores there. Trust me, I know. [Nik]Exactly. And the other thing with dual cure composite is, I know they’re getting better and the color stability everyone talks about a Delta numbers and they’re getting better and better. But you put it in a smoker, and you show me four years later because I’ve done it and every time on these ones where I’ve left the margin in the mid buccal aspect thinking I’m amazing. When they smile, I can see a little stain line. And it breaks my heart because I followed all the steps. And maybe it was my hands, maybe I’m just not good enough with dual cure composites. But having found that since I’ve been using a true light cures nanohybrid restorative. [Jaz]Amazing. Man that protocol was amazing. And I know for those listening out there who maybe struggle with these mini steps, I think you’ve covered it so well that’s worth another Listen again and again again because that’s how well and you float it so nicely. An interesting point you made about how composite drags together and how you can use the composite brush for example, to just brush the margin and use that Fissura instrument and I believe there is some evidence might have been by John Canker that if you use rotary instruments to clean up that you actually end up getting a void or a gap. I think David Gerdolle told me that actually in a Tubules lecture, and so, so much better to use like you said the brush to brush it out rather than using the rotary instruments afterwards. And I imagine you don’t get as nice of a finish by using rotary instruments afterwards. [Nik]Of course. And, you know, how many times have you seen a patient that’s finished ortho, and you can see a tiny bit of excess ortho cement on there tooth, it’s not the end of the world, right. And essentially, even with this onlay if there’s a tiny bit of excess composite at that margin, it’s composite, which we use for restorations if it’s smooth, I’d rather leave a couple of microns of excess composite. And if it stains over the years, I can use a brownie or a polisher and polish it back. We have this obsession with getting absolute flushed to the tooth. And it was bioclear that really turned my head around saying anything adhesive doesn’t like a margin. So we’ve got to get our things out of our head about having a finish line. It’s got to be an infinity bevel. So I always air abrade past my margin, because I don’t want flush, I want bond, I want a true bond to that residual enamel. I don’t want flush I’m having to pick off. It’s a different, whole different concept. But to me, it makes so much sense. [Jaz]Brilliant, chamfer versus bevel? Which do you choose? When? For example, when you’re doing the onlay? Are you finishing with like a shoulder chamfer? Or more just like a bevel? Or do you do vary between the two? Or obviously a butt joint sometimes as well, can you just throw that in there? [Nik]Yeah, I’m looking forward to when we’re doing a hands on course, because we’ve had some really cool type of dogs made that make this really clear, because I’ve tried to explain it a few times without pictures, and it’s tricky. I’ll give it a go. But essentially, the tooth has a point of maximum bulbosity, the widest point, and they call colloquially referred to as the equator. So the equator of the tooth is a very important point because coronal to the equator, you have an abundance of enamel, two millimeters thick enamel in all planes. Beautifully aesthetic, rock solid stiffness, that’s the key, aesthetic and stiffness. Apical to the equator, you lose enamel rapidly, and you end up with very, very thin enamel and rapidly as soon as you touch it with a bur you’re in dentine. So now you have a more flexible material, and you don’t have that residual stiffness that you’d have from your enamel. So this is why your margin has to change according to where you are on a tooth. If you are coronal to the equator, then you don’t need a big shoulder. You don’t need that millimeter of ceramic that we were taught schulenberg incredible traditional crown and bridge prosthetics. All you need is some form of what we call a contact lens margin, something that used almost like a rugby shaped diamond to create a gradual contact lens purely for an aesthetic advantage. But also like we do on anterior teeth you create this adhesive advantage because you expose not hundreds but thousands of enamel micro prisms. So we optimize an aesthetic and an adhesive advantage with a contact lens margin. If we now roll back, if we’re doing a contact area like a mesial aspect, anytime you’re breaking a contact, you’re going to be below the equator because by definition, a contact point is going to be the widest area right? So apical to that, if I’m going to have a more flexible dentine, as Pascal Magne shows us we need to replace the stiffness of the tooth. So if you have these knife edge finishes in lithium disilicate, which I’ve done, you can see chipping. And I again tried to be minimally invasive in the past showing ultra featheredge margins down in deep areas. And I’ve seen chipping in numerous cases. And I didn’t know whether it was my protocol. But now having read and understood a bit more on my journey of which I still consider myself young in that journey. And it makes total sense that patience is biting down, chewing in and out and what takes the force is the rest of the tooth near the cervical area but has taken that Brunt. And if you’ve got a flexible material and a thin ceramic edge, it’s going to fracture. So a buccal to that equator, we got to have a thicker shoulder, a traditional shoulder that’s going to be about one millimeter thickness and Marco Veneziani describes this really nicely as well to replace that stiffness on the tooth and then all you do is take a round ended tapered diamond bur and you just connect the dots. So you’d do your contact lens margin buccal lingual wall, your shoulder margin, medial distal, and then you just roll up the walls and allow the two to meet. And you have this lovely graduation from shoulder to contact lens. And again I’m making gestures with my hands which looks silly for those of you listening on Spotify or whatever. I’m making Mexican wave type gestures but eventually on the course we had these typodont made where we have a colored onlay like a blue or gold onlay cemented on an ideal prep. So the delegates get to prep through that colored onlay till they get back to the ideal prep. So it’s gonna help them visualize where we want what and why? Because I’m a very visual person. And so I’m a typical Essex boy, I need things explained in the most simple way possible. And if I can get it, anyone can get it. [Jaz]Dude you explain that so beautifully and do send me details of the course. Because you know, what usually happens is someone that’s passionate you do comes on. And people always bombard me that, hey, you know what, Nik was awesome. I want to learn more about onlays from him. So I’ll rub, just take it on the website, it’d be easy to find. So I will add that to the show notes because those models sound amazing. And I think you guys were the FIPO protocol, what I seen a really got something great going there as well. Now we can really nicely touch on, because you’ve explained that beautifully about what type of finish to have where and it makes so much more sense in relation to the equator, which is just a genius term. How can we make our content lens margins or any margin that we’re finishing mid buccally? Because we want to be more conservative. How can we really get to blend in without having that, that show through, that visible differentiation between the restoration and the tooth, like, sometimes I’ve got haven’t I’ve had an aesthetically demanding patient on a premolar, for example. And for someone who’s not aesthetically demanding, I’m happy to finish mid buccal alright? With my lithium disilicate. With someone who’s aesthetically demanding, I turned it more into a Vonlay like a veneer onlays, that buccal, I’m gonna drop it right down.,sacrifice that enamel for the aesthetic advantage. Only because I’ve doubted my skill to be able to nail it in that high demanding patient. Any gems you can share with me? [Nik]Well, Jaz, you being harsh, Didier Dietschi, he himself says that the ideal place to have a finish is either in the incisal third, where it’s all enamel, or the cervical third where it’s all dentine, the user, the operator should be very careful about placing a margin in the mid third, where it’s a combination of both, especially if it’s visible in the smile zone. So this is the master of bonding himself saying this so it’s not like anyone’s doing anything wrong by dropping the margin more apically. So the first tip I’d give, sit the patient up before you numb them up, smile and mark the extent of the tooth that you see. I use just I’ve got a hundreds of black markers I just buy from Amazon, I just mark the line on the tooth. And when I’m then preparing if I’m anywhere near that black line, I’m going to extend it apically. So if I’m not in the incisal third, if I’m getting close to somebody is going to be seen, if in any doubt, I do exactly what you do this I like where you call it a vonlay. I’m going to I’m going to nick that, that’s great. And so then I’m with you totally because it’s risky. If it’s a lower molar in a patient that’s not as aesthetically demanding, then I’m going to push it and go mid buccal. There are some cases where I feel like No, you know what I trust even my lab technician and Steve Campbell, I’m going to go for it. And we do get really nice results. And the way to do that is number one, not have a flat tabletop, if you have a flat tabletop, you’ve got what we said earlier, you’ve got a finish line composite doesn’t like finish line. If you’ve got this contact lens, that is the same principle as our class four, you’ve got this margin of error with this bevel effects. The second thing is the translucency of the ingot that you use, because if you’re using a opaque ingot, no matter what you do, it’s gonna look so different to the tooth underneath. So you’ve got to start looking with products like LiSi, you want to look at the high translucency blocks. Because they are, they are like a contact lens. This whole process is like a contact lens. So they absorb the color very well from the tooth underneath. And then you submit with just a normal A2, A3 composite, we use the posterior A3 composite or whatever the tooth is on that on and it picks up the color beautifully. The only caveat being is if there’s any residual staining on the tooth and you haven’t blocked it, it’s gonna look rough and it will show through even if it’s on the occlusal it will still affect the color from the buccal aspect. And I’ve had a couple of cases that I really regret where the there was heavy occlusal staining and I didn’t put enough of the baseliner. I thought it’s okay, but buccal was fine. It totally showed through. It’s amazing. It really does flourish through that too. And then the other thing is using composite rather than luting cements. The composites are designed to be strong, but the composite is designed to be beautifully aesthetic with the optical properties they have the filler particles, they’re designed for that so why are we still messing around with luting cements I don’t get it. We’ve got a material that is designed to blend, heat it and that’s the key thing for me and that’s been a game changer, but in an aesthetic demanding patient. And with the 100% you got to, don’t make your job harder than it is. [Jaz]Well said and I think anyone who’s sitting on the fence who has been not confident in changing their protocol from a dual cured cement like Panavia, which I am a big fan of then moving to a composite, I think your protocol today and how you described it is really going to get a lot of confidence to move on to that and your your tip about heating the onlay is fantastic. Just a point about Emax in particular. So lithium disilicate Emax five, that’s the one I’ve used more of, I tend to go for like an LT, or low translucency or an MT, medium translucency ingot is one better than the other for trying to blend in your experience? [Nik]Well, the more translucent so low translucency is going to be difficult, because you’re going to have that obvious change. Because it’s low translucency and medium will be better. The high translucency are the ones that are going to blend in the best for sure. But the color of the tooth underneath has got to be good. If you’re doing one of Vonlays, you’ve now coined it, I like that, and you’ve got a dark tooth, let’s say non vital, then you don’t want to be using our high translucency block, then you can go for a low translucency block, it doesn’t matter because you’re in the cervical area anyway. And you’re finishing on the an area which is mainly denting which is more chromatic and easier for that lab to mask. So I think it comes down to operator technique of how we’re finishing that margin. It comes down to documentation with our photography, our labs are not magicians, and I feel sorry for them. They give a, they’re the hardest job. They don’t have the emotional glory that we get when something goes great. But they get all the when something goes wrong. [Jaz]It’s totally cool on this podcast, man, I love that. I’ve got I’ve got some technicians who listen to this actually. And they’re gonna love that. So shout out to Graham from truform lab is a buddy I’ve met and met on Instagram and we chat quite a bit now. Quite a few technicians picked up so they wil love that they will really appreciate what you said. [Nik]Oh man. And listen. I say to young dentists, if you want to learn how to prep a tooth, talk to your technician, people just don’t do a [inaudible]. People don’t talk to their sales representatives who are trained to know the best protocol for the product you’re using. And people don’t talk to the lab technicians who are making prep your onlays on your preps. Now get their advice. Let them you know critique I always say even now I say to either forced to I use for my high end cases, I’d say to either let me know if we’re struggling or something and what I can tweak next time. And there’s always something, there’s always something. To this day, every time I think I’ve nailed it, I’ll look at my postdoc photos and think close but now I’ve got to work on this. But essentially, communication with lab is very important. You need to have a lab that has got the gusto, the skills that can do it. So I’m not saying the dentist should blame themselves for everything. The lab also has to be damn good. And you need that marriage of harmony between you, find someone that you work well with. And if you’re dentist who’s trying to find a lab that’s going to do a lithium disilicate onlay for 20 quid, you’re not really going to have that quality. I mean, do you want to charge 20 quid for doing onlay? What do you expect if you’re getting charged 20 quid for the ceramic, right? I mean, even certainly not cheap. But I charge accordingly for it to the patient. But the time he spends that bespoke character we get from it the little craze lines he puts in, the white effects and you just put it on you think, Oh man, it’s just music. It’s beautiful. When you somebody wants to go on. That’s the key. I think she’s done. Amazing. [Jaz]That is also I love it. And this moves us on to the last big theme of this podcast, were reaching that critical one hour point, right? But this is so so so so big, right? Onlays, we’re doing more and more onlays, I feel that dentists are doing it more and those dentists who aren’t doing it, then they have an opportunity to learn from people like you, elevate FIPO, to learn how to do these preps to get because a lot of dentists don’t have faith. They don’t have the faith in bonding because they start to traditional methods. And they need to move and learn about the protocols. So, that you’ve done so beautifully described today. But one thing that annoys everyone is temporary. So when you’re doing the onlays that’s more in the direction of a tabletop, let’s say, it doesn’t have to be but even then, you know, compared to a traditional crown, you don’t have that retention form, right? You can have a little bit resistance. We don’t have that classic retention form because that’s coming from your composite, that’s coming from your Panavia or whatever you’re using. It’s coming from your etched enamel. So therefore, the risk of the temporary coming away is much higher. So what are Nik Sethi’s top tips to temporize onlays? [Nik]Well, first thing I say is it’s not as fun as with a traditional crown. I mean, I did Basil’s year course and he really I opened my eyes to how to do provisional properly on a traditional prep. And I love realigning with acrylic, and I love nailing my provisionals for full crowns or verti prep crowns, it’s stunning. I really enjoyed watching the tissues mature. With onlays, Listen, you’re saving so much tooth structure, there’s got to be a weak link in this chain. And the weak link is the temporary here. I’ve got some tips do I have all the answers? No. But what I will say is two things. Number one, if you’re working with a lab that can turn around work quite quick that even if the onlay attempt does come off, because you’ve done immediate dentin sealing and a mini core, there is no sensitivity. I’ve never had a patient that said to me, Well, no, that’s a lie, I’ve had one. But hardly ever do we get a patient that has sensitivity if the onlay comes off, and it’s a matter of a week or two and they’re back. I’m not saying that’s a great situation. But if it does happen, it’s not the end of the world. However, we have come up with a couple of little things that have dramatically helped. But one thing I don’t like to do, which I know some people do, some people like to spot etch and just bond the provisional on like we do for veneers. I find that risky because after I’ve done my immediate dentin sealing and my mani core, even if I’ve used an air block, I’ve had situations where my provisional has bonded and I couldn’t get it off. And then I’ve had to prep through and we start again, that’s no fun for anyone. With veneers, it’s different, you got a lot more leverage. And it’s not the same, your preparation even more smaller. But when you’re doing an MOD with an onlay you’re in trouble because it will lock into that MOD area. So I don’t like to shrink fit them as such. I’m not a fan of that, because it can bomb underneath. And also with shrink fitting, you often get access, you know, you can put wedges in to reduce that. But you know, you’re relying on precision gums at visit two and you’ve got inflamed gums and you’re trying to isolate this thing. That’s not fun. So I am doing a traditional putty index before. But here’s the key thing. I’m trying to improve that patient all the time. So if I’ve got a deficient, lower right six occlusal amalgam when the walls have cracked, a lot of the reasons why that would have happened is because the dentist infra occluded, which I probably did a few years back infraocclude that amalgam, the residual cuspal walls take a lot more pressure, they end up fracturing, right so before we start prepping a tooth, what I like to do is look at the opposing tooth and see how’s that tooth over erupted. Do I need to reduce that palatal cusp? Riaz came up with a great idea for the FIPO concept where we put a blob of composite on the tooth but some glycerin on the opposing tooth get the patient to bite together and we cure it. We take a scan of that because that shows the lack of perfect inclines that they need because it is a negative of the opposing cusp. And what I would then do is I would then take an index of that after I shaped it up. So my temporaries already gonna have a better occlusal function and what they came in with so we’re getting better every time. Once I’ve then made my using a bis-acry or just to make my temporary onlay.. [Jaz]So there’s this thing Bis-acry is like protemp or integrity that kind of stuff? [Nik]Exactly. Luxatemp, Protemp you name it. We put a bit of glycerin over the surface. I try not to use Vaseline because Vaseline doesn’t come off and it will interfere with your temporary cement. So I use a bit of glycerin I then use my Bis-acryl. I let the material set for a good three, four minutes you know trying to just pick it off after a minute is still too flexible and the shape will shrink while you’re adjusting it and it won’t fit so well. Then once I’ve adjusted it and I’m happy I don’t use Temp-Bond non eugenol i think is useless. I think it’s rubbish. It’s one of the worst materials I’ve ever used, the Temp-Bond is great if I know I’m going to be using glass ionomer cement then Temp-Bond is great but Temp-Bond non eugenol I slightly mixed Vaseline and on purpose just to piss us off. But sorry whoever makes Temp-Bond, no offense. But essentially I like to use Poly-F i find that it’s much more attentive to the tooth. It’s bactericidal, the gums come back looking beautiful. And if it’s very non retentive and I’ve got someone with bruxist features or parafunction, I will just get a bit of acrylic like tab 2000 or get a coe-pak, the acrylic.. [Jaz][Jaz] Trim? [Nik]Trim. I think you know, you just mix a tiny bit of a trim. You put a bit of monomer on the bit of, sorry, bit of bond, a universal bond on the adjacent teeth, and you just mix a tiny bit of trim, and you put it on the onlay and lock it into the tooth next door just under the equator, you make sure you’ve got space for the TPN. So also… [Jaz]That’s so Basil. [Nik]Yeah, that’s, you know where I got that from, right? So you’re just tacking it in with a bit of Trim, so that you’ve got that physical protection. It’s not bulletproof, but it was personally reduce the risk. [Jaz]That’s really good. I did appreciate it and it makes sense. I did appreciate that you can, because I make my temporaries also out of Bis-Acryl. But for some reason, I don’t do it, what you’ve suggested, because I just always thought I had to use acrylic to do that. But you’re so right, these modern, seventh generation, whichever generation we’re on now, with [inudible] and stuff, the acrylic can bond to that and you can tack them in. So you’re completely right, we’re reminded. [Nik]Just like we can re face Bis-Acryl immediately with flowable. Right? Or composite. It’s the same thing. It’s got a resin base to methacrylate resin maybe with a resin base. So you can apply the Trim before you started, you know, glazing or polishing, you still want to rough this Bis-Acryl surface there, lock it in. And it works really well. It’s, it is a I would say it’s an improvement on the amount of decementing that we have. But I do say to my patients, I show them the prep I’ve done and I showed them a prep I had done in the past on a full crown prep and I still do a full crown preps you know, discolored teeth, parafunctions. I haven’t checked Schilling Berg’s textbook in the bin By the way, I’ve got massive respect for Basil and people are doing traditional preps, I still do my other things are currently as a lot. But more often than not, we’re trying to veer away. And for those kinds of cases say to my patient, okay, the worst thing that’s going to happen here is your temporary may come off, but it’s unlikely to be sensitive. And we’ll see quite quick to get this turned around. But biologically, we’ve saved a tremendous amount. We look at the studies by Sorenson [inaudible name] And we look at Saunders and look at the rate of tissue, the amount of volume you lose with a full crown prep 60%, roughly, and you look at the loss of vitality around 20% with full crowns. Whereas with onlays like this, it’s no different to doing DO composite. [Jaz]Brilliant and two observations, I think I’d say is a with the zinc oxide cement that we or polyethylene or that we use as a temporary cement because I also do that i think that’s another reason why patients don’t get sensitivity is because if the onlay was to come away, it leaves that thick white cement layer which is just brilliant for preventing sensitivity again, and obviously a good ultrasonic scaler can just you know frazzle that way. [Nik]Absolutely picks off really nicely low power, and just be patient, and far too, or trying to, you know, be aggressive, but ultrasonic works by the power of the ultrasonic breaking down the surface, not the pressure of your tip. So, you know, I see young dentist, remember training them and they digging on that tooth and I’ll say, you know, chill. Turn the power down, take your time, find that little edge and just work on it. And then suddenly, a whole sheet just pings off. And it’s just being a bit more patient, I guess. [Jaz]Brilliant and a real pearl I took from you as well as to use the trim and put it in the side onto your Bis-Acryl using a latest generation bond material. That’s, great. And that’s better than some ways I’ve tried it in the past whereby you can etch the buccal and the palatal. And then you sort of put a blob of flowable in a little bit on the enamel, leave on a Bis-Acryl. But it’s annoying, who wants composite on their buccal and the palatal? It’s annoying. It’s fiddly. Yes, it can be effective, sometimes not so much. But I think everything you covered in terms of the very beginning looking at the occlusal shape and the way that the opposing tooth will guide and excurse with it. To use it with cement use and these little accessory techniques, it’s just been absolutely fantastic. Any other points or I think you’ve covered that comprehensive [inaudible] [Nik]I know, I mean, I’m really excited about doing the kind of courses and stuff we’re doing as Riaz as next year. Riaz blow my mind with occlusion, my understanding is picking up very, very quickly on that. And the preparation kind of protocols. I hope we’ve made it quite simple. But in terms of bits of guidance, you know that the type of dentistry we’re talking about, you really can’t do unless you’re using magnification. So I mean, all these kind of subtle contact lens margin, equators put that all in the bin if you’re not using magnification, so I tell any young dentists, go and get a good pair of loupes. And don’t start off with 1.8 and build yourself up, jump in and get a decent magnification get us get a powerful light. And, you know that’s the only way we’re going to start to ever see the type of modern adhesive dentistry, that the loupes, a micro etcher and, you know, in terms of protocols, it’s lovely talking about how we can blend in a margin but understand the bonding agent you use, go look in the drawer rather than say, nurse, give me the bonding agent. Have a look what it is. Is it a self etch? Is it a total etch? Have a look at the manufacturer’s instructions. You know, we somehow just like kinder eggs we become kids when we start using these things. I don’t need the instructions. Give it to me. You know, these things are there for a reason. Pick up the instructions. I’m not going to tell you which bond to use, but use whatever bond you’re using to the best capability that it cannot be and light cure, get a radiometer which of cheapest chips from eBay and measure the power. Is it 800 milliwatts per millimeter squared? What’s the wavelength range? You know, traditionally we know that composite has a photoinitiator camphorquinone which is set for 50 to 490 nanometers is activated to that. Camphorquinone is very yellow. So a lot of composites, you talking about blending in margins, and class four composites or posterior composites. The older ones used to go for a yellow one of the reasons is because of the camphorquinone, so in a response to try and reduce that they use different initiators now, for phenol P, all these other things, but they don’t activate at the same wavelength. Some of them activate a 400 nanometers, some of them activate 500 nanometers. So if you’re using an LED light curing, unlike the old halogen lights, the Optilux 501, a halogen light has a very wide wavelength range, and led as a very narrow wavelength range. So if you’re using a single LED light that’s catered for camphorquinone, which is 450 to 490, but you’re using a composite that has accessory initiators, you could be following the instruction and cure for 20 seconds, but you’re not giving light have the right energy to activate that initiator. So you need to make sure using a latest generation multi LED light, you can use the Valo, there’s a liight cure from GC, that translex 2 again, there’s loads of great lights out there. But it’s got to be more than 100 milliwatts. It’s got to be multi LED. And you’ve got to look at the beam distribution, it can’t just have a focus hotspot in the middle and then very, very weak on the sides. I know we’re getting a bit off topic here. But essentially, this is more important than blending in of a margin. Because if we don’t appreciate that bit, it’s going to get — in four years anyway. So what’s the point? [Jaz]Amen, brother, dude, I love your science. I love your passion. I love your geekiness man, I’ve actually forgot how geeky you are, Nik, there’s been a brilliant amount of but in a good way. We love Geeking this one and this is what this podcast all about. So Nik, honestly, you must send me any brochures, any websites you have for the course because people can definitely message saying where can I find them? So I’ll stick them on the show notes for this. This has been up there with probably at the level of Chris Orr and Prof. Paul Tipton as to the you know one of my clinical heavy and I mean that in a good way because we’d like these now and again these these heavy ones that Yeah, yes, you’ve got the the ones that we talked about like we’d Rajiv Ruwala, 10 successful habits of dentists, which is so much fun. But when you get this really geeky one, these ones I love with you, Nik, we’re just now it was so full of workloads at every stage, I was visualizing exactly what you’re doing the restoration, exactly what I’m doing what we’re doing for tooth. So I know we’re gonna get loads of like, applause and messages just saying wow. Nik’s protocols we’re on fire. So Nik, thank you so so much for giving your time this evening. I know you’re such a busy guy. [Nik]It’s no not at all, mate. You’re super busy. But thank you. It’s been a real pleasure. And I’ve been looking forward to doing this for a while actually I was quite nervous about coming on air with you. You’re like a celebrity in the dental world now. Thank you. Jaz’s Outro: Guys, What did I tell you? I told you what infratry and certainly there were so many knowledge bombs in there. It was phenomenal. Nik, thanks so much for doing a wonderful job. Guys, Thanks so much for listening all the way to the end. If you liked it, share it with someone who might be placing their first onlay or maybe their 100th onlay. And they might just gain something from the temporisation or from the bonding protocol that they can use on Monday morning. So thank you so much. I’ll catch you Same time. Same place. Next week.

I am joined by a Dentist fellow podcaster himself, Dr Payman Langroudi, to help you improve your teeth whitening results right away! https://www.youtube.com/watch?v=n-PSjGsICbw Yes – that’s a fluorosis case I treated in the thumbnail! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Using the patients’ aligners as a whitening tray – and better yet, the use of Vivera retainers and Enlighten whitening to Guarantee B1 shade! https://youtu.be/VSQp-etyhZI Are all whitening gels the same? In this energetic and conversational (yet educational!) episode, we discuss: Light based systems – surely it’s all BS? OTC products? Is there a dark horse? Why and HOW to do more whitening cases (simple but effective!) Predictors of poor whitening response (watch out for these patients) Why impressions are still better than scans Whitening tray seal The best way to improve sensitivity If you enjoyed this episode and want more free training with Dr Langroudi, check out his free online training for Dentists You will also like my episode with Manrina Rhode on the nitty gritty details of Porcelain Veneers Click below for full episode transcript:  Opening Snippet: But you know, if we don't talk about this, where is the dentist? Where's the patient going to get this information from? They're going to get it from the hairdresser. They're going to get it from high smile on the internet. They're gonna get it from their best friends. They're going to look for this information. There's no doubt about that. You don't even need to be in the dental field to understand that the color of teeth is the most important thing... Jaz’s Introduction: Hello, Protruserati. This is Jaz Gulati, and welcome to Episode 58 of the Protrusive Dental podcast. I appreciate you for joining us. Today is such an impactful hour that we have on teeth whitening. Now a lot of you thinking teeth whitening, come on, Jaz that’s so basic. Just get a tray, wax, some gel in and that will whiten the teeth, right? Well, no, there’s so much more to it than that. And this is going to be probably the most impactful Real Talk 60 minutes of teeth whitening content you ever heard. I think everyone needs to hear it because today’s guest is Payman Langroudi. He was a dentist. And then he founded Enlighten Whitening, which is the premium brand of teeth whitening in the UK. And what he’s doing is amazing. He’s such a massive supporter of young dentists and dental education. So it was an absolute honor to have him on and he really covers it in a real talk fashion, right? We don’t know it’s not to scientific, it’s not to blah, blah. It’s actually so easy to listen to Payman Langroudi talk about these things. I hope you enjoy and follow along with great ease. We talk about all the important things that you should know as a practitioner for teeth whitening like comparing the different tray designs, what might surprise you is that a gel is not a gel is not a gel so all the gels may not be the same and you know we’ll look into why that might be the case, how to maximize success by reducing sensitivity and how and why you should be doing more teeth whitening right now. The Protrusive Dental Pearl I have for this episode is whitening related. Did you know that you could be whitening your patient’s teeth during tooth alignment. So a lot of my Invisalign patients will be whitening as they go along. But the magic really happens at the end like some of my patients will whiten so well during their aligner phase that there’s hardly anything to do at the end. But that’s rare. That’s when they got all the best enamel and their protocol is really good and everything just aligned. But a lot of patients will need the final teeth whitening at the end in their retainers. But the Vivera retainers by Invisalign and this is not sponsored by Invisalign or anything. They are fantastic, right? We all know how good Vivera retainers are. And because the seal is so good, that enlighten whitening actually guarantees a B1 shade if you use their enlighten whitening system in the Viveras. So the first time I learned that I was like whoa That is crazy because it speaks volumes about Vivera retainers, but also speaks volumes about an enlightened, the fact that they understand that hey, it’s not just their high quality trays they respect that, there’s another system out there in Viveras that will produce a good seal and that’s why with that gel that able to guarantee that B1 shade and sometimes right when I told dentists about this they said you know where the attachments are, don’t need get like a tan line where where the tooth has not whitened it’s just not the case you know, we know that the teeth whitening gel goes under the enamel if you like and it’s not gonna leave any patchy areas that didn’t whiten so that’s not a concern that I have and it hasn’t been for my patients but certainly but especially in the retention phase if using the Viveras they make fantastic whitening trays. This episode is sponsored by Enlightened Whitening and I really appreciate their support for the podcast. Payman is one of the Protruserati and I’m ever so grateful for that. So it was really great for that reason to have him on as well. And I hope you enjoyed this episode but I just want to say what a few more words about my experience with Enlightened. Everything from the branding to even the courses that they put on with the mini smile makeover has that premium feel and patients can really sense it when they go on their website for Enlightened Whitening or when they get the packaging. Even the trays when you get the trays from Enlightened, you can tell there’s something a level above for their trays. So I just want to say thanks so much to Enlightened for sponsoring the show. Really appreciate it. And I hope you all enjoy this episode. Main Interview: [Jaz]Payman Langroudi, Welcome to Protrusive Dental Podcast. How are you? [Payman]I’m very good, man. Thank you very much, Jaz. As one of the Protruserati myself, I’m very proud to be on the show you know my favorite podcast, my favorite dental podcast. [Jaz]That’s really awesome to hear and I really appreciate that with your what you and probably doing with their DLP, Dental Leaders Podcast is amazing as well. So many great guests you’ve had on the, international superstars from us, here. I mean, that’s been probably going on for just over a year now with DLP? [Payman]Yeah, but you know, we talk about this, Jaz. Yeah, we’ve perhaps got a 20 man marketing agency. I’ve got five people in my marketing team and yet you managed to do more on your podcast than we do. Now, let me tell you they’re not all 100% working on our podcast. But it goes to show, that passion is where us at. You know, [Jaz]I appreciate that. I have got two guys working for me now, though. So thank you, John Ali media and Paris Kahn, who do this all the bits on the side for me. So it allows me to have more time with family and stuff. Because it’s great, fun and passionate. Before the beginning, it was all me. But then you know, there comes a point we need to let others do the work so you can have more time with family and stuff. So So yeah, it’s a much more automated process now, thankfully, otherwise, where would I find the time. Right? It’s one of those crazy things. So I don’t know how you guys squeeze it in, you know, you’ve run, Enlighten, MSM and Prav with, you know, not eating or drinking anything for 21 days. All the crazy things he does. I don’t know where you guys find the time. [Payman]Yeah, he’s a totally different animal to me, man. [Jaz]It’s just amazing. So it’s so good to have you on because I want to talk about teeth whitening, particularly the bits that, you know, when I’ve done your one hour training before, used Enlightened before. I’ve done whitening, I feel I’ve done more complex cases, as you’ve seen as well, some really horrible brown marks I’ve created with purely whitening and micro abrasion. I use whitening as part of my icon protocols. I use whitening alongside clear aligner therapy. So what I want to tackle is the controversies, that troubleshooting, the bit when things don’t go right, and how we can identify and help dentists with that. And who better than to you but you know, there are some people who may be listening from around the world who don’t know who you are. So Pay, just tell us a little about your backstory, and why you are a great person, in my opinion to talk about whitening. [Payman]Yeah, so I’m a dentist, but I haven’t practiced now for 10 years. I we started a whitening company. And we started off actually with light activated whitening, which I’m sure you’ll get to. But back in around 2005 we stopped with the light activated, and we decided to move into tray-based whitening. And yeah, so we’ve got a tray based system, it’s probably at the higher end of the different systems. It guarantees results, you know, we get very, very good results every time. The, for your listeners in the US the closest thing would be the KöR system. So we did collaborate a lot with Rod Kurthy. Back in the day, when he had written his book and all of that, so yeah, that’s kind of the whole story. [Jaz]Brilliant. Well, you mentioned it straight away. So let’s not you know, let’s go straight for the kill. Light based systems, okay? Let’s do some myth busting. Okay? What it’s all that about? Because we, you know, early on dental school, we get taught that it’s a load of BS, and it’s just a sales ploy. It’s that sort of stuff. So what could you say to the dentist? I mean, are we right? In our interpretation that is all BS? Or is there some positive benefits that perhaps we’re not really stopping listening for? [Payman]No. It’s all BS. You know, dude, like I say, we started with light activated, and we believed it at the time. And then, you know, it came down to cover half the light over and see. But if you go to the research, then no, it really doesn’t make, the real shame of it is that while there is still dental systems out there that used lights, then all of the sort of over the counter, things that people are seeing pop up on their on their feed, you know, the high smiles, the snow whitening, all of those ones are sort of referring back to the light of the dentist. And, you know, I guess that’s not doing harm to patients. But, you know, at the time when we were isolating the teeth, and then putting these UV lights on and all that often nothing, often nothing. [Jaz]I think you raise a good point that there was at the time, a belief that hey, you know what this could be helping, this is activating. So it’s not that from the beginning, it was all like, hey, let’s scam people. It wasn’t I’m sure it was never like that. I’m sure there was a belief system, but then the evidence came out actually, it doesn’t make a difference. And so I admire the fact since the last 15 years, you guys are trained by systems. So you have that’s much to be admired there. So we’ve hit that one on the head where we can move on now. So light base is rubbish. And I guess you raise a good point, the high smile and those little lights that people show. Conor, Who’s that boxer the Irish guy? [Payman]Yeah. McGregor. [Jaz]Yeah, he had a little Instagram ad I saw of him showing it off or whatnot. That little light you stick on him. Yeah, that just shows there’s a lot of marketing to be done. People perceive it as a high quality system because they still think that hey, there’s that whole laser whitening, the light whitening, you know, all that sort of stuff. So there has that history behind it, I guess. So. [Payman]The over the counter stuff has changed the way things trend on the internet. But you know, we also the charcoal trend that came and kind of is going. But that didn’t have any basis in professional, you know, there’s no dentists using charcoal to do anything and yet it trended. Whereas these light ones, because you know, people can see that there are dentists using light, then it somehow makes it much more like it’s a real thing. I honestly, you know, since I was involved in the business myself, and I fully believed in it, I think even the people behind these lights believe in them, because they know no better, you know, I don’t think they go out to scam people, most of them. But they don’t make any differences as he asked the question. [Jaz]And what about these? over the counter whitening systems? I know, they’re all like, you know, they’re not going to be as clinically efficacious? Or as your hydrogen peroxide or carbamide peroxide? No way, it’s impossible. But is there a black horse in there? I’m sure you guys have looked well into this, maybe test some stuff out? Is there something out there that actually is looking promising? Maybe something enzymatic or any, anything that could be good? [Payman]well understand, first of all that outside of Europe, you can use up to 6% hydrogen peroxide over the counter. So you know, the, you know, the same concentrations that we’re using in the clinic, are available over the counter, all over the world, outside of Europe, and certainly for me as a [?] on a developer of teeth whitening systems, that’s a goal. Yeah, you know, I feel like I have two goals, one to really make that one hour thing, work, you know, to make teeth white within an hour. And two, to produce the best system that’s possible without actually visiting a dentist. That’s not gonna be possible in Europe. In Europe, people still have to go and buy that from a dentist without making a tray or whatever. But there’s a long way to go. Because the first one of trying to make teeth actually white within an hour, we’re nowhere near that. You know, we’re sort of trying to get the difficult cases down from four weeks down to three weeks. And that’s a massive achievement for us. we’re nowhere near an hour. But on the other side,. [Jaz]Is that because we’re limited to the gels, or do you mean like any gel, any percentage, that for an hour? [Payman]Any way, I don’t think it’s possible. But the other one of creating a system that people can buy, and actually make their teeth white. You know, people are spending millions on these high smile and snow and over the counter products that do nothing at all. I think there’s the space there for improvement. And certainly, you know, I’m working on that I’m you know, I see that as my two goals. [Jaz]Let’s kill it. Let’s ask a question. Hopefully, you don’t, Pay, I know you won’t mind you take these really cool. What do you feel about them? Because you know, dentists feel hard done by that, hey, beauticians do what they do, or the fact that people can spend their hard earned money and on stuff on the pharmacy, that doesn’t really work. But what you’re trying to say is what if you could make something that people could buy? That would work, but then what about those people who will never bother going to the dentist and now are potentially if a successful product exists? Whitening without having seen a dentist in that potential scenario, if you want to be successful with point number two? [Payman]Well, we can see it with the the white strips, right? That they’re selling. There’s not harm being done to patients. Okay, it would be good if they visited a dentist just for their dental health. But I don’t think that you know, as a dentist, obviously, I would like people to come see dentists. Yeah. But I don’t think that strips are doing harm to people. You know, my thing is, there could be improvement on the strips themselves, a better over the counter system. As I say in Europe, you still have to buy that from a dentist. And the way I’m thinking about it is if we do manage to make a breakthrough there, it would be something through a hygienist you know, like do you want fries with that? From the scale and polish? You know that you can have your teeth cleaned? Hygienist, do you want fries with that? Just go home with this box. Yeah, and whiten the teeth? And you know, the biggest problem in whitening I’m sure we’ll get to it Jaz is that we don’t do enough of it. We don’t.. [Jaz]Absolutely I want to talk about that. Absolutely. [Payman]That you know that we’ve got a massive opportunity. Now the public want this. They’re probably more interested in the color of their teeth than everything else put together, you know, outside of a missing tooth. I really think they’d be more interested in the color of the teeth than alignment you know, anything where you know all the stuff that we look into in examinations, man, I mean your occlusion expert, you look you know, the dentist will look into slides, interferences, center line, shifts and all that and then not mentioned shade to the patient, the number one thing on the patient’s mind. We’ve got to get over that. We’ve got to see it as education. [Jaz]Let’s go straight for that. Let me there are so many questions I’ve got to ask you about that. That was one of them. Right? How can we do more whitening? Is it basically as simple as we are, as dentists as clinicians, not communicating in the best way possible to be able to give our patients the shade they deserve? [Payman]Yeah, we’re not discussing shade. We’re not discussing shade. I mean, I know you’re a progressive dentist, Jaz. So maybe you do, maybe with every single patient, in every single examination. [Jaz]I’m not doing that. And I’ve listened, I’ve heard this, I read and I’m listening to you say before I went to your online training, and you said that right? Discuss shade with every patient, probably for about two weeks after you told me I did it. But guess what happens? You know, you get a habit and you don’t and you know, it’s a hands on. But say you’re right now, but [Payman]There are good reasons for it. Yeah, and the reasons are, we don’t want to annoy people. We don’t want to offend people, we don’t want to come across as pushy salesmen. We don’t want to embarrass people. And you know, those are all really good reasons. But the My thing is, it should be part of the education, it should be like oral hygiene instructions. But you know, if we don’t talk about this, where is the dentist, where’s the patient going to get this information from? They’re going to get it from the hairdresser, they’re going to get it from high smile in the internet, they’re gonna get it from their best friends, and they’re gonna look for this information, there’s no doubt about that. You don’t even need to be in the dental field to understand that the color of teeth is the most important thing to our patients. And that’s the sort of the massive elephant in the room the disconnect, the most important thing to the patient isn’t being talked about by the dentist, you know, and [Jaz]You’re so right, so what is it, is it as simple as just taking a photo with a shade tab with for every patient and saying, hey, you are here on this scale? And then let the patient make the comments or you know, is it as simple as that? [Payman]There are different ways. Linda Greenwall, she advocates using an a three shade tab only, and saying, look, this is average, you’re either average, you’re slightly below, you’re slightly above and introducing it that way. For me, the reason why I think the reason why we don’t ask lots of patients about it, is because there is a type of patient who may get offended, embarrassed or annoyed. Anecdotally, I would say one out of 20 is like that. But we see, you know, pre COVID, a lot of us would see 20 patients a day. And so that’s one a day. And the problem we’ve got is we don’t know which one, we don’t know which one it’s going to be, is it going to be the first patient or the third patient or the eighth patient? Who’s going to feel that way. And because of that we sort of tiptoe around the issue. We don’t discuss it anywhere near as much as we should. And then I don’t know what you think. But I would think anecdotally, that half your patients would be interested in whitening one day, maybe? Yeah? But those guys never get to hear about it. Because we’re so worried about that one. And so we’ve put a process in place in these, you know, our regional centers, the ones where we really focus on those practices to try and get over this issue. And the way that I’ve figured about it is for the for the receptionist to get over this issue. So before the patient even sees the dentist, the receptionist takes permission for shade taking. And she says in a very simple way, she says, we’re going to take shade on all our patients, so no one feels like they’re being singled out or embarrassed. Or, you know, we’re taking shade on all our patients, because we’ve become a whitening center or because the color of teeth changes. The color of teeth change, you know, because we want to monitor that, because we’ve got whitening offers whatever it is, as long as there’s a because in there, we’ve seen, we’ve done this 140 times now. And we’ve seen 80% of patients say yes to that. [Jaz]So this is you giving permission to the receptionist to inform the patients that part of their examination will involve a shade analysis? [Payman]Yeah. And 20% say no to that. And that’s super cool. The whole thing is there to filter that 20% out. But then 80% say yes to that get a piece of paper that then positions the practice as a whitening center, maybe offers or on their scheduling, you know, timing, patient comes in with a piece of paper. Now the patient’s asking you for shade taking, there’s no excuse you know, there’s no reason not to do it. I’ve seen dentist go from doing two a month to doing 20 a month because of that one change. And you know, there’s massive unmet demand for whitening in most practices. [Jaz]I love that. And you know what? I like I said, I went to your online training. I applied it a little bit. I didn’t continue. So I’m going to give it a go. So by time this episode comes out, I will maybe in the intro when I record it I can tell people it’s different. So, tomorrow so Zoe, my nurse Zoe if you’re listening, my nurse, Daria now if you ladies are listening, make sure I’m on this. And we’re going to do it as a practice. So that’s amazing. I love that. And I also, I mean, I don’t want to let this gem let go that you just mentioned. You said as long as you mentioned, because, yeah, because that is important. Okay? Because we know there’s a there’s a famous study, I don’t know, for me referring to that study, the photocopier study in Harvard or something.. [Payman]Cialdini. [Jaz]Yes please tell us about the study. [Payman]Basically, as long as there was a because 80% of the people let the person in front of them, when they said, Can I jump in front of you in the queue? They said, because it didn’t matter what they say after because.. [Jaz]it was a cue for photocopying, basically. And it was you know, if you just ask, you get to get many yeses people don’t get annoyed. And when you add a because that becomes so much more powerful. [Payman]Yeah. If you don’t put a because it actually flips it and 80% say no. And 20% say yes. That’s a simple, call it a trick of the mind. But actually, it’s getting over the dentists, variability. I mean, there’s variability between dentists and even within the one dentist as your say, so that you know that some dentists will mention it to lots of patients, many dentists won’t, when patients come in with this piece of paper, then, you know, you’ve already got permission to talk about this. [Jaz]I think I can immediately think it’s so easy, I think to apply this to new patients, because you can have it as part of your new patient. And obviously, more difficult now pandemic, paperwork and sheets and stuff with because now I’ve just started working in practice where they had the same dentist for 32 years. And now I’m the new guy, right? So this might for my situation a bit more challenging, but doesn’t mean I can’t do it, you know, because they’ve already seen new changes, we have now got intraoral scanner, we’ve got Telly in the room, we’ve painted the damn wall now that I’m here. So there’s so many changes, I’m sure they can accept one more that, hey, I’m doing a shade analysis, because color of teeth changes. It’s important to keep an eye on this and they’ve already used to be taking photos. So let’s do it. I will definitely do that. And I think if anyone’s listening, and you want to do more whitening cases, because let’s admit it, whitening is fun to do. And patients like it. And it’s good for the gingiva. I mean, let’s be honest, has health benefits as well, and for root caries, and there’s so many health benefits to discuss in that respect. So I think we can all, Protruserati crack on. And let’s see if as a group, we can be doing more whitening. So thanks for sharing those gems. [Payman]One other thing, but we, A lot of us do mention whitening when we’re doing a treatment plan or some sort. Yeah. So you’re going to do some aligners, you’re going to do some composites, when you smile making whatever it is, you’re going to mention whitening in that situation. The ones that get missed a lot of patients who need nothing at all. There’s many of those in some practices where there’s you know, the hygiene team are doing their job properly. There’s loads of it, the majority of patients come in every six months without need nothing at all. That patient gets ignored from the whitening perspective all the time. And that’s perverse patient to do whitening or who’s you know, the reason that guy’s brushing his teeth too well, isn’t to keep his gums pink. The reason is brushing his teeth so well is because he wants to keep his teeth white. And for the dentist or the hygienist to say to that guy, Look, you’ve done so well with your brushing, that it’s that affirmative thing, that’s what he wants to hear is, you know, valid. So you’ve done really well with your brushing, you need nothing because you’re brilliant. What about stuff you might want, like whitening? A majority of those patients will go ahead. But you know, we’re so stuck on the reason I’m asking you this. I’m so worried about asking you this, because, you know, I don’t want to offend you. But the reason I’m asking is this, because you can’t have your whitening after these fillings. That’s a very easy and obvious thing. So stuck on that one that we forget, you know, those guys who need nothing too healthy patients are most likely to go ahead with whitening. [Jaz]That’s so true. I never even thought about it that way. Because it’s so easy for me to say, Hey, we’re going to build up your lateral incisors. Why don’t we improve a shade and a matte shade? That’s an easy conversation. Now we know I think every dentist should be able to have that conversation. But you’re right, these are people who are doing great. They obviously care. They’re maintaining oral hygiene and a whitening will do wonders. I think so that’s another group you’ve identified that we can definitely help. Now that leads nicely to the next question I will ask you is sometimes you help these patients with all your best intentions. And something doesn’t go to plan. They come back and they all know it has happened to me before they say it’s not as white as I was expecting or haven’t found the result. And I think I know where I’ve gone wrong in the past. And it’s a diagnosis issue that I’ve had, and I’ve overcome it. But can you think of some good two, three points, Why whitening is not as successful as it is? As we know, as we know we can because we all got great cases in our hands and photos of that. So let’s tackle that one. [Payman]So first thing is most dentists you’ve done quite a lot of whitening will have some cases that were amazing. But the teeth went off the charts right? That sensitivity was low. The teeth stayed white, there weren’t lots of white patchiness or opacities and so on. Maybe the patient was delighted and referred a friend or whatever it is. What I would say to you is, on those occasions, everything went right by mistake. And really what you’ve got to try and do is try and make everything go right on purpose. So from the, if we stay away from the clinical factors, what actually makes things more difficult from the patient perspective, just if we’re talking about what you’re doing, there’s four key areas that go wrong. And it’s the impression or scan, and we should get to it, but we still prefer impressions to scans. So the data capture whichever way you do that, the lab work, the gels, and the desensitizing protocol, whatever that is for you. Any one of those four goes wrong, the treatment will go wrong. And so from the operative perspective, you know, we’re getting hundreds of impressions in every day and lighter. There are, you know, I’m sad to say, quite a lot of poor impressions come in. And I think it’s something to do with, it’s your mindset, when you’re using alginate, isn’t an alginate mindset, you sort of may be in a hurry and thinking of study models, where it really doesn’t matter what that gingival margin looks like, I think the same dentist, if it was taken an impression for Invisalign with silicon would be paying a lot more attention to making sure that gingival margin’s perfect. So the best thing you can do as a dentist in the operative senses take a really good impression. It sounds obvious, but we do get quite a lot of poor ones we do. So that’s the first thing, then, the lab work. And we should get on to that you know what tray, and what doesn’t. And what I can tell you about that is that as important as the protocol is the technician themselves. So you know, it takes us six months to train the technician to the standard that we’ll need. And a lot drop out before or get kicked out before they get to that point. Sometimes you can tell within a month that someone’s not right, for the job. And in technician circles when I tell them that they balk at it because from a technicians world, making bleaching trays is like the lowest of the low. But to make a really good bleaching tray, the technician is key. There’s a lot of sort of flaming of the edges going on, which actually, instead of you know pushing it in lifted out, there’s lots of things you can do wrong, you can manhandle the thing too much in the finishing and ruin it that way. But the protocol is also important the amount of pressure in the machine, that the material you use, a bunch of things like that. So a good tray. [Jaz]I mean, essentially, the most important factor of the tray is the seal, right? I mean, the ability to keep saliva out, Am I right in saying that? [Payman]Absolutely. And you know, for me, Jaz, the best way to test that, if I’m testing two different designs, the best way for me to know the answer to that question is to make them both for myself. And try I mean, it sounds unscientific here. But when I say myself there’s a few of us in the office, let’s say there’s six, eight people, will make the same mouth will make three different designs for and all of us will try them in and you can tell, you can tell I was very focused on the front of the mouth as far as retention and so forth. But as I’ve got more experience, I’ve noticed the back is more important even you know that flapping about of the thing. Get saliva in, you know, it just makes it a problem. So, you know, the right tray, the right retentive tray that keeps the gel where it is absolutely right. Well, let’s go to the gel. Right? [Jaz]Yeah, sorry, I just got up. Yep, [Payman]And the gel, look that the end, it’s this common thing that surround that peroxide is peroxide. And this one is the one that kind of annoys me the most of all of the different myths out there. Because, you know, I can see when what happens when we get batches of our gels delivered to us. And then those are used by the users. And the ask, this is why we changed our whole protocol regarding how it’s shorter, the distances between the factory and the dentist, because we were finding that near the end of the batch. We were getting problems. We were getting problems with sensitivity and with whitening at the same time. And it’s counterintuitive because you think, well sensitivity is a function of more oxygenation. And yet we were getting more sensitivity and less whitening at the same time at the end of the batch. And, you know, talk to a bunch of people about it. I’m no chemist, but what I can tell you is that it goes beyond the sort of GCSE chemistry, which is the two h2o, 2 goes to 2 h2o + O2, oxygen, it goes beyond that, you know, we’re in the sort of the hydroxyl radicals and peroxyl radicals, the oxygen ions, and then there’s a hydrogen ion that happens. So as this thing breaks down, it becomes acidic. And it’s that acidic nature of a broken down gel, which increases sensitivity in the process. So we’re very focused on this. But even if, even Enlightened gel is different, in different parts of the batch, and we try and really minimize this batch variability, by ordering small amounts, using it up on in small amounts, reusing it up, we had a problem over lockdown that some was left, some was left over, you know, over that three month period, we had to get rid of. So the idea that Enlightened is the same as Polas, the same as Boutique is the same as Zoom is magnificent, because you know that they’re there, the viscosities are different. You know, the, if you’ve done, if you’ve used any number of gels, you should know, I mean, some cause more chalkiness, some cause more sensitivity, some take you to the grayer kind of angle of white, some take you to the yellower angle of white, there’s so much variability. It’s not even, you know, a close, but I think this dentist, you know, we named these things by concentrations. And for that reason, we think it’s like 200 milligrams of ibuprofen, you know, this is totally stable, solid. Yeah. Whether you buy it from, you know, ibuprofen or from boots should be stable. Bleaching, the reason why the thing whitens teeth is it’s a volatile liquid, it breaks down and this isn’t that breakdown, where the action happens. So, you know, the same syringe, two syringes are different, depending on how you keep them and what you do with them, let alone different brands. You know, it’s,.. [Jaz]I think that’s a busted that myth. And I really appreciate it because I saw a recent I mean, we see these threads all the time, and they use exactly what you say on Facebook, whatever. Oh, it’s all the same [inaudible] It’s a 6% hydrogenperoxide. Right? And there’s that mentality that we have, but recently, just three days ago, someone said, on a Facebook page, which is the best etch, right? And then people were like, acid, like as a joke, right? I think what might make gossip like it, whatnot. But then but then my buddy, Rajiv, who has also been a guest on his podcast before he said, Listen, it’s the same — right? It’s acid etch that 87% of phosphoric acid, with a lot of people said actually don’t have, you should the UltraDent one versus this one was that one, some are running some of this and I get a better etch pattern with that. So as you mentioned that I was thinking this is similar, but different. Chemistry is different. [Payman]We all accept it with composites, right? You know, we will have our favorite composites, but they all got the Bis-GMA, the glass filler, the silane coupler, and if you want to talk about the ingredients of them, they’re basically the same. But we all agree hopefully, that you know, no offense, — composite is different to — hopefully. [Jaz]I might beep that one out this one. I’ll beep that one out. So no offense, unnamed, composite brand. And then the last one was of you going all the four things were important to get right sensitivity, tell us about what’s the best way to manage sensitivity? [Payman]Yeah, so one important thing is that, you know, I’m preoccupied by improving the tray. Now, as you improve the tray, you keep the gel against the tooth for longer, that makes whitening better. But that does increase sensitivity. And every time we improve the tray, we’re waiting for a problem with sensitivity. We’ve done it enough times now, and that is the case, sensitivity is a common side effect. From our perspective, we like external desensitizers. Desensitizer that are not in the gel, and we have the absolute bare minimum of desensitizer within the gel. It’s actually doing an opaquing of the teeth is that’s there for a different reason. But we desensitize externally. What that means is you can target your desensitizing the say exposed dentine, for instance, but it also means it’s almost like the way I think of it is, you know, that famous thing about shampoo and conditioner. One’s doing one thing, the conditioners doing the opposite thing, the it’s similar thing, but the gel is kind of opening the tooth up, the desensitizers kind of closing the tooth and having them within the same format. If you can’t optimize on both is the way I think of it. So we do use external desensitizers, we have a dentist applied one and the patient applied one and the 10 desensitizing toothpaste. Those things altogether, minimize sensitivity but but as important is the tray and the gel, as we said, if the gel is broken down in this acidic, that’s gonna cause lots of sensitivity to. [Jaz]It can mean it goes without saying that the patients I found who have struggled to get on with whitening due to sensitivity. They’re sort of doing one day and then two days off, then one day is two days off. And then eventually they get bored, and they only really get a one week like a whitening. And then they’re the ones later on is that Oh, yeah, I tried whitening once. It was okay, it wasn’t as good as I expected. It’s because they weren’t able to be consistent and get enough whitening time in, Why? Because sensitivity. So that’s an obvious one, obviously, that needs to be managed so that you can get the response. [Payman]A lot of times we’ll blame the patient in that situation. Right? And it’s an attractive idea. But compliance is the patient’s responsibility. It sounds like it should be right, the patient’s not compliant. But compliance is definitely sensitivity related. You know, if you can manage sensitivity properly, you’ll get compliance, there’s, that’s a key thing. And you know, you’ve got to manage sensitivity. We’ve got to anyway, I mean, as a dentist, right, you might treat 100 patients with really 1000s of patients, it’s important for us to be able to, to manage sensitivity. As I say, it’s linked to all the different parts of it. It’s the kind of the one that goes wrong when everything else goes right. The perfect impression, a perfect tray, a perfect gel means you’re gonna have these high concentrations for long periods, sensitivity goes up. So you’ve got to manage sensitivity as well. [Jaz]I’m surprised you didn’t mention three other things, which I was thinking that you would mention in what makes effective whitening and helps you to reduce those patients who are left unhappy, and those three for me are two are diagnosis related. One is communication related. So one diagnosis related for me is parafunctional patients, nocturnal parafunction, surely they should be having the daytime hydrogen peroxide and not the Carbamide Peroxide, your views on that? [Payman]So certainly look, parafunction is by far the biggest problem but I was focusing on system relations. So let’s get to the patient. From the patient there are six things but the by far the most important one is parafunction. We still prefer carbamide over hydrogen peroxide, even for daytime bleaching. [Jaz]Okay, on a daytime. Right. [Payman]But and we still go for nighttime first, for two weeks, if it’s not working switch to day time, simply because an hour during the day is different to an hour at night. As far as muscle movements, saliva production. [Jaz]Means you’re dry mouth. Absolutely. [Payman]Obviously, in parafunction, you’ve got more muscle movements at night. But it’s difficult to diagnose always that the pattern of parafunction. You’re the expert, right? It’s one of those things that you do we’ve I would say three quarters of whitening issues. Once you fix the other part, the impression, the tray, the gel and the desensitizing, three quarters of problems are bruxism or parafunction related. And when you’re examining your patient, number one on your question list should be, is this patient a bruxist? Yes or No? That are by far the most important variable as far as the patient factors. The secondary ones.. [Jaz]Are you asking the patient? [Payman]Well, you asking yourself. [conversation overlapping] [Jaz]Absolutely. I was gonna say the patient’s completely unreliable, they’re oblivious, but you’re spot on. So as a dentist, you should be identifying the wear facets, and also looking at whether it’s active, look at the tongues, it’s masseter. Oh, absolutely. muscle tone. So you’re completely right. [Payman]And, you know, I’ve been asking people that what percentage of the population brux? You must have the answer here. I think 10% you know, all the time. But the people I would be asking Raj Ahluwalia where he thought about it. He said, 100% some of the time. Yeah. And so.. [Jaz]I completely agree with Raj. [Payman]So it’s really interesting, because you know, there could be a patient who has shown no history of parafunction, going through a crisis. And then bleaching the teeth during that crisis is then grinding their teeth. It’s not working, it’s a young patient, everything looks like there aren’t wear facets yet because a young patient and you haven’t identified it as a default when whitening doesn’t work we do switch to daytime and that does work a lot of the time to do that. The second thing I would say is enamel thickness. Enamel thickness, the where it comes into play more is in the gingival. And you know that by far the most common complaint in whitening is the neck isn’t as white as the tip or the canines not as white as the lateral, that’s the other one and we’ll get to the canine later. But but the neck isn’t as white as the tip. And if you don’t notice that the enamel is particularly thin on this particular patient at the neck of the tooth, and you don’t warn the patient and the way I would do is I say “Look your tooth, naturally, the neck is darker than the rest. So once they’re bleached, the neck will be darker than the rest of all. And there’ll be a natural whiteness.” You prepare them for that issue. If you don’t prepare that patient with the very thin enamel at the neck for that issue, you have constant problems on this subject. And you know, then you’re into, “Hey, come on, you can’t even see it.” [Jaz]Yeah, definitely have to warn them beforehand. Otherwise, you know that Yeah, you don’t have anything to fall back to except that. [Payman]Exactly. After that, the other things after that are much less problematic. And we all know about age. We know about tetracycline banding and then you know, problems near the gingival margin of any sort, white spots, brown spots but that again goes to enamel. Thinner enamel over there, saliva getting in in that point as well. So that’s it. Those are the things. [Jaz]One thing I want to cover for sure this episode because there might be dentists out there who do whitening or carrying out whitening but they don’t take photos and I don’t know if you find it hard to believe what you find the easiest [inaudible] because you know, everyone who whitens I suppose. What percentage of dentist you think are doing whitening but are not taking photos? Because it seems ridiculous to me. [Payman]A good percentage. [overlapping conversation] [Jaz]I just don’t get it because I’ve had so many patients before, who I’ve whiten before, and they say and they literally said to me, “Hey, I think my whitening cause recession.” And it’s just because they’ve noticed it, now that they’re paying so much more attention. Or they say that, you know what, it hasn’t worked. And I show them their photo and I you know, one of my pet peeves is seeing photos on Instagram. Where the you know, there’s before and after whitening, but not only are the teeth whiten, skin is whiter, the lips are different shade everything’s going whiter. [inaudible] My hack I can give to dentists is to use manual flash not ETTL when you’re doing a whitening cases, because if you use ETTL with the white or substrate it feel it will you know,. [Payman]It’s difficult to get it right. It’s still, the thing is with you, Jaz, you take it for granted that everyone can take photos. Probably you take it for granted that everyone can use rubber dam. But that’s not the case. When I was a dentist, I you know, I have trouble keeping still with a camera with one hand and all that. Yeah. And then I saw Minesh, I see Dipesh when they pick it up just one hand and it’s completely still. You know, not everyone can take photo, man. That’s a really important factor. [Jaz]But nowadays with the phone, but I mean, medical legally, put that aside, but just sort of imagine patient expectations because you do get those patients who feel as though they haven’t had a good whitening effect, but they generally just don’t they, people patients often forget where they’re coming from. And they often have to be reminded hang on out you actually here before? [Payman]Yeah, over although you know, Linda talks about, Van Haywood talks about the bleaching the top arch and not the bottom arch to show them this. For me, if you’ve got to do that, then you’re really not whitening teeth enough? You know, the teeth need to go whiter then for you to have to prove it that way. You’re right, they do kind of get used to it. And in the photography, it makes sense to put the before shade in the after photo. Yeah. Not a normal thing is to say, what’s the shade now, I’m going to put that shade in it. And you do need to do that. But to put the before shade in the after photo, to show the patient how far it’s come from that original point. Makes a lot of sense, as well. [Jaz]Absolutely, it’s something I’ve been doing good to know. So that’s a great little tip there. Pay, you’ve answered all my questions. So that the last thing I know is what message do you want to give to everyone out there about anything that annoys you, that dentist could be doing better with teeth whitening tomorrow. [Payman]You know, the communication message really, that I really, really do believe that we could all be doing a lot more whitening, I mean, I can be selfish about it dude, and say it’s you know, to do with the company. And don’t get me wrong, it helps the company as much easier for us to have all our users double their whitening, than to find another set of users or double the number of users. But the reason I say it is that our patients are super interested in it. We’re the experts in this area. And we’ve got this this issue around embarrassment. And you know, your patients are not going to ask you for it. You know, some will, some will. But you need the information, you need to understand what it is you’re asking for before you cannot. I mean, I’m getting these not getting because I’m not suitable, but I’m looking for laser eye treatment. I was amazed by how little I understand about, you know, is it harmful, Isn’t it? Is it reversible, isn’t it? Is that surgeon the key point or is the system the key point? You know, unfortunately, when a brand gets stronger, like for instance, like Invisalign, people start going after the system. And we all know that the dentist is even more important than the system. So is that you know, which laser is right? Should I go for expensive or cheap? You know, which way should I go? All of that. What are the risks? How much does it cost? Didn’t know any of this stuff. So I doubt that your patient knows. I mean, unfortunately for me, most dentist don’t know the difference between Enlightened and normal. I’m doing my job right. But most dentists don’t know that. And so the idea that your patient will and your patient will come out and ask you, it’s not in the culture in the UK, for the patient to come out and ask you. The patient comes in ask you for an examination, the vast majority and tiny minority of dentists mentioned shade in that examination, that tiny minority end up doing a lot, [Jaz]Not anymore, because the Protruserati are going to get on it and talk about shade. Because I doubt there’s any dentist listening to this right now, who doesn’t want to do more whitening? It’s impossible, you know, unless you just only make complete dentures and even then you’re prescribing whiter teeth on your dentures. So, you know, there’s no dentists out there who wouldn’t benefit from from having that communication aspect. It’s interesting point, you mentioned, actually, that so many patients that I do have that conversation with now and again, about whitening where they didn’t mention to me but I just think you know what, they would be good to speak to them about whitening and so many of the things “Oh, doesn’t that damage your enamel?” So these are just misconceptions that a lot of patients have, is it a generational thing? or I don’t know what, but to them, it’s almost like a dirty thing, like it’s damaging. They see, you know, Katie Price’s teeth on TV or [name of artist] and they think, you know, somehow that’s associated with whitening. [Payman]It’s almost the magic chemical, hydrogen peroxide. It’s good for the gums. It’s produced in the body, you know, it’s not like, you know, like, compared to something like Botox, right? Poisoning your face. It’s a whole different. Patients are really into it. We’ve got the answers, everything’s in place. And yet, when you talk to a beautician, who does whitening, which I have, I’ve talked to them. Talk to them, “How many whitenings you do?” “Four a day, five a day?” And he said, “Wait a minute, what’s actually going on here?” That, you know, a dentist, we’re doing one a week. And the beauticians doing three or four a day. It’s that communication, all right, people come to the beautician for wants not needs and they come to the dentist for needs not wants and you know, we try and flip them around, or whatever it is, you know, but that communication problem, it’s in our heads more than anything else. If you feel like you’re pushing something on your patient, they don’t need, that’s how you’ll come across. If you feel like you’re educating your patient or something they’re super concerned about, that’s how you’ll come across. And the hack for it if you want a hack is talk to your patient as if it was your family member. If they look like your mother, not physically, but you know, age and sex wise, if they look like that person, your sister, your mother, your daughter, your friend, talk to them as if they are your family. When it comes to this, particularly, it’s kind of like the daughter test, but in kind of in communication. Because, you know, hopefully, you’re not going to be selling this hard at your family. You just if your family member comes in and say, “Hey, you ever thought of whitening, then we’ve got this amazing thing that does it”, you know that? That doesn’t hurt. That’s you know, all you know, that doesn’t harm. That’s a nice hack. Think of it that way. [Jaz]Thanks so much Pay. And listen, a few episodes ago, I did give one of the Pearl to check out your one hour training online. And now you can go to protrusive.co.uk/enlightened will take you straight to your page to get the one hour training. So yeah, a little bit of geekiness in the background. But you know, I’m hoping a lot of people have jumped on to learn. I mean, a lot of the evidence of the point you actually covered in this podcast, I really appreciate that. But there are a few more things that you go over, a bit more about branding, and how to get the team on board as well, which is so important. So that’s great. But is there anything else that you’d like to know? Where can people maybe if they’ve never tried online before, how they even bought their first case? [Payman]Well, you know, just do that training, do that training. So either through your link, there’s enlightenedonlinetraining.com. And by the way, the majority of people who have that training don’t end up becoming Enlightened users, t’s a useful bit of CPD. Anyway, whether or not you end up doing Enlightened, you’ll improve whitening I think by coming on that of course. But I honestly mean it’s a real real honor that you asked me on this because I really love your show. And you know, I feel really honored that you’ve actually asked. Thank you so much man. [Jaz]But no, but it was a great I mean, look at an hour an hour almost went like that. And I feel as though we have just a normal organic chat. And I you know, I probed you a little bit, twisting your arm a little bit. We said a few things about some people maybe we shouldn’t have who knows. We’re trying to bleed those bits out where we can but it was very real chat. And I do feel dentist, typically young dentist will gain out of that. I mean, I’ll be honest with you. They don’t teach us anything about whitening at dental school like nothing. I don’t know how much you know that but they don’t teach us. Back when I qualified back when I was only seven years ago, but they didn’t teach us anything. I didn’t do a single whitening case during dental school and then you suddenly come out And you think, hang on a minute. So you just asked your principal, so I just order a whitening tray and NHL and [Payman]It goes back to that legacy that you know, it was illegal for that period until 2012. So dental schools just stayed away from it. I think that’s the reason also dental schools are very slow, you know, to include new things. Hopefully, they’re talking about scanning now. I don’t know whether did they mentioned scanning, though it was.. [Jaz]Definitely not then. But I’m hearing some promising things that some dental schools are starting to introduce that. But again, like you said, it’s going to be a slow movement. You know, big establishment, universities are going to be, they’re both pioneering, but on a research scale, but in terms of actual students and stuff using it is a bit far behind. But anyway, I mean if you’re young dentist, fresh out of dental school, or if you’re a dentist to listen to this, you will learn so much about teeth whitening, and what makes teeth whitening effective and loads of communication gems. So Pay, thank you so much for sharing those with us. [Payman]Really, thank you, man. Really, thank you for your infectious enthusiasm. But anyone who can make me listen to four podcasts on splints? [Jaz]Oh my god, I can’t believe I listen to those. Thank you. [Payman]You really one of the best teachers. And don’t get me wrong. You’re an educator and you know if this is what going forward education might be like this. Yeah, it’s a really wonderful. One of the amazing who wants me, that makes me want to pick up my drill again. [Jaz]That’s an honor. Thank you so much, Pay. Cheers. Jaz’s Outro: Thank you so much for listening all the way to the end. I told you it’d be a very impactful episode. I hope you went away with lots of new knowledge and lots of confirmation of ideas that you already probably had. Payman’s a great speaker, so easy to listen to and speak to. So he was a great guest. Payman, thanks so much for listening all the way to the end as well. I really appreciate you as well. So guys, the next episode is also going to blow your mind, it’s Nik Sethi on ceramic onlays like he does not hold anything back. It’s just an absolute jam packed episode. A bit like Paul Tipton when he gave every sentence was a pearl on fixed removable bridges in that episode. Nik Sethi is one not to be missed as well. So Catch you next week. Same time. Same place.

Is it time to ditch the analogue occlusion tools like facebows in favour of Digital Dentistry workflows? In this special feature episode with Ian Buckle, we will explore the world of Digital Occlusion. https://youtu.be/M0OR0XJdUvg I was tempted to make this a 2 part, but the flow is too good. Need to Read it? Check out the Full Episode Transcript below! Protruserati, get your onions ready for chopping (lots of them) – this is a behemoth episode! We tackled a lot of key themes, include Specialising vs Private courses route (a common question I get sent by Dentists). One of my fav quotes from this episode:‘If you don’t have a clear goal, don’t be surprised if you end up somewhere you didnt expect’ – what we can learn from this is to MAKE a best guess! I also mentioned how it was through Ian that I learned about the FACE Group (Roth) of Orthodontists. These are Orthodontists who are well versed in articulators, facebow, occlusion and ‘stable condylar position’ (or Centric Relation, to many!) There are a good few gems in here about face scanning apps, use of photography, inciso-facial mock-ups, but my favourite gem I want to share on this blog is this:If you record your bite registration AT the DESIRED vertical dimension, you will eliminate any errors in opening the bite on an articulator/digitally. You may need to read that again or listen to that part of the episode again. Once it sinks in, it can be a ‘ah-ha!’ moment. If you want to find out more about future courses by Ian, check out his website. The SplintCourse is just weeks away from the launch offer – have you signed up for the big update? If you liked this episode, you might enjoy the Posterior Guided Occlusion 2 parts with Dr Andy Toy! Click below for full episode transcript: Opening Snippet: Which is complete dentistry and full mouth rehabs or whatever you want to call them only happen when the patient says yes. And, you know, we as dentists are dreadful communicators. And we say things like oh Mrs. Jones, you know, you then need 17 crowns you need to have equal intensity contacts and posterior disclusion and this this, this. So when would you like to get started? And we wonder why they don't do. Digital is a fantastic communication tool... Jaz’ Introduction:Hello, Protruserati. I’m Jaz Gulati and this is episode 57 of the Protrusive Dental podcast. Thanks so much for joining me. In this episode, we will talk about digital occlusion and not the nitty gritty over complicated kind of stuff when it comes to occlusion. The really important stuff like for example, how to use digital photos and digital scanning to make sure that you do not get cans in a patient smile, how to predictably raise the occlusal vertical dimension, using these two techniques to make sure that when it comes time to fitting the provisionals, or fitting the definitives in the patient’s mouth, then everything will be much more likely to work and need less adjustments. Because really, that’s what occlusion is about, doing less adjustments and more predictability. Okay, so I’m sorry, not sorry that this is such a long episode, right? This is a mammoth episode, I really appreciate that so much to do it. Like in two commutes, or three commutes, or that’s a lot of onions, you have to chop to listen to this episode. But there is a reason for this, right? The flow was just too good. Like, originally, I was gonna do this as a two part episode. But I just loved in storytelling. So for those of you who know Ian Buckle, he was an educator for the Dawson Academy in the UK, which I don’t believe exists anymore. But I did all the modules of Dawson with Ian. And you know, what I hung on to his every single word. He’s such a great educator, great storyteller, I learned so much about occlusion from him, but also about communication. But to you my friend, I appreciate that this long episode is not for everyone. So if you are really hungry for that special knowledge, that hot tip for digital inclusion, and when Ian gives it away, then I’ll probably start listening from the 50, 52 minute mark onwards if you really, really want to, but you will miss out on lots. For most of us who are happy to listen to the journey and listen to the stories before we get to the sort of the sexier part, which is actual how to make Digital Occlusion work for us. Man, you are in for a treat in this episode in the beginning. I mean, let me just put this into context for you without actually ruining the story. The story is that imagine you or your your partner is pregnant, and the doctor tells you that the baby will have lots of conditions, disabilities potentially, and one of those disabilities or complications is that your baby’s teeth, the baby will be coming to the world. Your baby’s teeth will be malformed. Maybe they will not have any teeth. Right? So when Ian found out that this was going to be happening with his daughter to be, he was heartbroken, right? So what do you do as a dentist, right? If you’re told this, what’s the one thing you could do, what the one thing you could do is at least you can fix the teeth. And so that took Ian on this journey of learning and upskilling and making connections so that when the time comes, he can help his daughter, and he will have a team around him to be able to help his daughter, which I just think is so noble. Right? So that’s his story and listen to that and how that inspired him. But we also talk a lot about career decisions. Do you do specialize? Do you do a masters or what are the complications in going in a private route and just upskilling with courses. So we talk about these themes. So as loads of communication gems in there, which you would expect for an episode with Ian Buckle. Now, just before we joined the episode, I want to share the Protrusive Dental Pearl for this episode. So many episodes ago, I gave you a pearl, which I think is now false, right? So I changed my mind. And another pearl I gave you in the episodes was that there’s something very unattractive about someone who can’t change their mind. So I think it’s a beautiful thing that we can change our minds. And so the pearl I want to adjust is the one where I told you that how you do anything is how you do everything. So how you do anything is how you do everything. So there is some beauty in that. And I think there’s a lot we can learn from that. But let me tell you why I’ve changed my mind right? The time now right now is 5:50am I woke up at 4:15am UK time I did my beard which is a thing when you got a beard like this, you have to tame it. And I had coffee, had breakfast and now it’s 5:50am. And I’m recording this. And I’m telling you this not to gain your sympathy or your bravado or anything like that. It’s because last night I was supposed to do some recording. So supposed to do an evening session, my producer supposed to have it by now so I can start working on it. But I didn’t do it. Because my son was just, it’s such a great time. So my son is 18 months. His name’s Ishaan, he’s 18 months. And wow, you know, he’s developing this unique personality, he’s got so much energies, he’s bouncing off the walls. And last night, he was just, he was a comedian. He was being a comedian. He was just doing all these shenanigans. And I was just loving every moment of it. So I just decided that you know what, I will not be doing my recording, I will be spending more time with my son and I don’t regret it at all. I love it. And so because this podcast needs to come out there, and I value you and I value your listenership and our value podcast, I love podcasting. So much fun, right? So I am up early to do it. And I mean, yeah, I’ve got good energy about me. As you can see, hopefully, I’m not sounding like lack of energy or anything like that. So the lesson to be learned here is what do you value? Because whatever you value that should govern what you do care about and what you should give everything for. For example, on the Protrusive Dental community Facebook group, Sheetal Kharbanda, Sheetal buddy, what you posted was you said, “Is there a way to get Alexa to play the Protrusive Dental podcast?” And I sort of made a video saying, look, Google can do it. Siri can do it. I’m sure Alexa can do it. Right. So find out if Alexa can do it. If not, I’ll make it happen. And then when I post that video, I realized oh my gosh, my desktop background is so messy. Right. So who else has a really messy desktop background? Right? So I’ve got a very messy desktop background. And then Dami,` Dami Bakare, an old friend from dental school, he commented saying, “Wow, that is one messy background. You’re such a busy guy.” How’s it? Oh, gosh, he’s right. You know, it’s such a messy desktop background. And I thought, why is that? You know, I’m pretty organized, in my dentistry and stuff. And so why is it that my desktop background so messy? I thought about, I thought, you know what, I don’t value the desktop background. And I think sometimes we have to limit all the things we value, we have to write them down. And that’s what you will apply how you do anything is how you do everything, right, because there’s impossible to do everything at the highest level. So last night, I valued my son and I value my son, so I spent more time with him and valuing you, and I’m here right now recording in the morning. I don’t value the aesthetics of a clean desktop background. And also I don’t have normal person OCD. Obviously, as a dentist, I have OCD when I’m doing teeth. But normal person OCD I don’t have so I can live with a messy background. I know some of you probably can’t. So it’s all about that, what I’m trying to bubble here is that find out what is it that you value, make time for it, you’ll always make time for the things that you value. And things that you don’t value will get squeezed and crushed and move to the side. And that’s totally cool. Don’t be too harsh on yourself. If that’s the case, accept it, except that that’s the beauty of it, that you can value some things and really give it your all and everything else that you don’t value doesn’t deserve the best of you. So hope you enjoy that pearl, and let’s join Ian Buckle with the story of digital occlusion. Main Interview:[Ian] There’s still that it was very basic, it was pretty basic dentistry in those days. And then, you know, I sort of moved on to get a little bit more interested in dentistry. And the probably the first thing that we were able to get better at if you like, was endodontics when rotary just came out. And despite what many people might think about me, maybe you as well, Jaz, as I’m quite shy person and I bother going to six text. Well, you know, I I’d say yeah, you know, I was brought up in the generation with my grandmother saying children should be seen and not heard. So I knew my place. But, so I went to this section 63 meeting, and I was, I thought it was very interesting that I could get good at this. And I wanted to provide good care for the patients and also have an interest for myself, you know, there was a selfish part in there as well. And so I stay behind waited till the end. And I said to the guy who happened to be the dean as well, you know, I’d really like to get involved, what is it I need to do? And it’s just like, well, it’s a three year course, full time. If you don’t like it, you know, you tough luck. And, you know, I was extremely disappointed, you know, because, you know, I had a young family at the time, you know, mortgage like everyone else, all those things. And it was, it really just seemed like a massive obstacle and you know, I didn’t know how to get past that. You know, always like to mention my friend Mike Horrocks at this stage because Mike was round. He was a year older than me but he went and got on with it and did it. And what he’s done with his endo stuff, I think is fabulous. And the way he’s encouraged practitioners to, you know, say, look, you know, let me show you how to do a better endo, and then and then it gets people interested, when you get someone interested, then they start really getting into all the other stuff in the research and there’s different ways of doing it rather than traditional three years, study some stuff and then come out on the you know, everything. You know, I think there’s a great way of learning. I think a lot of us. I think a lot of us in dentistry have a practically based so we like to do something and then when we’ve done it, then we like to find out how did that come together? So that was, that was my first sort of thing, you know. [Jaz]I just wanted to stop and say that what you said there was very relevant to some of the themes that we’ve had with the guests on the podcast for whereby we’ve talked about the specialist route and actually doing the MClinDent in ProRes, or endo, whatever. And then there’s the the sort of the other, which is the one I’m pursuing. Now I’m doing external based courses. I know, my limitations. I’m using mentors as much as I can. And there’s a whole beauty of that side as well, which I think sometimes when you’re a new grad, you’re all starry eyed and you sort of map out your career path. I’m going to do Dental Foundation, then a core training hospital, then I applied for my MCAT. And then and then I’ll be a specialist and a lot of people about 50%, I think seem to be geared towards that. And then the real world hits you mortgages come, the time thing, comes children come and then you sort of think actually, there’s this whole other route, that it’s very fruitful. [Ian]Yeah, I know, for sure. You know, I mean, you got to be respectful of anyone who puts time into anything, you know. But you know, I think both have value. I obviously have experience more of one than the other. But dentistry at the end of the day is a hands on sport. It’s a practical thing and no learning while you’re doing the job, but it I’ve always seen dentistry as an apprenticeship more than anything else. I think I’m still in the apprentice. We should all be apprentices. But so I think there’s value in those. But I think because everyone does it, it doesn’t mean it’s the right thing for you. I think there are some some great opportunities in postgraduate education that aren’t along that MClinDent on. And I think there’s all Be careful what I say, you know, but I think there’s a lot of things out there, which is about getting a piece of paper, rather than actually what you need to know to be a really good practitioner. I think there’s advantages in having the piece of paper. You know, it’s too late in the day for me, you know, so, but I think there’s advantages to that. And I can imagine how that sits in the modern world. But certainly, the, I think the absolute key is what you just refer to, which is whichever it is, get yourself a mentor or get yourself someone who you can resonate with, get someone who has, you know, your best interests at heart, not theirs. Yeah, I think they know, we talked for years about having a teacher’s heart. And really what that is, is that whole idea is the purpose of teaching is to get your students to be better than you are, you know, I mean, I said I was quite late to the game in many ways. And I don’t regret it because I was busy doing very interesting things. So but, you know, I again, it’s, you know, that old expression, when the students is ready, the teacher appears, but to have someone know, find someone that you that you like, what they do, that you think is a good ethos, and, you know, is ethical, etc, and then ask them if they’ll help you. You know, I mean, there’s a lot of, we’re so fortunate in dentistry, that there’s a lot of great people out there, who will help you and guide you towards the things that will help you in your career path. I think, you know, one of the things that we talk a lot about in dentistry, but I think it’s, it’s just as important, if not more important in life and in your career, is to have very clear goals for what it is you’d like to achieve. I know I mean, my, it’s a little bit changed for me now because, you know, I talk about these things, and my son’s going to be 30 in a couple of weeks time. So, you know, he sort of lived that whole thing with, but what are your goals? Where are you going to end up and, you know, I can remember him saying to me, but you know what, but I don’t know where that’s going to be. None of us do. And but the thing is, if you don’t have a clear goal, don’t be surprised if you end up somewhere you didn’t expect, very often. If we try our best guess right now that’s what we’re aiming for. So if you’re not absolutely certain, don’t be shy. Don’t be afraid of that. Don’t be shy of it. It’s your best guess right now. Go for it. And you’ll be things, no fate will take it and you’ll see other things Along the way, maybe you’ll refocus your goals. But, you know, planning is really important. You know, I really like being a general practitioner, that’s what I want. That’s what all what I wants to do. This to dentistry is about people, it’s about the whole functional system, it’s about, it’s not just about teeth, it’s not about perio, it’s not about ortho. And certainly when I was taught dentistry, it was very departmentalized. And almost everything was competing against each other. On my patients just want me to look after them and look after them appropriately, and to, you know, to have the knowledge and advise them. So it doesn’t mean to say that you’re the expert at everything, there’s a lot to be said for being a great generalist, who you know, can do a lot of great things, can serve our patients tremendously well, but also just know stuff so that if the situation needs it, then we can refer or get involved with other people that help us I mean, I am incredibly fortunate. Now I have a tremendous periodontist, and orthodontist and all sorts of other people that helped me out when it gets beyond my range, you know, but we, we all have the same goals. We’re all looking to achieve the same things. And so.. [Jaz]One interesting thing you mentioned about your orthodontist and the great team, but people need to know that you’re very unique in that. When someone when the right case comes along, and the best person for the job is your friend in San Sebastian? [Ian]Alberto? [Ian]Alberto. Yeah, so a lot of the places will come to you in the world. And as part of your comprehensive diagnosis, some of them will end up having orthodontics, am I right? And they will have a little jolly in San Sebastian and see, Alberto Is that right? [Ian]Well, yeah, you’ve got the theme, correct. You know, I mean, we again, I came across Alberto. Alberto was it in Barcelona, Domingo is in in San Sebastian, both are great cities to visit as well. So if you ever get the chance, it’s great. I came across both of those guys. As part of my journey, and it was, you know, going back to what I was saying that before, we talked about endo a little bit, I always wanted to know, the thing I liked was to try and make teeth look like teeth. It was just a bit of a fascination for me. And we came across, I won’t go into down that line at the moment, but came across very many dead ends as far as that was concerned. And, you know, the cosmetic stuff helped me a lot with that. But, but 20, almost 25 years ago, our middle child was born. And she was born with a genetic disorder called Incontinentia pigmenti. And part of that, when we, when she was six weeks old, we were told she might be blind, deaf, mentally retarded, and still might not grow. All these different things. But as part of that, and she might have missing and misshapen teeth. And I think many of us as dentist, we just love to fix things, you know. And, you know, obviously, when you’re told things like that you sort of takes a little bit getting used to, but I was afraid to go, Okay, so what can I do, and the only thing that I could do, because most it was just about waiting. The only thing that I could do was to try and get to know the people that could help her if she needed it when she was older. And I knew she might need ortho, I knew she might need implants. So my, you know, I as I say I personally I was much more interested in esthetics, cosmetics, whatever you want to call it, and try and make things look nice and make them work well. Because, you know, our American friends are very cosmetically based. But you know, with us being Europeans and British, we know that it needs to work properly as well. So I was fascinated about how to bring those things together. And that’s what led me towards Dawson and all those other stuff. But with this, it really brought me on that journey to try and find particularly orthodontists that would put the teeth where I needed them to go and as I was that whole Dawson thing, as I said it was more about being a designer, you know, where did the teeth need to go in the patient’s face to make them look great and work well and be biologically healthy? And that’s, what that’s about? It’s about design, and then how you get them there is really between you and the patient, which is about an appropriateness and what’s best for them. No, I mean, some of that cosmetic stuff got a little bit out of hand and you know, it was diamond driven orthodontics, you know, but I mean, that’s just misuses as often we do. But the interesting thing is and you know I if you look at Pete’s book from 50 years ago, no, it talks about treatment options. He’s talked about reshape, reposition, restore, and then surgical stuff. And when I first I saw that list, I thought, well, that’s great because they like restoring teeth. I’ll choose that one. But actually what he was talking about was, this is the most minimal way to do stuff, maybe we could just alter things a little bit, maybe we need to move the teeth first. And again, if you look in Pete’s book, he was using rubber bands and paper clips and all sorts of things to try and move teeth, you know, just to get them in the right place to minimize preparation, and the restoration was just about on the top. And certainly, if it’s going to be my daughter, you know, what would I want for her? Well, we need to put the teeth in the right place. So what I have to do is, is minimal to nothing. And then through that. So through all this I met I came across a group called the face group which was known in the States, more perhaps more as the Ross Williams group. But they actually practiced orthodontics with the same goals that I had in my prosthodontic. So they like the stable composition we like to to come together at the same time, we like a nice envelope of function and guidance, etc. So we had some people that were looking at the same thing, they weren’t just straightening teeth, you know. So, I came across those guys, I actually came across a guy called Carl Roy over in the States, who’s phenomenal and such a nice man and helped us tremendously. But he said, you know, in, you should go meet Domingo in San Sebastian, he’s much closer to you. And I’ll be honest with you, I at that stage, I’d had a lot to do with the states. And I thought, well, you know, I’ll go and meet him. But we’ll see I think we will be coming over here. And Domingo is just the most charismatic person that tremendous guy, Orthodontist, most motivational person you could you could ever meet some. And his right hand man was Alberto who like just that tremendous pleasure working with them. And so we actually, you know, with no disrespect to any of my countrymen or wherever, you know, my decision was that if I wanted to get these teeth exactly where they needed to go, then I was prepared to take it to San Sebastian every six weeks to have a treatment on which is what we did for almost three years, you know.. [Ian]But do you mind, when he told me that, but it blew my mind even further that you’ve continued that relationship now. And you know, you send your patients, the right patient who is who has everything aligned, and it works out to get continued treatment, in this modality of referring, you know, getting a flight going to a very nice part of the world to get some orthodontics on a regular basis, it blew my mind. But it showed me so much about how much you care about the vision end result. And you found someone who a team that is so in tune with your philosophy. [Ian]Oh, you know, you don’t just we talk about this, and we talk about what do they call it, but they call it the daughter test? You know, so what would you do for your daughter? Well, nothing could be further if you’ll be closer to the truth, I should say, you know, for me, you do anything. So it was really just a case of if I believe it’s the right thing to do. misguided as I may be, then that’s what’s going to happen. So, you know, and so, you know, but through that, I’ve had some of my orthodontic friends take the face training courses. So you know, we’ve had, we’re very fortunate. We had our are working here for a while. And then we have also worked with other face trained orthodontists here, and, but we do get, you know, Alberto for me, and Domingo are sort of top of the tree with ortho TMD surgical things. And so, you know, I mean, for better or worse, in my practice, I see some very challenging cases now. And, you know, my goal and my duty, more than anything else that I do is to make sure that patient is taken care of as well as I can. And, you know, I think I said, I don’t wish to be to comment, I’m sure people, although other people have better situations than I do. But, you know, sometimes I’d send patients to the orthodontist, and the teeth would come back where the orthodontist wants them, not where I wanted them, and you send them to the implantologist. And the implant is where he found the bone, not where you wanted the tooth. And so for me, everything was about the design, the final design, and then we moved, we got everything into place to do that. And so I needed guys that were respectful of it. And that’s where my team was and when it came, particularly when it comes to it. I mean, I don’t think anything could be more challenging than ortho, orthognathic stuff. And so you need a great team of people who I know is going to take care of someone and Alberto has a phenomenal team in Barcelona. So, no until, you know, I’m hoping to find someone in thought and hope just up the road. But that hasn’t happened yet. So.. [Jaz]Let me tell you what I’m hoping we have someone look. So you inspired me massively with that when I learned about that, then you actually introduced me to the face group. And I was actually at the time I was doing my diploma in orthodontics. And now a good friend of mine, who’s now a specialist orthodontist. I won’t embarrass him, won’t name him he messaged me, they’re saying “Jaz, I know, you know, into occlusion, you like that kind of thing. I’m considering to go to Seattle to do the Kois. And he’s an orthodontist. And wants a Kois, I said, hang on a minute, hold your horses. Have you heard of the FACE group. So I joined the Facebook group of FACE, I invited him and I’m getting his exposure in a little bit of selfish way. But hopefully, one day, I’ll have an orthodontist nearby who will have this whole same philosophy. So thank you, Ian, for introducing me to so much and something that’s so broad, and it was a great thing to be able to give him a sort of a pathway as well. [Ian]Well, the the fantastic thing Jaz is, you know, we talked about this, and then as they gradually sort of haven’t got down sort of like occlusion war type things, you know, which is all the little details that people know, debate about now that the best thing you can do is get with colleagues, and, you know, again, a lot of the reason why things don’t work out with orthodontist is you send the letter with no detail, and they do whatever they feel like, and then we wonder why we didn’t get the result that we wanted. Why is that? Because there’s no clear goals. So and no, the thing is to find an orthodontist to find people who have the same goals as you who want to listen, who want to work as part of the team, who have the ultimate goal to take care of the patient. And, you know, if we can do that, then I mean, then we can hopefully, point them in the right direction to get the training that they need to be able to do it, you know, so I commend you for that. And it would give me greater pleasure than, for all of us to have an orthodontist to touch up close by that could do these things, you know, but until then, I’m still going to advise people, this is what I think is best. And then it’s up to them, whether they do it or not, you know, we all make our decisions. So and, but I mean, that was a no big commitment for us. We believe we know, it was a, she got tremendous treatment, she unfortunately had me to finish it off. So she’s now, should be 25, in a couple of weeks time. [Jaz]I seen her smile. She come on the dinner. It’s amazing. So you’ve done great work and as a team. [Ian]Thanks, Jaz. But she’s, the most important thing is she knows she’s very happy. And it’s given a huge amount of competence. You know, I see, you know, through that I came across a lot of youngsters who had similar problems. And, you know, it’s just, I mean, I’ve got one, I mean, I’m sure there’s lots that are very successful. But you know, I just one that springs to mind. I mean, this lady should be having orthodontics for 14 years. And, you know, she actually had the same problems as Dorsi. But the reason why she’d been having ortho for all those times is because there was no real plan. And there was no real design. And I know it comes actually came back to your I was sent as a dental problem. Because when often when you don’t have teeth, there is this you have small Jaws, and x and y and z and all these other things following and we look at teeth and we look at Jaws, and we think about how we do that. And, the first question I asked him is what’s your problems? Amy, what can I do to help you? And she said that I really don’t like the way I look. And I said, both to that your smile look? She said no, my face? No, I really don’t like my face. And because she’s got small Jaws, you know, she’s got the nose and the chin coming in to your very small mouth. And she knows she was 22 years old. And she’s saying to me, you know what, and this isn’t getting better is it and no, but that she, that is you know, that’s an aesthetic thing. I think it’s a really important thing. But here’s another thing. So then when you do your complete examination, which is of course my happyhorse is like, Well, you know, on the rise if you sleep Okay, well, not very well. And to cut a long story short, she had severe sleep apnea. So doing she was actually, Jessie had surgery and ortho and implants and whatever else. And what she now breathes properly, she’s healthy. She’s Well, she’s got a beautiful smile. She’s, you know, she’s loving life, you know. So, you know, but it comes down to that. No, forget tha you’re a dentist, forget that you’re an orthodontist, forget what is it that the patients looking for, you know, if they didn’t come in, because we’ve just bought a scanner, they didn’t come in just because we’ve bought Invisalign, or whatever it might be. They came in for your valued opinion, you know, now, we all go on the internet these days, and we come up with these crazy things that Oh, all my teeth have fallen out. Do you do pinhole gum surgery? Yeah, but how are they related? That it was a patient this week. So, you know, and we choose, what we think is appropriate, our job, or my job is if my pal walked in the door, which he did yesterday, and he said, what can you do to help me? That’s what I’m there for, you know, I just got to use my knowledge to help them as appropriately as possible. So it’s not just about teeth, and also, it’s about the patient and what’s appropriate for them, and actually trying to help them be healthy for a lifetime, you know, that would be the best, the secret of a good job is that no one ever really appreciates it. So I’m hoping that in, in 30,40 years, when Amy’s there, she’s not even thinking about what’s going on, because it just worked well for her and she was been healthy and well, and she doesn’t realize what the other path might have looked like, you know, so. Yeah, so that’s, my… [Jaz]Philosophy. This is your own story. This is your philosophy. [Ian]Yeah, and you know, it’s just a bit, it’s just about taking care of people and trying to do the right thing. And we also get plenty people we talk about those things, but maybe it’s not appropriate for them or for whatever reason, and sometimes there’s other things that we can do for them, which maybe isn’t as optimal, but a compromise can be okay, provided that we don’t harm people, and that everyone understands the compromise, you know, we always plan for the optimal, but there’s this compromises life, full of compromises, it’s absolutely fine. You know, but we just got to understand this should also be a line at which we go, that’s, I’m not doing that, I wouldn’t do that to my pal, I’m not doing it, you know. [Jaz]I’m getting flashbacks from being on the courses with you in the world. And one of the most the biggest takeaways I had, was just the way that you communicate with patients and how you pass it on to us. And these little lessons that you know, you’ve burned your fingers, you’re not afraid to share the times that you’ve burned your fingers, you know, ask me how I know kind of thing, and you pass it on to us, and the quotes and the sayings that you had one of my favorites being ‘when all is said and done, more said than done.’ All the various things that you know, I sort of memorize what you say in one of the episodes I sort of talked about the thing, one of the pearls in the episode I gave was, is how I now start most of my new patient conversations, saying that the secret of success is to be thorough in what you do. And that is then my cue to do everything exactly A to Z comprehensively on every patient, every time so they get the best of me. And that’s like, that starts off. So there’s so many communication gems I got in there. So now we know your origin story and your philosophy. And now I’d like to go deeper into the part two into digital occlusion. [Ian]I just want you to know, I mean, those little sayings that I have, they didn’t happen overnight. I mean, I often think a lot of what we do is like comedy, you know, it’s like you tell a joke. Goes, Okay, you know, but you know, if you tell a joke, and it works, well you make sure that stays in for the next one. And it must have taken me 5,10 years to come up with that little saying that I’ve given you in five seconds. So I’m glad you’re using it and it just gets you started. And you know, and this is the thing about mentors and things like that. It’s like what your, my whole, it wasn’t always an easy 5, 10, 20 years. So the one of the things that eases the pain for most of us who cared about those things is is if I can get other people and share that with them. It makes it worthwhile and also and then eventually, you’ll maybe find your own little phrase which is better still. But it’s a good start so thanks for this. So now I’m going to talk about digital. There’s another word for that but I can’t use it on a play podcast like this But yeah, I mean our storytelling is interesting as well. I think you know, I’ve always enjoyed stories, I’ve always enjoyed comedy, I’ve always enjoyed communication. See a lot more about storytelling now as a way of communication. And which is a you know, I really like to learn about stuff. I suppose it almost like Don’t want to know because I was just doing it because it was me. And now I’m learning out why I do it. If any of you like Ted Talks and things, if you go on some of the TED talks about storytelling, there’s some as an amazing guy on and he talks about how as you tell the story, that the different chemicals that it releases, and how you can sort of basically manipulate people, which is, which is not my intention at all. But it’s a very interesting thing. But I think, you know, for not just centuries, but millennial, we’ve all been communicating through stories. And I think it’s a great way of getting the say, anyway, let’s move on to digital because that’s a fun thing, and will make me feel a little bit. [Jaz]That’s the bit I’ve been getting all these questions sent in about and that’s the direction we’re going to take the part two of this podcast now. So Digital Inclusion is essentially you know, the foundations of occlusion what I’ve done with you with Dawson. And we’ll come on to the end about, you know, the future and stuff. But it’s a lot of the analog teaching, and you gave you a few snippets of the digital stuff. But now that I’ve been using the trio scanner for about 3-4 years, and the itero. I’m loving the digital workflow. And I just want to learn from you and share with the listeners, a few tips and pearls, and some background information about how you merge building great, long lasting occlusions and beautiful smiles which go hand in hand in to the digital workflow. So you’ve been doing digital for a long time, tell us a little about how you got started digital. And what percent is that fair to say? What percentage of your work you do is pretty much digitally oriented. I mean, I know when I was there in the Wirral, you’re scanning and you’re printing your own B splints in the practice. So you’re very far ahead in you know, from what I can from compared to me anyway, tell us about your sort of digital experience. When I was at Liverpool University. [Ian]I say 35 years ago, I qualified. So a few years before that, we actually had a static machine, you know, and there was a guy there, Nick Cavitch and he was very, he was a dental geek. And so we loved all that stuff. And we were very dissimilar in lots of ways. But I had an interest in dentistry. And I really had an interest in computers. And I was fascinated by things like that. So it seemed like a good idea. My brother in law at the time was a designer, and he was really getting into computer aided design. And so I used to spend a bit of time with him and actually seen and what was, what they were doing. And I was thinking, this is phenomenal, what we could do now. But in those days, with the static machine, you take a block and you put it in the machine, it would be in there for about four hours. And then you take it out and carve it to fit the cavity, and pretend you’re doing something that was worthwhile. But it did seem like a good idea. And then over those years, you know, we have the red cam and the blue camera and all those things. And, you know, I mean, [inaudible] We’re sort of market leaders in those fields. And a lot of it was based around single tooth dentistry, you know, so it was about it was really more about in house milling than anything else. And so, over time, and as I got my own practices, then I came to a point where we were able to, you know, again, standard was important to me, so it was important that we could make good restorations, but I was doing a lot of inlays onlays and posterior crowns, which I thought I could do very nicely with digital. So we became very, very efficient, just with in house milling of single posterior restorations. And occasionally we’d fool around with anterior stuff. And you know, it was a lot more challenging. And, you know, there was people out there showing great things, but I didn’t ever really want to be a technician, I didn’t really know, I don’t know that I’ve got that skill set. But I try my best. And I know I’m in the right cases, I’d have a little go but it was, but that’s really where we used it. And it was a very useful tool. But then there’s really been a massive leap forward. And I think your history is important. And I’ve been using it for a long time. But as you say, I mean that was more about in house milling single restorations mainly posterior. That was one side of what I did, which would fit into a bigger treatment plan if that’s what I was doing. And that was for me to decide. But then as you know, as I really started to Well, I think understand the analog system of complete dentistry and examination and records and then how to treatment plan etc. You know, it sort of gets you a window and wondering about, you know, how could you do this in the digital world and no, because, you know, somewhat some of the stuff that we’re doing is a pain in The neck. And, so one of the cool things is I’m very fortunate as part of my teaching that has taken me to Scandinavia. And through that I came across 3shape, which is a Danish company. And, they actually, whereas Sirona [inaudible] from the clinicians perspective with in house milling, they were more a laboratory based program. And so they were coming at it more from lab design, and then sort of the scanner and thing was tacked on to the end of that. But because of that they had, for me, they certainly at the time, a much more powerful system, that they had an orthodontic program, they had a restorative program, they had all these different things and so then I became fascinated about how we could make all these things talk to each other. The problem, as I found out was that they were very departmentalized, as well at the time. And some of the programs are written in different languages, so they didn’t talk to each other. I was like, Oh, so the thing, the main thing that I have going for me is that I persevere, you know, I crack on, you know, and, so, whereas a lot of the time people get pulled off, I’ll usually have a little bit of a, I usually say a few bad words, and then I’d go right, well, what are we going to do to make this work or better? And, at the time, of course, you know, everything gathers pace and gathers pace, because you know, that people can spot a market because it helps a great deal. But then No, the scanners were getting better, the accuracy is improving tremendously, you know, and we’re thinking, well, how can we reduce this to look at some of these bigger cases? So, you know, very simple thing, taking impressions. Well, taking impressions is a no, you got to get a good impression. If you if you go to a lab and you see most of the impressions that are there, you’ll see that the at least a second molar is a missing, you know, an all are distorted in some way. Taking a good impressions is a difficult thing. But with a scanner, you get to see your impressions straightaway, there’s no escape. So you get to be honest with yourself about what’s the, so we could certainly make sure we got some great impressions with digital and I didn’t have you know, instead of having to duplicate models all the time, I could press copy. I like that. [Jaz]So much better. I love that. [Ian]So, there was so many things that even simple things like that, you know, I sometimes they forget now. And they made it so so much better. British saying a lot of the time I was printing models and then put them onto articulator and so we’ve bent on digital orthodontics was commented on. So we could actually start to move teeth and see what how these would look, which is, again, a deal better than then sorting teeth out and doing sort of casting setups, the way we used to in house restorations was going real well. Also, the fact that I could work with a lab was great, because I mean, I could scan a patient and they have the information in seconds rather than three days. You know, I mean, nothing was worse than the impression go into a lab, or to get a phone call to say, no, that impression you’re talking it’s not the best. Whereas now that if we wanted to if we weren’t sort of ads that the technician could look at it straight away and go, Yeah, that looks great. Let’s carry on, you know, so. So it was a great communication tool. So there was so many bits and pieces that were coming together, implants. I mean, if you look at implants, look at Digital, a lot of people associated with implant or work because we’ve got, you know, everything is driven from CB CT, and we’re gonna make this guide, we’re gonna do this. And, it sort of lends itself to that. That’s just one part of it, you know? So how do you make this big picture fit together? So now we come back to know, the sort of, you know, whether it’s Dawson, whether it’s Pierre, whether it’s Kois, it’s about this sort of complete care and looking at the big picture, and how, if you come right back to it, don’t forget the complete examination, you know, digital will not save you from being a good dentist. No, you got to know how to examine patients, got to know how to communicate with them. We’ve got to know how to do some basic things, you know, but then, you know, my training then is got Okay, this is a this is a complete patient. So, you know, I think you put an email about it being a full mouth rehab, let’s think about every case not being in a full mouth rehab, but a full mouth consideration, a full system consideration. So no matter how little we’re doing, we’re looking to go if I just do that tooth, is it going to be okay? And then you know, if it’s okay, great, let’s just do that. No, but so I want to be able to look at that. And the traditional way is you would gather records, and then we would so we’d have photographs, we would have mounted models and then we’d be able to look at that and work out, diagnostics, and then work out a treatment plan about where these teeth needed to go to fulfill the goals that we’d set out to achieve. So then, you know, can we start to do those things digitally? And of course, whenever we move to some sort of new sphere, we always try and just mimic what we’ve left behind. And so for years, you know, many of us and I being included, I can certainly say seven, eight years have tried to copy that system. Exactly. Digital brings new tools, and new ways a year or two ago. [Jaz]What are you trying to say is that you were using digital, but to try and to conform it in the workflows that you had within analog, right? [Ian]Correct. [Jaz]So where is it heading now? [Ian]So Well, what what you need to do is every so often, not very often in my life, but every so often, you get a moment of clarity, you know, and you think, what am I doing? And you get so obsessed, I mean, so obsessed with inventing a digital Face bow, you know, it’s like, so many hurdles And you know, get into that, why don’t you think, okay, and we’ll save this for a little bit. But what is it I’m trying to achieve? What is it I actually need to do? Those digital have new ways of being able to do that, rather than just trying to copy the old ways of doing it. And so there’s things that have made me rethink, and it’s about going back to basics, what is it about achieve? What is it I’m trying to achieve? And you very kindly sort of mentioned Pete and I say, in no way where they ever compare myself with humans, just the most amazing guy, you know, but when we, historically, if you look at the old mythological days, and, you know, all the way we would try and measure everything, and, you know, then we say how everything worked perfectly when it didn’t really, because patients aren’t symmetrical, they don’t have mandibles that have the same side, they do have a bit of flex in the you know, there’s then they’re not made of metal, you know, biology is horrible in all it just those dreadful things to us, you know, so but articulators put our best guess. And then as a younger guy, Pete came up with this thing, but he said, Well, you know, what, we do all these things, and it’s all great. But really, what’s it about? Well, what it’s about is, how do we work ahead of time, make sure that when we actually get the patients in the chair, what is efficient and predictable and productive as possible? That’s it. That’s the basic thing. And so, what Pete was saying was, well, you know, if I use a semi adjustable articulator and I use a face bow, and we do this, I’m going to be pretty darn close. And so it’s going to take me much less time upfront, but I’m going to save myself a lot of time at the end, maybe just as much as time as you did when you spent 10 times more time up front, you know, so, and that was the whole deal of that analog workflow, and certainly, you know, can call it awesome philosophy. It’s the spirit, of course, it’s all those things. It’s all those people came from Pete’s idea, you know, and, you know, if you if you read Pete’s book, you know, and I was fortunate to get these stories firsthand. But if you read Pete’s book, he talks about he’s one of his favorite things was called blood on the walls, where he was invited to the pathological societies meeting, you know, when, and to hear his new way of doing things. And there was like, 1000 dentists there and so Pete gave his presentation, and everyone’s very polite. And then there was a luncheon. And then the speakers were introduced at the luncheon, the introduce everyone, then the guy who was the the big methodological cheese, said, you know, and, of course, Pete we want to thank Peter Dawson for his presentation, but we will continue to do the harder right rather than the easier wrong and, you know, to be, you know, to be put down like that in front of all those people as a relatively young man would would see most of us off. Peter has a lot of self confidence and a lot of belief. And you know, that sort of just sort of Stephens his resolve a little bit and he was also fortunate, because the next guy that got up to speak, was one of the, again, one of the other big cheese’s and he came up with a big pile of papers. He says, you know, this is the, this lecture is the one that I prepare for more than anything else. He said, But after what Peter’s just told us, I think I just need to rip it up and start again. And so you know, so in this, So, for me, again, in no way a comparison, but I think we’re at the same point, which is, oh, well, that doesn’t work. This doesn’t work. No, no, no, no, it does work. It’s just different. And so what we’re trying to do is how do we spend time upfront, which is allows us to plan the cases so that when we come to put this into the patient’s mouth, we’re pretty close. And then what we have to do is a little bit of refinement. And when you start to think about it like that some of these digital tools are amazing. And there’s so much better than what we’ve ever had in the analog world. I just want to before I forget, before we get into details of stuff. There’s one part of it that people don’t talk about so much. It’s almost like a different field, which is this complete dentistry and full mouth rehabs, or whatever you want to call them only happen when the patient says yes. We as dentists are dreadful communicators. And we say things they Oh, Mrs. Jones, you know, you then need 17 crowns, or you need to have equal intensity contacts and posterior disclusion, and this, this of this, so when would you like to get started? And we wonder why they don’t do. Digital is a fantastic communication tool. Okay. So now, when we talk about digital, we could talk about ways that we can use it an examination, and we certainly use it as for, for intraoral scans, for getting models, and I think that’s a routine thing. these days. We take photographs. Photographs are, you know, Jaz, because you’ve been, did a great record of what we’ve done today, they’re a great communication tool, so that patients can see what we can see. And they’re also helped us in our planning our two dimensional planning. So photographs are still a real important thing. But we need to find ways of engaging with the patients. And it comes back to that to the story with Amy, which is right became which is, what are they here for? What’s their motivators? You know, because, you know, they often are motivated by they might be motivated by aesthetics. And we’re talking about biology. You know, now, if you’ve got, again, one of my interests was sort of personality types and things. But if you’ve got that sort of a personality party person, and you start telling them about, you know, the bacteria that’s causing their periodontal disease, it might be very correct. And it might be exactly the right thing to do. But it’s probably not going to stimulate them to clean the teeth. I need to find the motivator, I need to think to find the thing that’s going to motivate you to do this work. Not for my benefit, but for your benefit. So again, one of the great things about aesthetics is people want beautiful smiles, but they want a beautiful smile, it allows you to access the health benefits for. So it helps us improve their biology because nothing looks better than a nice, natural, beautiful smile. So and now we do nice things for people, then hopefully, they look after it. So that’s all part of that deal. So, you know, I use digital, you know, in the examination, but then I also use it as an engagement tool. It’s a real way of engaging with the patient. What’s their prime motivation, and I sort of divided it into three main groups, are they, you know, just because everyone’s like acronyms these days, are they functional patients? Are the aesthetic patients, or are they more of a biological patients? So it could be like a F.A.B. patient, you know, and very often, it’s a combination of all those things. But what you know, if someone’s motivated biology, that’s going to speed up vital part of strees, because we love biology, we love caries, and perio and things like that, so that’s easy enough that we can show them pictures, and we can tell them what it is that needs to improve that those things are great. But a lot of the patients that I see a huge amount of them are motivated by aesthetics, you know, even old fogies, like maybe like to look decent, you know, most of us want to look younger and healthier and whatever. So, that’s certainly a big motivation. And some people are motivated by function as well, because they can’t chew properly, they can’t eat properly, or maybe they’ve lost teeth and how are you going to make this work for me? So, we can use these tools to help the patient understand what’s possible, you know, and so much easier than ever we could so if we take, let’s take the aesthetic one because that’s the one that probably is the most common one now. And is also it’s sort of out there in the bigger domain. Now, one of the things I learned from cosmetic dentistry 25 years ago, you know, was the motivation of sort of smile design, you know, with digital smile design now, you know, it’s a reinvention of an old theme, you know, but emotionally, you know? Well, I’m always a little, I’m always a little wary of the emotional phrase, you know, because I know they call it that, but, you know, it’s like, there’s a thing called buyer’s remorse? No? So just be aware of emotions, you know, so, let’s call it motivational dentistry or engagement, or something like this. But, and, you know, maybe I just can’t help you in the dentist. But yeah, just be careful of the emotional side of things. No, let’s figure out what’s their motivation, and then talk to them in those terms. So know, one of the, again, in the, you know, and certainly back to Pete’s day, and people since then it’s like, well, we take all these models and things, and then we mount them up, and then we spend four hours doing our wax off. And then we show that to the patients, and they’re bound to say yes, and we all said, Oh, okay, that’s fabulous. You know, and that’s the most people were prepared to go along with it, because they never do it. And those of us that did do it, were so invested in it, that we didn’t want to say that we weren’t that good at it. So it didn’t always work out great. The honest truth is, and I know I’m a bit of a observer of humankind is that the dentist that I saw that were fabulous as it were, actually, they were good clinicians, but more than anything else, they were great communicators, and they communicated to the patient their problems, and they communicated the problems to the patients in the terms that the patient wish to receive. And so and that’s why they were successful. That’s why they got to do the work, you know, so. And the cool thing with the digital now is that we can do smile mock ups and things like this, we can share our vision because someone can walk in and just be arrogant for a moment. And I’m thinking, yeah, I know, I can sort of see what I could do for you. But you’ve always got to remember, they can’t share that vision, we’ve got to find ways of sharing the vision with them. So you know, and digital, whether it’s photographs, whether it’s a 2d smile, where we can show them befores and afters and we can do it, we can do a 2d smile now in 10 minutes with the great software that we have, or whether it’s like an additive mock up, we can, you know, I mean, the way that we do it is we will put down certain markers. I mean, I can I can do it myself, but I’ll send it to the lab, they will do the design, they sent me the STL file, we print the model, we make the stents, we put that in the patient’s mouth, you know, I mean, it’s so, so efficient. And, you know, it’s rather than that, for me, there was a hole that we all fell into, which was this thing, which is I need to do a wax up. I can either I can spend four hours, and it’s gonna look pretty average, or I can pay the technician but I’m not sure that the patient is going to say yes. And no.. [Jaz]That’s the big debate. [Ian]Yeah. And so, and that’s the way I was brought up, because people always said yes to Pete, you know, because by the time they got to see Pete Dawson, it was a done deal, you know, but he was a different person. I was like I get patients, it’s like, they’ve got kids at university, they’d rather go on holiday, they just got made redundant. All sorts of things going on. I have lots of patients, as I’ve probably told you with booko syndrome, which means they’ve got lots of problems and very little money. No, and so I want to have solutions that can help them as well. And that’s why design is such an important thing. So being able to do additive markups, simply quickly and cheaply is a big thing. And we can do that now, you know. [Jaz]Are these digital wax ups significantly cheaper than like, for example, if you send a personal wax up to a good lab, you’re kind of looking at 25 to even 50 pound a unit of wax up in there, you know that’s significant. What has digital made it quicker, easier and more cost effective to turn around this model that you can transfer for a 3d motivational sort of a mock up you might? [Ian]Sure like, this is where there’s a really important part, Jaz. So let me try and explain this. So there’s a difference between what we might call incisal facial mock up just to show people the way it is, which, in with in my own sitting on my high chair judging everyone I would look down upon because where’s the function in this? So there’s a difference between that and a proper fully Functional Diagnostic Wax up. But there’s a big gap between patient fully functional diagnostic wax up. This additive mock up can be the link, I think, Well, I know it is, I said he is in my hands, in my practice. Because we can do those. And I’m working with some of the labs right now we’re going to be seeing some things pretty soon, where we can do those inexpensively, okay? For a lot less than that. Because that’s the problem, you’re sitting there thinking, I need to spend, let’s say 30 pounds a tooth on this. Now if it’s a smile, let’s say it’s a teeth, you know, and you saying to a patient, okay, it’s sort of, let’s say, 500 pounds to do this, just like, that’s a big leap for someone that’s not sure. Now, if you’ve got someone who’s totally motivated, that’s a different thing. But that’s, those are the easy ones, you know, but we have a lot of patients who aren’t sure and to spend 500 pounds, to do something that they’re not convinced about. So the journey, as far as I’m concerned with engagement is, you know, first of all photos, and doing all the things that we do, I don’t want to lose track of that, I think, a great code diagnostic examination, where we’re explaining to patients what the problems are, and how we can help them with what they’d like to achieve is super important. Photographs, real simple. And really, really important. And then we come to, we come to that decision is this a general patient, someone who just wants to deal with the biology, or maybe this is a complete patient in waiting, you know, I, one of my mentors, like is either tells me, don’t forget data before you marry them, you know, it’s not a bad idea to get to know someone, before you start doing big stuff, you know, and you know, Tif Qureshi as you know, was a big part of mine. And, you know, Tif talks about the same things, you know, this, these things don’t have to do this. You see all this stuff, I mean, on Facebook and Instagram. And as if the patient came in, we did that patient came in, we did that. There’s nothing wrong with getting to know people. And know, and know, if biology needs to be resolved, let’s get that resolved. But at the same time, again, to know them, we’re seeing whether to respond to they turn off, you know, do they pay their bills, so we can get to know someone before we move to that next stage. But let’s say we show them the photos and they’re showing interest? Well, you know, we can do a 2d smile design with some very simple software. I mean, we tend to do that for free, takes about 10 minutes, and it gives them an idea. And then if.. [Jaz]What I’m saying about that, because I want to get tangible for those listening to this part you do yourself or is that something that you are now outsourcing to labs because labs offers sort of smile mock up service in 2d images. [Ian]So let’s just talk about that for a moment to try and keep my focus on the bigger picture, but let’s just talk about that for a moment. I’m really, really keen on our relationship with good technicians, you know, what it is that we’re doing. And, you know, I have a lot of tremendous technician friends. And so when I say this, I’m not trying to be unkind to anyone. But again, like, we talked about the orthodontist who has the same goals, we have to work with someone who has the same goals, you can’t just send this to someone and get what they think, you know, we need someone who is on the same on the same page as us. Unfortunately, I work with the [inaudible] over in the States, Shamek Vanek, who’s over in Sweden, you know, and we just communicate digitally, I work with Phil Reddington, a lot of you know, we’ll be those of tremendous, we do different things together. But we have the same goals and they know what my goals are, they know what it is that I’m looking to achieve. So, you know, we need to be able to do that. But if you’re as far as this is concerned work, we can get the technicians to do as much or as little as we like. So my journey with this is when the smile design software first came out, I thought it was a pain in the neck. So I used to get Shamek to do it for me. Now, it’s really easy. So I learned how to do it, you know, I’m a bit of a old fashioned leader, you know, in the I like to stand at the front where even Magon say and follow me. So it’s like, I would use it to start off with and I learned how to do it. And now you know, my assistance. You know, they’re not in their houses, because they’re so they do so much for me, you know, but my assistants are trained to do it. So they would do the smile design for me in 10 minutes or so. We Yeah, no, and this is the thing and this is the you know, so by all means you can take the pictures, send it to one of these great labs and they’ll do something for you no problem very often they’ll do that for free to see because it doesn’t take them long to do. But because we’ve got the software we’re able to show someone real well, and you know, I mean, as far as your staff is concerned, you know this, do they want to just stand there and, and suck, spit and mix eugenol or would they like to be taken photos, doing smile designs, doing all these things, and really making the most of their job, you know. So those are the people that I’m looking for so in our practice, we started off, the technician was helping me, then I learned how to do it. And now mainly the staff are doing it, I still do it occasionally try and keep my hand on it, but you can choose whichever of those is appropriate for you. What I’m hoping is that you just get involved. And once you get involved, you’ll see the benefits in learning yourself and getting your staff trained as well. Okay. So that’s the 2d smile design, the additive smile design, I think is something that you could probably learn. But you know, to be honest with you, I have guys, you know, in various parts of the world, who are amazing at doing this. And here’s another obstacle for us. All this stuff costs so much money. Well, why? Well, it costs money, because we have to buy the software. And then we have to spend lots of time learning how to do it. If I know someone who knows how to do it, and I can, if I can describe them exactly what it is that I want. They do it, then we go on TeamViewer. And I can say could you change this or this or this? They make those tweaks just to make it look as though I’m actually in control. And then they send me the STL file and we print the STL file. And now we have a smile design in no time at all, you know, really, really efficient, very, very effective and cheap. And a great way.. [Jaz]How cheap we’re talking? Bacause I want numbers. [Ian]You want you will you would want numbers. So this is something I’m working on with some other labs at the moment. So I know no one’s listening, Jaz, because I know what I’ve learned from when your time which is the no one that listened to you anyway, say. So I know no one’s listening anyways, so it’s okay. But as you say, I mean, typically you’re looking 20, 30, 40 pound a units, I think we can definitely do these things. Because no, there’s two ways I was looking at this is if I said by the time I’ve got the patient to this point where I’m thinking of doing this, what’s the number that I think would be high enough to get rid of the cap, tier kickers, but low enough to have them do it? Okay. And I think somewhere between two and 300 pounds is a reasonable figure. So if we could do this for say 15, 10 to 15 pounds per tooth, it’s costing you, maybe 120, 150. And you said them? No, Mrs. Jones, we could do this when we can actually show you what this would look like in your mouth for 200 pounds. I think that’s a good place to be. And I’ve spoken to lots of other people about it. And you know, I think, you know, I’m not a great one for totally free. I think we do ourselves down by that. I think there’s lots of people out there who will take the mick out of you for it. And take advantage of you. And you know, I’m being polite right now. So but I think that’s a fair get that, if we could bring that additive smile design in for, you know, somewhere between 100-250 pounds, and you were charging the patient 200 pounds, I think that’s a good place to be. I think if the patient isn’t willing to invest 200 pounds at that stage, it’s probably not going to happen. So that’s sort of what I’m waking up to. But let me tell you this, it’s not just an additive smile design, okay? Because this is the thing because like, which is nice, we put this in the patient’s mouth, and they go Wow, that’s amazing. And then we have to start again to work out how to make it work. Okay, so let’s think about being able to use that additive smile design to really enable function, okay? So let’s think about the three main things that we talk about in function and treatment planning function, upper incisal edge position, lower incisal edge position, vertical dimension, okay. So if you think about it, if we do an additive smile design really nicely. We have the upper incisal edge position, we have the lower incisal edge position. And then what we need is a little bit of knowledge to work out the vertical dimension. And now we have everything in place to do the full diagnostic wax up. [Jaz]It feeds into the next part. That’s fantastic. [Ian]It feeds into the next part, and we’ll make the next part even easier still. So let’s take this simple one, people don’t think it is necessarily the simple one. But the simple one is generalized wear, because it’s easy because we’re going to, without going into the occlusion bit, open the bite to a little bit have some space. So if we add a couple of millimeters to the upper incisal edge, and maybe a millimeter to the lower incisal edge, then we can see how that looks in the patient’s face. And then we just got to think about where do they come together? Do we reduce at the back? Do we add to the front? Or is it a combination of those two things. And that might be the, it’s a big topic, as you know. [Jaz]Well that’s far behind a podcast episode, but it’s just getting the whetting everyone’s appetite for digital understanding or workflows Ian and already you’ve told us about the how easy it now can be to have that 2d motivational photo to the extent that now you’ve got your staff train, which is amazing. And then you’ve talked about going to the additive mock ups and how that can feed in to the next part. And that’s really great. [Ian]Though, let’s also think as well, Jaz about sort of how that whole thing fits together. Because you talked a lot about individual parts that you know, so. And that’s sort of the whole picture. So and you said to me, you’re one of the questions you asked or mentioned to me was about when I take advice at the right vertical, I seem to be very successful. And that’s absolutely one of the keys. It’s an old trick that we used to use with splints. That if we took the bite at the right vertical, we didn’t need all the face bow stuff. All the big articulator because we were playing with the arc of closure, it’s the same with these things. So if we’re just playing a little bit with that, maybe we don’t need the old style Face bow stuff. Now there are times and the key is to understand when those are when we might need a little bit more information. But but to come back and say okay, what’s your protocol Ian for records for smile designs, rehabs, comprehensive patients? Well, so we do our complete examination, we do photographs, we talk to the patient about what’s there in the terms that they would like to receive it. And then if they’re motivated from the aesthetic perspective, then we will show them a 2D smile design, and we’ll get them, If they’re then motivated to spend that, let’s say 200 pounds on their smile design, then we’ll move forward with that. Now for that, here’s what I’ll take is, I will take scans. Now for those of you. Because I was only joking before I know loads of people listen to you. So for those of you who are analog and would like to stay analog, you can still take impressions, and we can have those scan by the technician. Okay, so this, you can get into this whichever way you want. For me, the real power of digital is in wax ups, treatment planning, etc. So you can take that we can take an impression and have it scanned. No, obviously, again, I’m hoping that eventually you just say, Oh, it’s a waste of time that we should just get a scanner, you know. But we take the scans, we take a bite registration and the bite registration that I’m going to take, I’m going to take it from my place in a stable condyle positions, you can choose whichever way you’d like to do it, I’m going to choose a stable condyle position. And I’m going to choose the vertical dimension that I think is most appropriate for that patient. So now there’s obviously some thinking that goes into that, that we could maybe discuss another time. So we take a bite at that stage. And then often now we’ll take a face scan as well. And the reason why we take a face scan is because the photographs, we can set the patient up pretty well using the photograph. But with a face scan now, I mean, I can take my iPhone out, and I can take a face scan on this. And then we can use that and we can with things like Bellus 3d, we can incorporate the intraoral scans together with CB CT scans into the patient’s face. And we have a virtual patient and now the technician can actually see the teeth sitting in the patient’s face and what, I mean, that’s amazing, isn’t it? And when you think about it.. [Jaz]And that essentially your Face bow then right then. So but before we get to that, I mean, this whole scanning, the source scanning the face something I’m not doing the moment it’s very new concept for me and you mentioned that some software that you can use for that. In terms of one of the questions I had sent in is that if you’re relying on your photographs to become your digital Face bow, is that a good entry point into transferring that information if you don’t mind Ian just for the listeners who are hungry, A lot of young dentists listening, what is the main benefit of Facebow in general cases? and Why would you, Why would I even bother? Right? And then how would you transfer that, using photographs to a laboratory along with the scan? Is that a predictable way or not? [Ian]So this is where you have to come back to basics. No, I think in the analog world, a facebow. You know, so where that came from, and the old pathological days was a hinge axis recording which your if any of the younger guys or girls want to go on and look at that, by all means do so. But it looks like something from the museum. And there’s still things that we can talk about with hinge axis, it’s quite interesting. Because I’m sad. But no, we then move to this Earbow, or Facebook or whatever you want to call it, there’s a few different varieties out there. And really, what we were using then is like, this is a quick and easy way of transferring information to an instrument, which in some way replicates the masticatory system. That’s what it’s for. So what did it do? Well, it went in the ears. So we said, well, let’s we related the top teeth, to where the condyles are, okay? Where also, then that’s going to help us with the arc of closure, because that’s important if we’re going to take a bite and open bite, open register, open vertical, or if we’re going to play with the vertical dimension. And it also we also then used it to give us some idea of the incisal plane. So let’s blow up a few sacred cows, you know, it’s just me and you. [Jaz]Has to be done. [Ian]But let’s think about that. Well, you know, I mean, don’t get me wrong, if you’re in the analog world, this is still a great way of doing it. Okay? Because it’s going to give you a lot of great information. And I’ve done it for years, and it works. So well. Let’s think about it. So we put it in the ears. Well, where are those? You know, we’re actually looking for the medial pole of the condyle. Unless you’re pressing real hard, you’re not getting there. So they know far too hard. So, you know, what has got the most Facebows do I think they allow, you know, excuse my lack of knowledge, but something like nine millimeters, because that’s where we think that is? Well look at my fat head. And then look at lovely slim Jaz. I think we’re probably a little different. So we’re making an assumption straight away. Okay, and then if we’re going to use it to get the incisal plane, what are we going to do? I’m actually going to fudge it round in the ears a little bit. Oh, that’s super accurate. Okay. And then it’s going to be the arc of closure. Okay, so you can see that it’s good, and it’s quick, and it’s easy, and it works better than the other stuff, better than doing nothing. But here’s the thing, if we think about all those pieces that we just said is, why do we need the art of closure? Well, we need the arc of closure, you’ve got to mess with the vertical. But if we actually take the bite at as close to the right vertical as possible. Maybe that’s much less important. Okay, which is why you’ve been successful with those things, as you mentioned is exceptional. [Jaz]I mean, the reason Ian mentioned this guys. I emailed Ian little bit about what we’re going to talk about and one thing I told him was my experience of digital so far is when I’ve recorded the vertical dimension near abouts where I want the patient to end up before I restore them. I found that once I’ve done there and typically as is composite my level experience a moment moving with ceramic but at my level at the moment quite Junior doing a lot of composite work and transferring the sort of digital wax up into the mouth, and then getting the patient to close together and this after usually I’ve deprogram them, we’re using a deprogramming appliance. And that’s a whole another section we’ve talked about, I found that when they bite together, I’ve got these beautiful contacts and the excursions are just where I want them. So it just needs a bit of polishing. And the first time I did it, it blew my mind. I thought I flipped it, then a couple of times of the day it was it became very reproducible. That’s exactly the reason why Ian just said you know, when you record it at the vertical, you remove that element of potential error of actually opening the vertical. So that’s what Ian has been talking about. And now going forward from that, the questions we’ve had is we’ve essentially answered it Ian the virtual Facebow is essentially what you’re using is a face scan incorporated but one thing I perhaps misinterpreted was that you said the CB CT but if you’ve got a comprehensive patient who does not need implants, but you’re doing comprehensive dentistry so you want to transfer that information, would you be taking a cbct to as part of your records to then be able to relate that to a virtual Facebow? [Ian]Okay, so let’s talk about relating, or so that virtual facebow thing and see if this answers the question for you, you know, one of the things that relates to that correct vertical, the correct vertical only works with a stable condyle position. So that’s, just let’s be clear about that. So if we think about what we just said about face bows and how we relate the teeth to that, and how do we do it, we can choose a photograph that will give, that will be reasonable. Now there’s certain things we put to 2d to 3d, we can use a face scan, which will give us more information still, we can use a CB CT scan, if we have one. Now, I think it’s grossly inappropriate to be taken CB CT scans to my models, and many of the patients that I treat, have joint issues, ortho issues, implant issues. And I’ve got good reasons to take full volume, CBCTs, but I also have a lot of patients more smile design. It’s inappropriate, you know. So we’re taking appropriate radiographs, appropriate radiation. And so if we have one, that’s probably the most accurate way of doing it. But if we don’t have one, perhaps a face scan is the most accurate way of doing it. And the next thing that we can mention, so let’s but there’s a reality to all this as well, a photo is quick and easy and cheap, we all know how to do it. A facecam these days is quick and easy and cheap. And it’s easy to learn how to do CBCTs if they’re necessary there. Then we have things like MODJAW which are more like jaw trackers, etc. And they can give us tremendous information. And we can combine that information with the intraoral scan with the CBCTs, and we can actually see, we can actually record the hinge axis, what used to take us hours would take five minutes these days, you know, so it’s amazing information that we can get from stuff like that. But there’s a cost that comes with that. And I, my goal with these things is to get the best treatment for patients, for my patients. And then if I can encourage other dentists to do the same, then I think I’ve spent a lot of time well. And my other goal is to get them to sufficiently interested that it makes the, want to treat patients well, but also makes the days more interesting, you know, because they we all spend eight hours or so here. You don’t you may as well have an interesting day. And, you know, no, but also as well, I think many of us over time have bought expensive pieces of kits that didn’t, we didn’t particularly get a return on the investment, you know. So things like MODJAW I think are great, I think there’s huge amounts that we’re going to learn from things like that, as far as research and education. And I think as far as you know, treatments concerned, it’s a really valuable tool. I think at the moment, it’s at the high end of cost, it’s not something that I would suggest go out and buy one, if you like stuff like that, go out and buy one, you’ll have great fun with it, it’s great fun, and you might be you know, you’ll be able to patients will think you’re amazing, all those great things. So I think it’s a great tool to have if you’re going to make use of it every day. Okay. And I think that going forward, these sort of technologies will get incorporated more into what into the other things that we’ve spoken about. And like everything else, they’ll tend to come down in price a little bit. And it will become part of what we do. I’m absolutely convinced about that. And at the moment, there are things you know, I think, in some of the cases that I do MODJAW is incredibly important. But for some of the simpler things that we do, it’s interesting, but it’s not as important. So I think if we look at that, so I don’t know because the people that MODJAW are fantastic, and I encourage you to look at it and to think about it and if it rings you, floats your boat, get yourself one and get involved. And you know, I mean I’m really enjoying working with it myself, you know. But it’s no good having something like that if you’re doing just a couple of fillings every day, you know, it’s not going to help you too much. So let’s just recap over those so we can use a photograph, simple, easy, cheap, gonna give you a decent result. Facecam simple, easy and cheap, gonna give you a pretty good result. CBCT if appropriate, so relatively simple, easy and cheap, if it’s the right thing to do, and super accurate. And then MODJAW, super accurate but a little bit more expensive. That’s the overarching thing. And then let’s compare that to face bow easy, cheap. And, you know, I’ve done have to take the Facebow, take the models, mount the models do all those things rather than a, lot of time, you know, I mean, now I can take my scans, take my bite registration and check my first point of contact in 10 seconds. Usually we’d have to cast the models, mount open model where the face bow, mount the low level with a with a bite registration. And maybe two days later, I get to check the bite. Yeah, I mean, I sort of forgotten about that until one of my pals it pointed out to me, because you do that right away. And yeah, so I can tell if I’m on the money straight away. So there’s so many things that help us predictability and efficiency, productivity. And that I think we just got to think differently. So that’s the, that’s my view on Facebows now. I think if you’re in the analog world, it’s still a great way to go. And But otherwise, I think we have other ways which are, let’s say just as effective. [Jaz]Well, that was the most common question that come up. So thanks for those who sent it in. Now in the interest of time we’re gonna have to wrap up so one of the questions which I think is I do want to learn about is Sid Gupta, if you remember from Dawson, I met them at one of the Dawson event. Sid, young dentist and when he put in one of the part of the courses that we did with you is that we get to present our cases and his photography, and his motivation was just fantastic, I believe he is in Wales, fantastic young dentist, really great work. He wants to know when your digital courses coming out? So if you’d answer that? [Ian]Well, as you may or may know, already, I’m probably about the worst salesman as far as dental courses out that is concerned. So they are coming soon to probably on 40 to a webinar near us. So but they’re coming to you and I’m working with the guys what we’re hoping to do. And I’m actually that’s as soon as I finished with you, that’s my afternoon is working on, on those digital courses. Because what we’re aiming to do, and it’s little bit related to this beautiful COVID situation that we’re all in, but actually, it was something that I was working on before, which is now the idea that we could have smaller groups in a location that was more appropriate for you. So, you know, say for sit down in town in Wales, because let’s face it, Who else wants to go to Wales, and I haven’t been rude about them for ages. Now for for those of you who don’t know, probably 50% of my patients are Welsh. So, you know, I always mean to the people who live next door, you know, so and I’m a Scouser. So I’ve got no chance at it. So but but the idea is that maybe we could have five is that we would do a little bit of located lecture, which would be centralized, and then in that smaller location, you would then do a hands on exercise. So let’s take, say, taking the extraoral scan, taking the bite at the right vertical, so we’re going to be rolling those things out pretty pretty soon, they’ll always be the opportunity to come here and, time me when I do it, but, you know, so that’s but you’re going to be seeing those things very soon. And you know, what’s great for me, you know, is you’re very kindly invited me to this sort of thing, Jaz, and I know you have a lot of listeners and people like Sid, you know, it’s what’s been very, very rewarding in recent times, is to have these young people who are far more motivated than I ever was at that age. I know, well, if we can just encourage them to do a little bit of learning every day, every week, every month, they’re just going to be so such great dentists, and get such payback from this, their patients are going to be so well looked after you know that spending our time doing these things will be well worthwhile. So the courses are coming soon. Jaz, by the time I’ll make sure that you’re the first to know and if you can let these people know that would be fine. [Jaz]Yeah, I want to put that up to people use swap me on Instagram for information where it’s always usually on the website protrusive.co.uk. So when it’s out, I’ll update the blog post associated with this episode. So we’ve covered a fair bit I mean, it’s impossible to get into nitty gritty detail bits that we all love in just a video over 45 minutes or so which is the aim but I think we’ve covered a good deal to everyone’s uptight about getting the mean you talked about communication, that’s so so important about how to actually communicate and find out what motivates that patients. That itself was just phenomenal. We talked about 2d smile, we talked about the additive mock up and how you price that. So we talk a lot about the business element as well. It’s like a lost leader. But it’s one way to get that patient on board with a vision and how you beautifully took it to the next stage with implementing it into the upper incisal, lower incisal and the vertical dimension. We talked about a few hacks with the vertical dimension in central stable condyle position. And it’s come beautifully to full circle now. So Ian, thank you so much for your time. Is there anything else that you want to put out there? [Ian]Ah, you know, it’s a big old subject, I think, you know, it’s a combination, I mean, of new ways of doing things digital is exciting. You know, I mean, as I’ve been doing this 35 years, my daughter’s just starting just about she’s with all this A-level chaos. She just got into do physio with Sheffield. So it looks like I’m going to be working for a while longer yet. And while we’re going to work, you know, I think we have a duty to our patients to do the best we can. And we have a duty to ourselves to as enjoy everyday as much as we can as well. So, and all these things help us to do that. And so I appreciate your time. And I appreciate your listeners time and listen to us go on about dentistry. But we spend a lot of time doing it, we may as well make it as fun and productive and beneficial as we possibly can. So that’s sort of what it’s all about. Jaz’ Outro:I really appreciate that. Thanks so much, Ian. And I will catch you at the Digital Course. Thank you. I hope so. Thank you. There we have it, I did tell you that you would love his stories. And I really hope you gain value from that. As always, I really appreciate you listening all the way to the end. If you could do me a massive favour and go on YouTube, hit that subscribe button and whichever podcast platform you’re listening from, please hit subscribe and please tell a friend. That’s how the podcast grows. Next episode is going to be awesome. It’s with Payman Langroudi all about whitening in a way that you’ve never thought about before. Like how can we do more whitening, why we shouldn’t be doing more whitening and few tips and pearls to get better successful teeth whitening outcomes. SO come and join me in that one next week. Same time, same place.