Protrusive Dental Podcast

Jaz Gulati

The Forward Thinking Dental Podcast

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Jan 23, 2021 • 14min

Implant Assessment for GDPs: from Space Requirement to Ridge Preservation – PDP052

Learning Dental Implants can be confusing. There are so many layers of complexity, from space requirement, restorative components and surgical nuances. This 2nd part of the 2-part series on Implants with Dr Hassan Maghaireh looks to guide us through the fundamentals of assessing your patient for implants. https://youtu.be/VZfWZf1lpoU We cover A LOT of clinical Implantology for GDPs Need to Read it? Check out the Full Episode Transcript below! How do you assess the Implant space for the right mouth in the right patient? When patients ask how long Implants last for, what should we tell them? https://youtu.be/COtd1bpx0Jg How long will my Implant Last? How to respond to this? Can you place implants on Smokers? What is the protocol? Bisphosphonates – at what point are implants contraindicated? How can you tell if it’s going to be a complicated case? How about Perio Susceptible patients and placing implants? How will Parafunctional patients fare with implant restorations? Who should take the tooth out?! GDP or Implant placing Dentist I routinely section molars. Is that a good practice? What is ridge preservation and when to consider this? Protrusive Dental Pearl: How to use a pencil to draw line angles for anterior aesthetic composite restorations. I learned this from Dipesh Parmar on the Mini Smile Makeover course (next course in 2021) https://youtu.be/JDEibGUHA1w Please do not use your wife’s Eyeliner If you enjoyed Dr Hassan’s style of teaching, do check out the BAIRD Implant Course. If you liked this episode, you will love revisiting Complete Dentures with Mark Bishop! Click below for full episode transcript: Opening Snippet: Name two patients gave you hell in these 35 years. And he said, people who had history of periodontitis before having implants are going to get or at high risk of getting peri-implantitis after having an implant, so there will always be at high risk. And people who have parafunctional habits will always go into grind and break these implants for you... Jaz’s Introduction: Hello, Protruserati. Welcome to Episode 52 of the Protrusive Dental podcast. This is the part two of the implant series with Dr. Hassan Maghaireh. Hope you enjoyed that part one we think about when you’re actually getting into implant when you’re thinking about starting implant journey. Is it right for you? Because that was the last episode. In this episode. We’re getting a little more clinical, reassessing, like what’s suitable for your first case? How would you assess the space, the mouth, the patient that might be suitable for implants? What are the patients to avoid? What about smoking? What about Peri-implantitis? What about bisphosphonates? So you really look into the nitty gritty clinical details about selecting patients that are suitable for implants particularly if you’re starting out. And in fact, I had to listen to this episode again, because so many gems in there about the timing of extraction. Sometimes I wonder, should I be the one extracting this tooth? Or should the person who’s placing the implant be extracting it? So we cover that as well, as well as something I do a lot which is sectioning molars. I’m a big fan of sectioning and elevating molars. And I asked Hassan, Dr. Hanssan what he thought about that, is it right that I’m routinely doing this? Is that a good thing? Or can we run into trouble? So lots and lots covered in this very clinical episode with Dr. Dr Hassan Maghaireh. This episode is sponsored by enlightened smiles and mini smile makeovers. So I want to share a great pearl that again, I get from Dipesh Parmar from the MSM course, which I went on over a year ago. It’s one of the best composite courses or courses at all I’ve ever done. The setup was great, the hands on was awesome. The food is always on point. Thanks to Payman Langroudi, that man. So the pearl I want to share with you is about line angles, right? So when we’re placing our restorations, let’s say composite restorations direct and we’re wanting to create those perfect line angles anteriorly. How do we do it? But you might have seen the trick where we can use a pencil to draw the line angles, and I’m going to show you two different ways to apply the pencil. And because I’m in the studio and not the practice, I don’t have a pencil. So instead of a pencil, I’ll be using this video and eyeliner. It’s my wife’s eyeliner. The funny thing is, I don’t even know if this is eyeliner or not, and I’m just assuming it is. So maybe the ladies can correct me but I think this is eyeliner is Maybelline ‘maybe it’s Maybelline’. Anyway, I’m getting distracted. And she’ll never know because she doesn’t listen to the podcast anyway. So I’m going to use it in two different ways. So if you’re watching the podcast and great, you’re gonna get see it. If you’re listening, I can describe it in a way that’s useful if you want to draw where your line angles want to be. So if you want to draw where you would like for the line angles to be, you should draw it with the tip of the pencil, like you’d normally use a pencil, right? So you draw it in, you know, left and right exactly mesial distal, exactly where you would like the line angles. So then you can use your soft flexed disc or burs or whatever you’d like to use to recreate exactly what you’ve drawn. Right? Now. If you want to see or assess where the line was currently are, so you know whether to push them in or bring them out. It’s a different way of doing it. So you have to hold the pencil, or the eyeliner, in my case on its side. And if you hold it on its side and you just brush against the tooth, the height of contour the tooth, ie the part of the tooth that sticks out the most, which is the line angle will pick up the pencil. So if you want to assess where the line angle currently is, you use the pencil on his side, if you want to draw where you’d like your line angle to be, you use it normally. So that’s a little tip on how to use the pencil. Now, how can we use it clinically in the best way obviously you won’t be using my wife’s eyeliner clinically, you the best bet you have clinically is using those clicky led pencils. So click click click because the beautiful thing about that is once you’ve used it, it’s been the patient’s mouth, you just break away the lead and then you click click click and you know that there’s no contamination there. And of course you can use one of those light cure covers plastic sleeves when you’re using it. So this is like the most infection control friendly way of using it. So hope you found that useful. And thank you again to MSM, minismile makeover for sponsoring this podcast. Episode now right over to Dr Hassan Maghaireh on a very clinical episode part two of the implant series. This is all about assessing your patients for implants. We even go all the way in depth from you know, from the start, we start basic all the way to talk about rich preservation. So, follow along, and I’ll catch you in the outro. Main Interview: [Jaz]Okay, Dr Hassan Maghaireh, Welcome back to this part two that we were doing on implants. So the theme’s implants. The first episode, we talked about where your true self as well, we talked about the implant journey, getting into implants, some challenges, the role of mentorship and continued development. And this one, we want to make a little bit more clinical, because you mentioned something fantastic in that first part whereby, if you’re a general dentist, and you don’t provide implants, we still need to give our patients the option of an implant. And then if a patient turns around to us and says, am I suitable? What’s involved? Is it as simple as this straightforward? We need to have some background knowledge. So I’m hoping this episode will just scratch the surface about that topic. So, Hassan the question to ask is, how do you know that the patient in front of you, the mouth in front of you, or the space in front of you, is correct for an implant versus a different approach? How do you even begin thinking about this massive topic? [Hassan]Okay. The first thing you need to remember that when you look at a space, you need to be looking at like in bigger picture, rather than looking space that can mouth, look at the patient, okay? And as the patient comes to you asking for an implant, try to look at that patient as a series of risks and start to tick box. Do they have that risk? Do they have that risk? Do they have that risk? And if they don’t. Have all the threads, then you could say right, it’s safe now to proceed to dental implant therapy. To keep it simple. The only absolute contraindication for implant dentistry is as simple as uncontrolled medical or dental disease. Everything else is suitable. So you’ve got a diabetic patient, their diabetes are well controlled, perfect, no problem. Is their diabetes uncontrolled? then we cannot go ahead with implant dentistry. We’ve got someone with perio, is perio well controlled? Yes, then we can go ahead with implant dentistry. Their perio is not well controlled, let’s stabilize the perio and then talk about implant dentistry. Now there are some medications which can complicate the implant work. And the most popular ones are obviously Bisphosphonates. And I highly recommend looking at the document by the ADR called the white paper. And it’s basically it’s a consensus document done or the review document done by one of the professors invited by the ADI and it summarizes the guidelines. When is it safe to go ahead and put implant for someone in bisphosphonates or all the grip of that medication and when is it isn’t safe. To summarize that document, basically anyone on intravenous bisphosphonates is a high risk. And that’s to do with the fact that people who take intravenous bisphosphonates, they take it in high dose. So that’s one thing to remember, anyone taking oral tablets for long, long time, which means more than three years that also become medium risk. Now, all of this bisphosphonates less than three years can be a minimum risk, but the risk is there. And you need to be talking to patients about the exact risks involved in having implant dentistry while being on these medications. Another good thing to do with people on bisphosphonates or similar medications is basically to go for a staged approach. So try to you’ve got a patient needing three teeth out, take a single tooth out and see how things go into here. And then if that heals, well, you could move to the second tooth and so on. And then [ ? ] well after tooth extraction, you could say right, then maybe implant too can be safer. There will be some preoperative and post operative antibiotics needed and you need to have a minimum traumatic surgery. So I would highly recommend go and check that white paper by the ADI and I think it’s available for reference. [Jaz]I will add that on the show notes on the website, Protrusive website and the Facebook group as well. So that’s a really good point, and it’s good knowledge to have about bisphosphonates when it comes to you know, surgery, extractions and implants is no exception. So if when your patient, your little old Mrs. Smith comes in, she wants to have some implants to restore her sort of ability to choose something. And she has been on implants where the oral implants for seven years, you can think okay about the white paper and then that’ll help to inform you what the next step is, would you refer? should you place,? whatever you need to do. So that’s a good point. I’ll make that available. [Hassan]So the thing is about oral bisphosphonates that, nowadays, you know, GPs prescribed it regularly. And some GPs wanting to make it easier for their patients rather than taking the tablet once a day, they start offering to give injection to the patients, like twice a year or what whenever. So they move them from a low risk to high risk, although their medical history hasn’t changed. So don’t assume that, oh, she’s only osteoporotic, surely she’s not on injections, some of these patients are on injections, and you have to be double checking that. [Jaz]That’s a good point, because I just assumed if they asked what’s your [inaudible], there’ll be an oral and it’s the more the cancer risk, or whatever that would be taking the infusions at all very severe. So yeah, it’s a good point to double check your medical history. [Hassan]So basically, going back to the very first point, unstable dental, unstable medical diseases all these people want to keep away from. Now, as you go into implant dentistry further down further deeper, you need to start to think about, okay, what are the things which can complicate the future treatment? And I remember was attending a lecture by someone who had 35 years experience in implant dentistry. And it was a beautiful lecture at the end of the lecture, the moderator asked him and said, name two patients gave you hell in these 35 years. And he said, people who had history of periodontitis before having implants are going to get out at high risk of getting perio-implantitis after having an implant. So there will always be at high risk. And people who have parafunctional habits will always go into grind and break this implants for you. And I watched your episode about stents. And it’s really amazing. And I think this is something else every dentist needs to know about. Because if you’re going to offer implant dentistry to a patient, like it or not, they become [inaudible] implants. And you become somehow responsible for this long term success of these restorations. And this is where communication is very important at the very beginning. Because like it or not even in the United Kingdom, you will have patients thinking that the fact they’re paying you 3000 4000 pounds per implant that said, it’s going to be there forever. And they will forget the fact that they bought a car for 20,000 pounds. And that car is not forever. So I think that sort of education needs to be there in the assessment visits to our patients that, you know, yes, you’re having an implant, but there will be lots of maintenance and review visits needed afterwards. [Jaz]Just the flash question, Hassan, when a patient asks you, how long will my implant last? What do you say? [Hassan]Well, that’s a very good question. Because obviously dentists are under pressure to say, my implant will last you for life, don’t worry. But actually, you worried because if you go to the person and say, I cannot guarantee them, but do you worry that this patient might go somewhere else? So the best way to do it is to go and say, and this is why I say evidence based studies. So basically, it’s not my theory, it’s proper research, suggests that if implants are looked after really well, we can have a survival rate of 95% up to 15 years, maybe longer. Having said that, the same study suggests that if you fail to keep the implants clean, and if you get gum disease around your teeth, and your implant, your implant going to fail within the first couple of years. So basically, I’m making it clear that we will do everything to make sure you get that long term survival. However, it’s a two way equation. I need your help and your support to look after by two brackets your implant and I think patients need to understand that it’s their problem. They came to us with a failing tooth. They came to us with a missing tooth, and we’re doing our part and I genuinely believe every dentist is going to be an honest dentist trying their best to help the patient. But the patient needs to understand that they have in a role in these long term success should they wanted to be there, [Jaz]That’s a really great point. And it’s the same thing I talked about parafunction splint, you know, the reason I coler in my splints and then they grind it, and then they see the markings is that so they can begin to own the problem, because quite often, they have no idea that it’s there. And then when they see, and then they own the problem, to just start that, they to own that implant and own the problems that could happen with their implants, because it’s in their mouth, and they need to uphold the basic level of care and maintenance as well. So I’m sure that’s drilled into them excuse upon in some from the beginning as part of the consent process. [Hassan]100%. And that’s the other thing, you know, in the consent process, you talked to them about pre operative assessment, and then you talk to them about what we’re going to do during the surgical and restorative stages. But then the third part, which is as important is what’s going to happen after completing the work, and this is, again, where we’re talking about general dental practitioner, you know, every dentist should have the absolute minimum knowledge on how to maintain a dental implant, at least how to diagnose peri-implantitis, how to diagnose continuous bone loss around the dental implant, and when to refer that patient back to the dentist. I had one of my lovely referring dentist bless her, she referred me a central incisor case, I’ve done the case everything went perfect. And then they for one reason or another patient driving with teeth at night, the screw went loose. So then the patient went to see his dentist and then don’t worry about it, we’ll wait for it until it comes out. She didn’t know that you biting on a a tiny loose screw is going to break that screw. And then that case was sort of converted from a simple case where you tighten the screw in three minutes, to a very complicated case where we have to put the patient through one hour of screw removal, which was very stressful for the patient and for us as well. So these little things, I mean, this is an invitation to every single dentist to go and look for these open evenings, continuing education conferences, they need to know about implant dentistry. And I think that’s something you and I covered in part one. [Jaz]Absolutely. And I think you raise a great point, if you’re a general dentist and you know, we’ve all seen it, the patient that comes in and their implants are swiveling around. And if you don’t know anything about that you think oh my god, what’s happening? the implant’s loose. You know, if you’re newly qualified, like, Oh, my God, what’s happening, I need to call someone This looks really serious. But it’s just as simple as just removing the implant restoration composite that’s on top and removing the ptfe your cotton revolute place there and just giving a little Titan quarter turn whatever, and then putting the restoration back and your patients are happy and you’ve avoided this complication. So it’s about that, just like I said, again, that level one, level two knowledge which is which is so key. And we don’t get that why certainly didn’t get that in my undergraduate to the extent that I’ll be confident to deal with that situation. Unless I had and sort pursued extra courses and knowledge to do that and or add mentorship and guidance. Hassan, that tell me about smokers? Because that’s a huge one, right? My patients smokes. And I need to let’s say refer them to my, our in house dentist who places implants. Is there any point where an implant dentists will say no, I definitely will not. Is there a minimum number and the evidence says that if you smoke above this point, there’s no implant for you. If you smoke between here and here, we might do it if everything else in our favor. Do we have a magic number? [Hassan]Yes. Well, I mean, we have very good research from Professor Bain. And he’s basically he’s a British Professor based in Scotland and he’s done amazing research on smokers and implants in the mid 80s, early 90s and at the time, it showed that smokers will have higher risk of implant failures okay? But then that most of that research was done on machined implant on the polished implants which let’s say the old style implants. Now, more research was done by Professor Bain and his group and other you know, research in the dental literature. When we have the modern implant services which are implant services treated differently, to encourage better osseointegration it shows the actually smoking will not really influence osseointegration as we felt before, having said that, we do have good research showing that let’s say if we talk about survival and implant dentistry 97% as a smoker, it goes to mid 80s so there is a risk. And that’s to do with the fact that we know, when you smoke, you’re going to affect the oxygenation to the little capillaries supplying blood supply to the bone and the surrounding bone. When you smoke, you’re going to get high risk of wound dehiscence. When you smoke, that normal flora inside your mouth gonna be converted into very aggressive bacteria. So that balance inside your mouth is not going to be right anymore. So you’re always at higher risk of having complications. Now, if you are a smoker, and you have a perio disease, that’s when you get like synergetic negative effect. And that’s when things start to even cause more damage. Now, to summarize, when it comes to implant dentistry, some research suggests that if you smoke 10 or less, you’re classified as light smoker, and that will not have as negative effect if you’re heavier smokers 20, 15 cigarettes a day. That’s really number one. So I’ll go talk to smokers. And I tell them, do you know what I know you will never stop smoking, despite whatever I’d say at least cut down to less than 10. Having said that, there are very good articles and studies showing stopping smoking for about 60 days or so will bring you back as a healthy person when it comes to blood oxygenation, and good healing abilities. So there are some random control trials done on rats. And they found that these rats who smoke they have very low bone density, very low ability of healing. But then when they make them stop smoking on within 60 days, they come back to as healthy as the control group. So stopping smoking does make a huge difference. [Jaz]I couldn’t keep a straight face that I’ve just got this image of this rat holding the cigarette. [Hassan]I have the image of the Big Bang Theory. Well, let’s say men. Yeah, [Jaz]Sheldon. [Hassan]Sheldon. His girlfriend, Amy? [Jaz]Okay, I forgot the name of the girl. Yeah, [Hassan]She’s, like studies on monkeys, if you remember, I’m giving them about six. So rule number three, we talked about, you know, smoking less than 10 is better than heavy smoking. Rule number two, as we talked about stopping smoking makes huge difference. And first, all that negative effect. And rule number three, smoking itself can work with implant dentistry. But I go to the patient and say, don’t come and ask me why I had no papilla or why I have recession after my surgery. So don’t expect to get cosmetic implant dentistry or aesthetic, soft tissue come to if you’re a smoker. And rule number four. If you need bone grafting, or sinus grafting, it’s an absolute contraindication in my book, because this is where things start to be more complicated. I will now with confidence, say I will never do sinus graft for a smoker. I will hesitate 100 times before I do bone blocking grafting for a smoker. Because anything needs advanced surgery needs huge amount of blood supply, smokers will just won’t work for them. [Jaz]Brilliant. That’s a nice little summary. So less than 10. 60 days you mentioned and really to avoid it in patients who might need advanced work and to tell the patient is that not expect a cosmetic benefit from the soft tissues. That’s a really nice, I’ve certainly gained from that myself. So when I’m seeing smokers now I have a bit more confidence speak about them and be make sure that my referrals to my Implant Dentist are more appropriate. Of course, I’ll send it to my Implant Dentist anyway to have that chat. But I can have that little bit of confidence in myself that you know we’re on the same page. So that’s grant. And lastly I want to talk about clinically because we there’s so much we could talk about and I want to make it most valued for those listening mostly GDPs, when you have a patient who has an unrestorable molar, let’s say and it may or may not have a apical infection, how do you decide between ‘Hey, should I send it to my, if they’re asymptomatic, should I send it to my implant dentist to assess before the extraction or should I extract the tooth then send it or can I can you predict whether something will be an immediate placement or will the implant dentist or wait a bit? How do you even begin to come to those sorts of decisions? [Hassan]Okay, obviously I mean different implant dentists will like to work differently. Okay. But I think the most important advice is try to communicate with your implant dentist. Personally, I prefer to see them before having the tooth out. Because as an implant dentist, one of the things which will help us to predict the long term survival of this case, and to decide how to manage this case is to look at the tooth before it’s been out and know why that specific person needing to lose that tooth, was it due to perio or was it due to infection, or just unresolvable cracked tooth. So that makes a huge change in the workflow and in the long term survival. So that’s number one. Number two, try to think about an upper molar. And sometimes this upper molars have roots, either touching the floor of the sinus or sometimes even poking into the side. And you know, the moment you take that tooth out, the sinus flow will just collapse all the way down. And the way I described it to my patients, I tell them, think about posterior teeth, like a pole supporting a tent, you remove the pole, the tent drops down. And the same thing happens, the moment you take a posterior tooth especially if it’s touching the sinus or bulking to the sinus, you’re going to get what we call Sinus pneumatization, expansion of that air cavity, which will complicate the implant case later on. Because that patient might need to go through sinus elevation or sinus grafting. Now, if we did decide to take that tooth out, and maybe go for ridge preservation in the same visit, take the tooth out and pack some process bone into the socket with some soft tissue graft on the top. That will minimize bone remodeling in that area and preserve the outer shape of the ridge and keep that sinus floor high up. So then that case will be straightforward case 12, 16 weeks afterwards. Why I’m saying that? Because you know what we said there are people who do implants. But to do sinus graft, you need to even have more advanced training, and you need to even pay more for your indemnity. So not every Implant Dentist can deal with sinus grafting because of either they don’t have the training or they don’t want to pay this for time indemnity. Okay, so we’re talking about the difference between like 3000 pounds versus 12,000 pounds for indemnity for example, if you touch the sinus so by doing this, you avoid getting your patient through sinus grafting. And another important reason some patients especially in England, you’re going to or Glasgow or Scotland or UK in generally, you’re gonna have people with really inflamed sinuses, thick lining or infected sinus and it would be nice to not do any surgery close to the sinus. So by doing this ridge preservation can help. So in general, my advice to you whether it’s anterior or posterior, the moment you and your patient reach a decision that this tooth unepairable and beyond repair, refer to the implant dentist while the tooth still there, it will make a huge difference. Now, what protocol your Implant Dentist gonna go for, don’t do the very detailed assessment. And then we can decide to go for immediate or early or delayed. Anything within the first 24 hours called immediate, anything up to eight weeks according to Cochrane classification called airly and anything after that, we call it delete. Now this is Cochrane Collaboration classification. The ITI has a different classification is to do with the healing process. Fresh extraction socket, type one. Soft tissue healing but not bone healing, and that’s type two. Soft tissue healing with partial bone healing, type three. Soft tissue healing and full bone healing, type four. So the difference between the ITI classification and Cochrane classification, Cochrane is more time scale, while ITI is more like biology and certain healing process because type two for a molar let’s say after eight weeks time, that molar will be type two. The central incisor will be type three three, for example. So you know what tooth you’re dealing with. Each of them has its pros and cons. You know, I know some people like immediate because it says patients having too many surgeries and, you know, get the workflow quicker. But then immediate have some risks, if especially if they’re done in the wrong patient, you need to have a scan to check the bone volume, to make sure there is no latent or sleeping bacteria if you like or infection in that area, you want to make sure that the person has thick gum thick bio type, because if you have the thin body type, you might get recession, you want to check that lingual plate is intact or not. So there are certain criteria, a person need to know whether this patient is suitable for immediate or not. Cochrane Collaboration through their systematic reviews found that the safest is to go for early because with the early, where you if you have any remaining infection that would be gone, most of the remodeling would take place. So when you open the surgical site, you know what you’re dealing with. And you haven’t lasted too long, like delayed, so you don’t get too much bone shrinkage. But yeah, I think it’s all about communication. And I’m sure every Implant Dentist would love to talk to you as a referring dentist about what, you know, the best way forward. [Jaz]I mean, everyone has their own clinical preferences. So definitely what you mentioned that have an open conversation to say, yes, you said that generally, it’s nice for the implant dentist to see the tooth. And it makes so much sense to me, you know, to actually all those reasons that you mentioned, for them to have that opportunity. Because you know, you don’t always get that opportunity. So when you have the opportunity, we know this tooth needs to come out, to have that chat, to have the scan, potentially stent or whatever, that can all happen with the implant dentist. And that’s a really good idea. But to have that open conversation. So even just to send an email or some photos or some x rays to your implant placing dentist if you’re not placing yourself can carry a lot of weight I think. The next question I had is, do you or would you always section and elevate upper molars, which is like a routine thing for you to do? [Hassan]That’s a very good question. Because, you know, preserving the bone can make a huge difference. And the way we teach and the way I was taught that rather than taking an upper molar, try to section it into three small anterior teeth. So imagine this big molar with three roots section into three small roots, and then they’ll come out easily. So that case will be converted into an easier case. And then the chance of you damaging the bone will be much less. Definitely that’s the way forward. But the question is, what do we do after having that tooth removed? Are we going to leave it? But are we going to do immediate placement, or are we going to do ridge preservation? And that’s where and this is another invitation for general dental practitioners to know more about ridge preservation even if they don’t want to do implants. Imagine you’re taking that upper pemolar , let’s say you’re taking up a second premolar out. And the treatment plan is to go for a bridge, just a conventional bridge from the first premolar to the first molar, right? So you remove the five, out then you do nothing, what’s going to happen to the ridge? It’s going to collapse all the way right? Buccal Lingually. So you come to restore it, you have two options. Either your lab technician gives you a nice looking tooth with like a ridge lap. So you don’t see that collapse. But then that ridge lap going to attract food, so it’s not going to be hygenic restoration. Or you go to your dentist, to your lab technician say no, don’t get me ridge lap, give me enough of a contact. So it doesn’t trap food, but it’s going to look ugly. Well, if you’ve done ridge preservation, it’s going to preserve the ridge for you. And then you can have a nice looking but also hygienic restoration. And hence, this is an invitation for every single dentist to look into ridge preservation techniques. Even if you don’t want to do implants and it’s simple. You take the tooth out, you clean the socket really well, you debribe the socket really well. Either with an excavator, or if I can say there are very good, deep granulation burs you could buy and then they clean the socket really well for you. They remove granulation tissue but they don’t remove bone on your slow handpiece and then you decide what bone material you’re going to use according to whether you’re going to leave it and not and put implants at all. So you could use xenograft calf bone for example. Or you could if you want to come back and put an implant then we can use allograft or alloplast and then you get a little piece of the gum which you can take it from the retromolar area, cut like a circle and stitch on the top, obviously that’s a very simplified way of it. But what I’m trying to say it’s not complicated. You don’t need to be someone really experienced in oral surgery to be able to do ridge preservation. And I strongly believe every general dental practitioner should know how to do ridge preservation, even for conventional dentistry. [Jaz]Hassan, I love the point that you made about actually forget implants, even for a bridge to do that socket preservation, it really brings the point home really nicely. So I really appreciate you making that point in that way that you did it. That’s really clever. And I think it’s a really good skill I can be really I’ve been a few courses that takes heads. It’s not rocket science, I have say, a silly GDP that myself, I think it’s very possible to pursue. And I think it makes a great difference. So the last question I have as a GDP, who wants to learn more about implant dentistry about the clinical side from you just a flavor is just on the very theme of let’s say, you remove a premolar and then you get that buccal, lingual sort of resorption natural healing process if you like, Is there evidence that early or immediate placement implants or preserve bone or is that false thinking? [Hassan]Okay, there was an old school of thoughts thinking that immediate placement will preserve bone and that’s false thinking. There are very good study on animals, random control trials, john, where they took it tooth out and then put an immediate implant and they found on no change in the bone loss. Let me just throw out some numbers here. Your buccal lingual bone shrinkage will depend on the biotype of that case, if you have thin biotype which means thin gum thin layer plate underneath you’re going to get 50% buccal lingual bone loss so that ridge of eight millimeter can go to four millimeter within the first 24 weeks which is huge damage. If you have thick biotype, you get up to 20% buccal lingual shrinkage within the first 24 weeks. So that’s sort of evidence base fact. Now people thought okay, let’s put an implant there and stimulate the ridge and see what happens. They found the same level of bone shrinkage. Other study said Okay, what about if we put an implant and do immediate loading to stimulate the bone even better, they found no difference, you will still get the same level of bone shrinkage and the risk here if you put a wide implant as people used to do in the past, to get good stability in that socket as the bone shrinks, these threads will start to get exposed and you start to get a dirty implant infected area. Therefore, nowadays even if people want to go for immediate placement, we know that we go for a narrower implants and allow for a little gap and that little gap will be filled with bone. So if we get that buccal bone shrinkage, the process bone will stop the gum collapsing further down. And we get our primary stability whenever we do immediate placement from the apical 1/3 rather than the coronal 1/3. So we always go for longer implant getting bone stability from the bone beyond the socket. So to summarize, no immediate placement will not minimize or stop bone loss. Putting diamond in the socket will not stop bone loss. So bone loss will take place just because you and I and everyone else listening are humans made it biology. [Jaz]Should you be doing socket preservation for every single extraction, then? [Hassan]Okay, personally, if I want to use the correct term, I like to use ridge preservation because we cannot preserve the socket. Okay? So that’s number one. Number two, depends what you’re gonna do afterwards. If I’m doing a conventional bridge, I will do ridge preservation. If I’m doing, if I’m placing an implant after the year, I will do bridge preservation. But if I’m placing an implant after eight weeks no, I mean, eight weeks is good enough for blood clot to form nicely. I will come back, place my implant and do my guided bone regeneration at the time of my implant placement. [Jaz]Amazing. Well, that’s a lovely sort of overview on some of the clinical aspects, you know smoking, you quite quite correctly said ridge preservation, and a few patient related factors such as bisphosphonates, which are such common things that we see in practice, day in day out. Hassan, any closing comments on clinical implantology for the GDP, or the ones who are sort of starting out in their implant career. [Hassan]I like what one of my friends told me the other day, you are, the average of your best two friends that the two best friends you have. So my advice to you always try to link yourself with successful people. Because you know, try to always be part of the group. And by doing that, you’re going to have motivation to take you forward, you’re going to have this push from your colleagues to become a better dentist. You need to be closing your eyes, not while you’re driving, but later on, closing your eyes and try to think Where do you see yourself five years down the line, how to target and work towards that target. And if you see yourself five years down the line doing implants dentistry, pick up the phone, and start asking friends look for a good course. And don’t allow anyone to put you down getting into this beautiful field of dentistry. It’s one of the most rewarding aspects of general dentistry is to try to build something out of nothing, or restore people’s confidence. I know putting veneers are great. I know straightening the teeth is amazing. But do you know what? I think there is nothing as good as converting someone from a conventional denture to a fixed bridge and giving them their life back. So you know, guys, the market in the United Kingdom needs more Implant Dentist, just to give you an idea. UK has the least number of implant dentists compared to Europe, when it comes to comparison number of implant dentists per population. And there is huge potential there for you, go for it if you think you can do it. But if you want to do it, remember, it’s a marathon. It’s a continual education, just like any other aspects in dentistry. Thank you very much. [Jaz]Hassan, Thanks so much. And any details of Hassan course? Is it part of the BAIRD? Is that the umbrella for your course? [Hassan]I am the scientific advisor. I’m the head of the Scientific Committee of the Bridge Academy Implant Restorative Dentistry, which is B-A-I-R-D. And please, if you have time, you can look at our Facebook page or our website, which is baird.uk.com. And we do run short courses, long courses. And we do collaborate with different universities in the UK and in Europe as well. And you know what? Pick up the phone come and speak to us, even if you just want to have a chat about how to pursue a career in implant dentistry, or whether you want to double check if it’s the right thing for you or not. [Jaz]That’s amazing. Hassan, I just want to say as well, I think the next step for anyone listening or watching this, and you haven’t started on the implant journey is would you agree, Hassan, maybe the next step is to pick up the phone and maybe find the person in your area who’s placing implants at the moment. And hopefully the pandemic is going to be by the time this come out on the downward slope. And hopefully, you can start shadowing some Implant Dentist, Wouldn’t that be great? [Hassan]Golden advice, Jaz, golden advice. [Jaz]I got it from you, my friend. Hassan, Thank you so much. I really appreciate you coming on and sharing your sort of journey, ideas about getting started and also a few clinical things that a lot of dentists tend to ask misconception dentistry about, you know, ridge preservation stuff. So really appreciate all that. And I wish you all the best. And it’s been great connecting with you. Thank you so much. [Hassan]Thank you Jaz and good luck with your beautiful podcasts. They’re very useful. And well done. Keep up the great work, man. Thank you. [Jaz]Thank you so much. Jaz’s Outro: So there we have it. Thank you so much for listening all the way to the end. Listen, if you found value from this episode, if you’d liked the implant sort of themes that we covered and you like the content I’m generating, please do me a favor and share it with a friend who you think will benefit. If you want CPD out of it currently it’s on dentinal tubules. So if you’re tubules member, check it out. You can get your CPD by answering a few simple questions. If you’re not a tubules member, then that’s just another added value you can get from tubues so check them out. And again, I really appreciate your listenership always, please do hit that subscribe button. I’ll catch you in that next episode. Thank you.

Dec 19, 2020 • 48min

‘My patients are choosing cheaper, inferior options’ – GF002

When you present your patients with the ideal options, but they end up choosing ‘patch-up’ Dentistry…this is a real world problem, and we will tackle it in a comprehensive way in this Group Function! Thank you Anonymous Dentist on Instagram for sending in this BRILLIANT question: Hey jaz! I’ve been listening to your podcast and I’m a huge fan!I especially enjoyed the Chris Orr one and the communication one.I just wondered if I could have some advice please..I’m working across two practices at the moment, 1 fully private and 1 mixed practice.At the mixed practice, often patients with broken teeth don’t want to pay for crowns/onlays even though I spell out the benefits, often they will go for a replacement amalgam (which I hate doing) or a large private composite (again risk of debond due to the size)What would you recommend? If a patient doesn’t want to pay for a crown /onlay but you’ve spelt it all out then I’m not sure what else I can do?Thanks in advance! X Anonymous Dentist in the UK, Instagram https://youtu.be/Y9xGee14LMg Real world problem in Dentistry…what is the solution? Full episode above You all know what happens when you get Zak Kara to give a quick answer….there is not such thing! Dr Zak Kara goes way beyond the call of duty and delivers us solutions in his signature comprehensive fashion! We tried to steer away from the NHS vs Private Dentistry debate too much – but definitely your environment and the values of your patients plays a huge role. Thank you so much for sending this question in – if anyone has a question they want to submit, do contact me via the website or send your question via DM on Protrusive Dental Instagram. If you found this valuable, share it with your associates and principals. If you liked this, you will also like Zak’s gems on Communication in Episode 10! Need to Read it? Check out the Full Episode Transcript below! Here are some comprehensive notes/episode summary was written by fellow Protruserati, Taha Adamji – Thank you, Taha!: PDP GF002 – Communication with Zak Kara – patients always choosing the inferior option ROLE PLAY Building rapport as you’re coming up/welcoming them in E.g. How was your journey in today?/How’s your day going today? Feel free to put your things over there and take a seat – give them clear direction when they come in about what to do What can I do for you? My molar broke – yes I heard, (Receptionist name) told me you’re having a bit of trouble with a tooth on the UL I’ve had a look through your notes/X-rays/photos etc – from your previous visits – this shows you are well prepared to help them Sorry to hear that/ that can happen sometimes (empathy) Is this the first time this has happened to you or has it happened before? (History) Am I right that it doesn’t/does it hurt right now? Is it rough to your tongue/uncomfortable? Patient mentioned the clinic/gave praise Thank you/that’s kind of you to say, I’m reassured by that/what do you already know about us?/it’s your first time seeing me /you saw (x) dentist previously is that right? – all shows you have taken the time time to read their notes/are interested in them and their past experiences Patient apologised for not coming That’s no problem/Don’t apologise/there’s no need to apologise. What we do here is always blame free/judgement free dentistry Let’s see how we can help you with this problem tooth today: Because this is a “get you of of trouble type of appointment”/urgent/emergency appt, the aim for today is to focus on that one tooth I’m not going to do a full health check/exam today if that’s okay, I’m going to focus on this main problem for you But let’s also check there’s nothing else urgent going on and then we’ll see if we can get this problem solved for you by the end of the visit What did you hope or expect was going to happen today? (Check expectations) “I was hoping it could be patched up and then I would be on my way” that’s definitely something we could do for you to make it smoother/perhaps take away that sharp edge so that it’s more comfortable Does that sound okay to you? “How long is that going to last me” Well why don’t we take a bit of a look at it/I’ll put my magnification on/mask up (emphasises you’re going to look at it carefully, in detail) don’t over promise too early – investigate it first, don’t make any assumptions about treatment options yet Often when a tooth breaks there’s a reason behind it / did you have an idea on why that might have happened in your tooth’s case? “ I shouldn’t have had that chocolate” Patient/dentist may tend to focus in on the tooth in isolation only – but we need to look at the mouth and the patients as a whole what is the patients goal here? any pain to resolve? Roughness/sharp edges – we are going to solve this today Long term goal/expectations? Examination Let’s put the chair back and have a look your tooth but first: I’m going to ask you to bite together, let me have a gentle feel of your glands under your chin Let me have a gentle feel of your jaw joint – so open nice and big for me Check the soft tissues etc Demonstrates to the patient that you are checking not just the tooth but the whole mouth Keep signposting exactly what you’re doing as your doing it – try not to have a silent examination – describe everything you’re doing as you do it the word gentle – implies not going to be rough, taking your time, nothing sudden Describe in lehman terms for the patients benefit and for the nurses – any technical terms means write this down: I can see the very back tooth – is broken down to a large extent/a quarter of the tooth missing/the inner wall of the tooth is missing/the existing silver filling is still in place Checking if TTP/palpating: Lets have a gentle feel of the tooth/ I’m going to gently tap/press on a few teeth if that’s okay/and number them 8,7,6,5 “If that’s okay?” Press and see if any response – don’t just start whacking teeth with the mirror handle unexpectedly Co-diagnosing with the patient: How about we translate this to English for you in just a second I want to keep you in the loop I know dentists are weird, we talk in technical terminology because we’re trying to sound clever Checking with a perio probe: I want to gently feel around the tooth to check where the edge of the broken section of the tooth is To check if it broken below or above the gum line – and that makes a difference – we’ll come back to that for you I want to take an X-ray of this tooth (nurses name) if that’s okay – so that I can see the root end of the tooth (knows it’s a PA) Takes X-ray We’re going to get that developed then we can see it on the screen In the mean time let’s take a photograph/intra oral camera/scan of the tooth to have a closer look and we can show you Tap on the shoulder/Why don’t you have a sit up I’ll bring the chair up, feel free to take the glasses off, we’ll take a look at the x-ray and photos together? Would you like me to give you a bit of an overview of what’s going on? Need to relate everything that is happening to the context of the patients life Demographic Their expectations What has been done before/what is normal for them – constant patch ups Cost/budget/practice plan fees Time/effort required The patients inner monologue/beliefs and values about their teeth – normal for them to lose teeth? Very difficult to change a patients mindset, takes a long time Instil your values, of comprehensive care to your patient base through your content- blogs/Instagram/newsletters? patient base becomes self selecting if they want things patched up that’s completely acceptable too – they need to understand the implications of this however Shows photograph of broken tooth “Errr Is that what my tooth looks like?” Can you imagine having a job where we have to look at this all day long? (Jokes lighten the tone) Can I give you summary of what I can see here? So there’s 3 things we’re looking at here: Bone support Is the tooth well embedded in its foundations – roots of teeth and bone is like a tent peg in the ground/molar has 3 roots like your fingers in a bowling ball – really well embedded Does that make sense so far? Chunking and checking – give bits of information then check they understand it – so that’s the first thing 2. Structural stability The second thing – and the main reason you’ve come to see us today – we need to check that the tooth is mechanically sound Did you know a silver filling is not glued inside the tooth? It sits inside the tooth/the channel in the middle keeps the filling in place- like a pear shape – it’s deeper at the bottom than at the top Can you see how thin this part of the tooth is – it’s so fragile – I can imagine that is what was going on before it broke on the other side You know when a bridge falls down over a river – can you imagine it wasn’t the last car that drove over it that caused it to collapse – it was actually the fact that it probably going wrong for some time – does that make sense? What I’m trying to say is this tooth hasn’t instantly broken from a bit of chocolate – it was probably heading that way for a period of time 3. Biological seal When you have a filling inside of a tooth it needs to be sealed all the way around the edges because it’s a bacteria seal if bacteria manage get in and around your filling they can get underneath (I know this sounds a bit horrible) but that means the filling is leaking And that leakage around the edges can soften the foundations a lot of people come to see us thinking they have broken their tooth on a olive stone or a chocolate – but probably the tooth and the filling has been deteriorating over time because the filling is sitting on soft foundations Patients value the explanation – because it matters in terms of what our options are next – can I show you why? Can I show you a picture of somebody else who has been in a similar situation to you? Get out iPad with photos to show example This is Jane who came to see me (always put context with somebody’s name on it – that matters because they can visualise that this was a real persons tooth) Here is Jane’s tooth with a silver filling in it – luckily we preempted the breakage in this tooth – can you see that tiny wall of the tooth is starting to crack – we realised that this was going to break at some point so what we did was we removed the filling – swipe on the iPad to show the filling removed Can you see the dark brown foundations underneath there – this is deteriorating underneath Can you see that the wall of this tooth here is very thin? – it’s so fragile that if i’d left that in place, Jane would be coming back a few weeks or months later and even this part of the tooth might have broken off as well So here is what we did – we have filled in the missing tooth structure – we shaped down the tooth to a degree and put a strong cap over the top and this binds the whole thing together Like having a helmet on top of a head/jubilee clip It prevents flexing of the thin part of the tooth from from breaking Can I ask you how much of a risk taker are you? The reason I ask you that is because today what I’d recommend is that I’m going to seal this section for you because we want to reduce the chance that surface of the tooth become sensitive at some point – it will also make it a bit smoother so your tongue won’t keep going there/feels a bit more comfortable for you The reason I ask you about risk taking is because it depends how quickly we want to proactively do something for your tooth – the longer we leave it the higher the chance that the other thin wall of the tooth is going to break away If you don’t want to do a larger MODP amalgam or composite – maybe don’t offer it? or present it in such a way that it is not a good option? If we want to do something that will help keep your tooth in your mouth for a long period of time i.e. hopefully years, decades and if your lucky – the rest of your life then we need to do something proactive and strong to protect this thin wall My worry with this tooth (patient name) is that if the remaining part of your tooth breaks off and you come to see me there may be no tooth left to rebuild – so let me ask you well how would that make you feel? (some patients would not be that bothered at this stage – just take it out – but others may really want to prevent this situation) If the patient is still choosing the ‘subpar’ big filling option – then you could play devil’s advocate and ask them – how long would you expect it to last for? Because they need to understand that this will probably not last very long If they are chipping bits of tooth off everywhere why might this be? NB: Can place a direct composite core overlay – as an interim measure – allows you time to assess pulpal health/periapical issues Always present the best option first “If it was my tooth…” ? for all the reasons I’ve explained, with the photos etc the tooth would really benefit from protecting these thin walls by putting a cap/onlay on there as you will get the longest lasting result – this will cost £x and I think it will last you a long time You have the option of going for a big filling BUT I don’t think that it’s going to last you as long, and it will cost £x Talk about the better option for longer – not manipulative “What would you do?” Just tell them what you would actually do (don’t dodge the question) honesty is the best policy don’t try to force them to make the decision themselves and avoid any responsibility because that may just harm your rapport with the patient (seems like you don’t care?) You need to have the context of the patient when knowing what the best option for them is going to be teeth are not in isolation – they in people’s mouths What are their life circumstances and approach to dealing with a problem in order to find the best solution for them Is the patient okay with continually patching things up or do they value having something that is going to last a long time do they know how long the patch up will last for and the cost for each time to have it fixed? Would they rather pay more to have a longer lasting option? Or are they okay with losing the tooth if it breaks down further? maybe its better/in the patients best interests to not offer the subpar option? There isn’t just the initial financial implication – but also to do with the number of repeats – They may be back again soon paying the same amount again to have it fixed Unlike building work – if everything goes horribly wrong – you can knock it down and start again but with teeth once it’s gone – the bit that mother nature has given you – is gone Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati, and welcome to another group function, the second one, and this is such a mammoth topic. So, thank you, you know who you are, you sent me a question on Instagram, and I hope we have delivered, and the best person I've found to answer this question, it's a huge mammoth topic around communication, basically. [Jaz] I’ve got Zak Kara, and the question is, I work in two practices, and again, I’ll read the whole question out when we get into the episode. But it’s along the lines of, I work in two practices. One’s private and one’s public funded or in the UK, we know that as a mixed practice and my patients keep choosing the cheaper, inferior options. So this dentist is finding that she’s having to do a lot of really large, ambitious composites and a lot of MODBL sort of amalgam restorations with a dovetail inside and just patch up dentistry. So she says, why is there such a big difference? Even though I clearly spell out the benefits. Patients are still going for the inferior option. Why is this happening? So, I got Zak in to really tackle this in a big way, as Zak would do so. So, initially the point of group function was, hey, let’s make, helpful bite sized 10-to-15-minute episodes. But Zak, what can I say? He’s a comprehensive dentist. He’s a comprehensive guy. So, he really went no holds barred. We have a full on discussion. There’s some role play in there. And you know what? It was all quite kind of fun. And I sort of streamed this as a live. It kind of failed, but then I premiered it and those people who watched it for about an hour and a half. It was live on the Facebook group. You guys gave some positive feedback. So I hope you guys listening, enjoy this. Let’s go right into onto this mammoth, mammoth question. Welcome to Group Function number two with one of our fan favorites. This is Zak Kara. Zak, welcome to the show once again. [Zak] Hey, Jaz, how are you doing? I can’t believe you caught me on a Saturday night for this. We must have uber dedication to this cause or something, or I must really like you. I don’t know. [Jaz] I can’t think of anyone better. I know, but I can’t think of anyone better for this topic. And basically the purpose of group function, I know you haven’t tuned into the first one, is to help answer questions of the Protrusive Dental community or the Protruserati. And I’ve had absolute banging question, something that’s really, really pertinent. And I’m just going to bring it up on the screen. Now, I know you can only see the first part of it. And I just wanted to show this because it’s someone who’s a huge fan, which makes you feel all warm and fuzzy inside. And then, she said that she enjoyed Crystal and the communication one. But what she means by the communication one was your one. [Zak] No, it’s not. [Jaz] You know, that’s you. [Zak] Must be all the other stuff. [Jaz] So anyway, she sent this amazing question and I’m going to read it out so that those people who will be listening in the future can tune in and really follow what we’re saying. And so Zak, you can see it as well. So the question is, I read it out. I wondered if you could have some advice, please. Right. “I’m working across two practices, one fully private and one mixed practice.” So those people from abroad, not in the UK, a mixed practice is like public dentistry and fee per item private dentistry. And what one thing I think me and Zak have agreed not to go too far down the rabbit hole of to discuss too much about NHS and public dentistry, because it shouldn’t be about that. There are other points that we can tackle, which will be much more sort of universal and those are the concepts [that will flow]. Oh, we can, we can touch that. We can touch on that. And then towards the end. “So, at the mixed practice, so this is both the public and the private, often patients of broken teeth don’t want to pay for crowns and onlays, even though I spell out the benefits. Often they will go for a replacement amalgam, which I hate doing, or a large private composite, again, risk of debond due to the size. What would you recommend? If a patient doesn’t want to pay for a crown or onlay, but you spelt it out, I’m not sure what else I can do.” So let’s hide that and I’m going to join you back on Riverside. Okay, Zak, that is such a real world question. I’ve definitely been there. Okay. In the past before. Where do you even begin to tackle this? [Zak] Yeah, I completely agree with you. This is stuff that we have all wrestled with and we wrestle with every single day, isn’t it? It’s classic day to day judgment call type dentistry where, to be straight up about it, it just sounds as though whoever’s written this question, by the way, hi, and thanks for the question. And by the way, I love this group function vibe and I’ll try and keep this short and sweet with you because I know this otherwise turns into an hour and a half podcast. So let’s not go down that rabbit hole, but- [Jaz] We love those. [Zak] We do, but this isn’t the time or place. So, but basically it sounds as though. Whomever sent this question has done the damndest to provide the most kind of thorough, in depth discussion of pros and cons and alternatives and all that stuff you were taught as a dental student, which is totally informed consent, which is absolutely the right thing to do. But then her patients are choosing the worst option in her opinion, right? And it kind of gets to me, it gets you to a point, doesn’t it? Where you get, you bang your head against a brick wall and you think, are my patients just like all thick or not listening or what is it? Why am I not explaining this right? And I got to a point in my career where I realized that isn’t that it’s just, it’s often more to do with, I guess it all boils down to one main thing, which is context. So when you sent me this question, which is yesterday on WhatsApp, I thought to myself, that’s a really good question. I thought to myself, this is really, really good question because whoever sent this question probably doesn’t have the same values and approach to life as their patients. Right? In fact, it’s impossible to have the same values, approach to life, the same kind of way of managing and dealing with a problem. As every one of your patients. And so I find it quite ironic, that question we’ve always had from our patients over the years, which is what would you do? What do you say to that, Jaz? [Jaz] We have that all the time. I mean, I always say that there’s two ways to approach this one. One is just tell them what is it, what genuinely is what you do, which is often the best option for them. And that’s sometimes why that can be effective. The other way to do it is, and I’ve seen some dentists type this on Facebook in this sort of context of discussion and they say, oh, but I’m not you. And they go into that sort of argument, and that’s, I think that’s a terrible reply to a patient, right? You’re then sort of, you’re arguing with this patient, no, you have to decide because you’re the person behind the lenses. And I don’t want to be responsible for the decisions that you have to make. [Zak] Yeah, yeah, I agree. And it gets to a point where you almost end up losing rapport over that, right? The whole thing, I mentioned the word context. For me, it’s like the context of. And the thing that we’re not taught at dental school, major thing, and we hammered on this about this on the podcast, and I’m sure we will continue to talk about this in depth, it’s all about who that patient is and what their backstory is and what their dental experiences are and basically what their approach to life is. That’s one part of the context, right? So you kind of have to put yourself in this position where you actually need to just get to know what your, how your patient deals with certain life circumstances. And I know that sounds really fluffy. It’s the kind of thing where you’re like, hang on, patient’s come to me with a broken tooth and Zak you’re telling me I have to get to know their life story. Well, no, actually, I’m not saying you have to get to know it straight away. I’m saying that it’s part of the decision making process and helping that person find out what the right solution is for them under these circumstances, right? The other thing- [Jaz] But Zak, it’s interesting that she said that- [Zak] By the way, I just realized I’ve got a friend. It’s Ralph, by the way. [Jaz] Oh, hello. Awesome. This is amazing. Okay. What was Ralph there when you, [Michael]? [Zak] No, no, no, no. [Jaz] Oh, he would have loved that. Okay. He would have loved that. You’ve got to think of the cats, but it’s interesting how in the question, she said that she works at two practices. She doesn’t seem to have that problem in the private practice. So, how much of it is influenced by the demographic? How much is influenced, by the, again, the values of the patient? Is it that in one practice, the private practice, the values of the patients may be more in tune with the dentist? Or do you think it could be something to do with the way this dentist is presenting the options at the mixed practice because she knows that she has to legally offer certain options big to take a box for the whole public dentistry. It could be to do with that. [Zak] Maybe for me, it’s much easier. And to be fair, I’m giving you this an answer based on my own experiences too. So I’m clouded and biased by the fact that actually it’s been a little while since I’ve worked in mixed practice type environments. And there is a conundrum that you play, isn’t it? It’s a day to day little fight that you have inside your head of actually. What I could do right now is kind of offer the gold standard, the right thing to do and say, look, this is what I can offer you in the health service. Cause that’s what is the ideal. So you might look at this tooth. If I actually could break it down, do you want to break it down into the different stages of how I actually would approach this situation? So actually in the clinic- [Jaz] Let’s make it really tangible. She said she specifically mentioned a broken tooth. Let’s say upper first molar broken down. And you know that just as she said, a replacement amalgam or repair amalgam or maybe a large composite is not the best thing. This tooth needs cuspal coverage. This is what we taught. This tooth is a classic candidate for cuspal coverage, but the patients keep choosing the large composite option said. And the perception here is that it’s due to cost. Okay. That’s one perception. Okay. And whether it is or not, who knows, but the patient keeps choosing the large composite. So upper molar broken down, and now you are addressed with that patient. How would you approach that situation? [Zak] Okay. So let’s say this is the first time this patient’s met me yet. Easy enough. Okay, so patient comes in, we come up the stairs, we’re building a bit of rapport, we’re getting to know each other a little bit, and I’m kind of finding out a kind of background story of how this is the first time you come to see us at the clinic, or maybe they’ve seen a different dentist in the clinic. Let’s do it that way, it’s probably a bit easier. So patient comes into the treatment room, this is Tash who’s taking care of us today, or Antonio or whoever, feel free to pop your box, crazy COVID rules, pop your box in the corner, and come take a seat. And so I get the door, how’s the day going today? So Jaz, how’s your day going today? [Jaz] Yeah, yeah, yeah, good. I just, this molar broke down and yeah, I was hoping you’d just fix it for me. [Zak] Well, I heard, I heard, Jaz, who is on our front of house actually, sent me a message this morning, said that you were having a bit of trouble. So what’s the issue? What happened? [Jaz] Oh, yeah, classic. I was just eating chocolate from the fridge and it just broke away. It doesn’t hurt or anything, but I was just hoping you could just, fix that for me. [Zak] Sorry to hear that does happen sometimes. Is it the first time this has happened to you? Is it a sort of broken tooth situation? [Jaz] Well, I think it’s just, now and again, it happens, right? It’s happened a few times before and then dentists have just fixed it. Thankfully, it doesn’t ever hurt, thankfully. [Zak] Okay. Am I right in thinking it doesn’t hurt right now? [Jaz] Yeah, that’s right. [Zak] Is it rough to your tongue or anything like that? Is it uncomfortable? [Jaz] Yeah, it’s a bit sharp. I can feel it in my tongue. That’s why I’m here. It’s a bit annoying to my tongue and I thought, yeah, go to the experts. [Zak] Oh, that’s kind of you to say. I’m reassured by that. What do you know about us? Because first time we’ve met today, isn’t it? Have you been to see ex dentists who’s otherwise in the clinic in the past? Is that right? [Jaz] Yeah, I see the hygienist here and I think I’m about due for a checkup as well. So, sorry about that. [Zak] It’s all good. I can’t believe we’ve got into a role play situation here, by the way. Well, let’s go with it. Okay. So feel free. Don’t apologize. There’s no need to apologize. What we do here is always blame free and judgment free dentistry. So no sweat. It’s no issues at all. Let’s see how we can help you with this problem today, because ultimately what we call this is a get you out of trouble type appointment. Urgent appointment, emergency appointment, whatever you want to call it, right? And the whole aim of the visit today is to make sure we focus on that one tooth. I’m not going to do a full health check for you today, if that’s okay, but I’ll focus in on that one problem. Let’s make sure there’s nothing else urgent going on and then we can see if we can get that solved for you by the end of the visit. What did you kind of hope or expect was going to happen today? [Jaz] Oh, previously people just patched it up and I’ve been on my way. [Zak] Okay. Well, actually that might be something we can definitely offer for you today to make it a bit smoother perhaps, or at least take away that sharp edge for you. Does that sound like kind of thing that might be on your, does that sound, sound okay to you? [Jaz] Yeah, that sounds great. Is that, how long is it going to last me? [Zak] Well, I’ll tell you what, why don’t we have a bit of a look? Why don’t I have a, take a peek at the tooth. I’ll put my magnification on. I’ll put my mask back up. I’ll come around this side and I have a bit of a look and see what’s going on and then once I can have a bit of a photograph of the tooth perhaps or even a 3D scan I can show you what’s happening yourself. We can have a bit of an overview about what’s happening in the rest of the mouth because often when a tooth breaks there’s usually a reason behind it. Did you have a reason, do you have a kind of inkling why that might be in your tooth’s case or what’s happening? [Jaz] I don’t know. It was, I shouldn’t have really picked that chocolate from the fridge. [Zak] I know, it’s always the shock. It’s always the finer things in life, isn’t it? So what we’re trying to do at this point is gauge context, right? What I’m trying to do is, before you, so you focused in when you explained this situation, you focused in, Jaz, on the tooth. You focused in on the, it was been on upper molar and this, that, and the other. And, and what does, this goes back to sort of training from Panky Institute, for example, and what LD Panky always says is, always said, was, I’ve never seen a tooth walk into my clinic. And this is the thing we forget. We always forget what that patient’s goals are. So what I’m trying to establish very early on is, yes, okay, I’m thinking, bingo, this tooth isn’t painful today. Actually, that’s giving me an insight into possible diagnosis, isn’t it? I’m probably thinking, okay, why is it not sensitive? But the patient doesn’t need to know this at this point. Okay. I’m thinking there’s a roughness to the surface of it. So we need to solve that by the end of the visit. Cause the person’s going to be happy if we can tick that off their list. They’re thinking, let’s get this solved. Okay. The third thing that’s going on is, I’m trying to establish a bit of rapport to say, okay, I understand because this person doesn’t want to come in and think, oh, this dentist is completely unarmed. I’m saying, okay, I’m giving you the context of the fact that the other dentists in the clinic, I’ve maybe even at this point might say, I’ve had a look back at your records or your photographs or your x rays from your previous visits. So I’ve got a bit of an idea of what’s happened in the past and you should have done, right? So in preparation for your day, let’s hope it wasn’t sprung on you as a complete surprise. You’ve probably got an idea of what’s about what’s happening in this person’s mouth. And only at that point am I trying to just give myself an insight and maybe give the dental nurse I’m working with an insight into what might be happening by the end of the visit. Okay. But I’m also trying to kind of pitch myself at a certain point where I don’t over promise too early. And also I’m trying to kind of go, okay, what does this person know about me? Because this is all about your values too. Okay. And it’s easier with patients that have known you a longer time because you’ve kind of been on a bit of a dental journey with them. And the things that you offer or the solutions you might put out there are much easier because you’ve probably had some of those conversations in the past and you can kind of refer back and you kind of go, oh, do you remember the tooth on the other side? It’s kind of a similar situation to this and they can always refer back and go, okay, this guy knows me. [Jaz] I mean, history is so important. So, I mean what we sprung up to Zach here is a trickiest of all scenarios where this is a patient who’s cold to you. And the reason we picked it, or we went down this path is we want to try and make it more difficult because when you’re challenging your suggestions and advice you give if we test it with the most trickier situations, the ones where you already have years of rapport with the patient, they’re going to be so much easier, right? So let’s go with this trickier scenario. [Zak] Okay. So let’s say I put my magnification on important because you’re telling the person that I want to see things big. I want to be able to see things in detail for you so that I can help you best. I’m going to come around the sides. I’m going to pop the chair backwards. Let’s have a bit of a look. Okay, the chair goes back. I’m very fortunate to work in a kind of clinic where there’s a TV on the ceiling and they usually they’ll get a response because they’ve not been into this chair before and they go, Oh, there’s a TV on the ceiling and you go blah, blah, blah, usual stuff. Okay. So let’s have a bit of a look at your tooth. The first thing I’m going to do actually, though, this might surprise you is I’m going to ask you to bite together. And let me have a gentle feel of your glands under your chin. Let me have a gentle feel of your jaw joints. Open nice and nice and big and close a few times. And you’re trying to get into this person’s head and signpost the fact that it isn’t just the tooth we need to think about. The next thing we’re going to do is, it’s completely cold patient to me, I would usually do a soft tissue check, but let’s skip over that for a second, let me grab a mirror and see what’s going on. So what I’m doing at this point- [Jaz] This is something that is actually a highlight for those listening, because I know the way from my previous chats, how you actually do these checkups and something that you’ve spoken about before is people or dentists that do these silent examinations, like they’re just looking at going around and they’re just registering everything in their head, but the patient doesn’t get any value from that. And I love the way that you so openly speak about never have a silent examination and all these things that you’re saying right now, let’s have a look inside. Yeah. But this is the reality that I think most dentists, okay. Perhaps a lot of us are introverted and we are doing our checkups, like just checking around open close. Okay. You’re fine. But what you do and what you offer and what you discuss. Bring so much more value. So I just wanted to highlight that, all these things that you’re saying to me. Let’s have a look inside. You’re actually doing this. [Zak] Yeah. The subtleties of it as well. And I kind of intentionally do things like, I use the word gentle just for the sake of it often, because you kind of kind of instilling in this person that you’re not going to do anything rough. You’re not going to do anything sudden. We’ll take it step at a time. No sweat. Okay. So nice, nice and wide for me. And I’ll gently stretch the cheek with maybe my finger and I’ll pop my minger into place. And I’ll have a little bit of a look. And okay. So at this point, what I’m trying to do is I’m talking half in dental and half in English. And the dental nurses that I work with and I’ve trained have a bit of a feel for when I say certain things in certain ways, that means write it down because it’s technical terminology. And sometimes I’m doing it just for the patient’s benefit. So, what I can see is the very back tooth. So up the very back tooth, Gabri, is broken down to a large extent. There’s about a quarter of the tooth missing and we can see that it’s the inner wall of the tooth that’s broken away. I can also see the existing silver filling still in place. Okay, so I think so I’ll stop at this point. Okay, I’ll stop at this point and I’ll go. Okay. Jaz, would it be okay if I have a gentle feel around the tooth? So if you close a little bit, so at this point, I’m having a gentle feel maybe in their buccal sulcus and maybe putting my finger on the tooth. I never, ever, ever starts start whacking teeth with mirrors. That’s weird. Don’t do that. How about just have a gentle feel with your finger? Because if a tooth’s TTP, again, I’m thinking why is this tooth not sensitive? I want to gently tap on the tooth maybe or press with my finger. I’m just going to press a few teeth. I’m going to number them 8, 7, 6 and 5. Would that be okay? One by one by one you press and you kind of feel for is there a response from this person? Okay, look, I know that we all know this. We’ve all been to dental school. But there’s a different way of doing it when you’re kind of trying to instill certain things in people’s head. As you go, you’re not just doing an examination, you’re doing something where you’re co diagnosing what’s happening in that person’s mouth and in that person’s body. You’re trying to get into their head. Okay, why is this guy doing all this stuff? And I often say things like, as we go, I often say, how about we translate this to English for you in just a second? Because we don’t want to keep you out of the loop. Okay. I know dentists are weird. We talk technical terminology. It’s because we try to sound clever. Something like that is generally what I say. I try to sound clever. We talk in Latin sometimes. [Jaz] Blind them with science. [Zak] Yeah, yeah, best way. So at this point I’m kind of looking inside the mouth thinking, geez, okay, there’s a great big MOD amalgam. There’s a very thin buccal wall on this upper six, let’s say. The pallet of walls chipped away. And I have a little gentle feel, maybe with a periproba or Williams. And I say to the patient, I just want to tuck just want to gently feel around the tooth to make sure where the edge of the broken section of the tooth has been or is. I want to have a little feel to make sure it’s above the gum line because when it’s above the gum line that has a difference compared to, or that makes a difference compared to if it’s below the gum line. Again, I’ll come back to it in a second for you. Do all the way around. Gabri, I’m going to take an x ray of this tooth if that’s okay so that I can see the detail at the root end of the tooth as well as above the surface. So Gabri at this point knows that means a PA. She’s already got it ready because before the patients come in, we have a good idea about which tooth it is, right? So the PA holder comes out, boom, boom, boom, x ray machine into place, x ray beam into place, come across, press the button, happy days. Okay, we’re going to pass that back to Gabri so that she can go and get that developed so that we can see it. On the big screen in front of us. And in the meantime, when I take a quick photograph, so I’ll grab a mirror and I’ll take a photograph with my SLR, or maybe you’ve got an intro or camera, or maybe clever and you’ve got a 3d scanner and all the works do whatever you need to do. Sometimes I’ll just do a brief 3d scan of that area because it gives me a good idea as to what’s happening and they can see that you’re actually looking at the details. Jaz, why don’t I just pop, I tend to tap on the shoulder or on the bib that’s on the shoulder. Jaz, why don’t you have a sit up for a second, I’ll click the button on the floor, and let’s, you can feel free to take your glasses off, they’re a bit silly those anyway, and we’ll have a bit of a look at the x rays and the photos. How about that? Would you like me to give you a bit of a, would you like me to give you a bit of a, kind of a, maybe a brief overview about what’s happening? Does that make sense? [Jaz] Yeah. [Zak] There’s two things that’s going on in my mind. One of them is that, wait- [Jaz] Am I Jaz the patient now or Jaz the podcaster? I don’t know who. I don’t know. [Zak] Where I am either, mate. This was supposed to be done about 10 minutes ago. I don’t know why I’m still waffling on, but. [Jaz] It’s cool. Let’s run with it. Because no, you’re adding so much more value. I mean, this is the classic Zak, you know. I ask you a question, but you not only answer it, and you will answer it, because we’re getting there, but you’re also providing umpteen multiple, gosh, times value of what we asked for. [Zak] Thanks. [Jaz] So you are really adding so much value. ‘Cause people are following this long and I think the role play bit was just a genius. I think people- [Zak] Impromptu. [Jaz] Have a few laughs, but also it’s going to make it extremely tangible. [Zak] Okay, cool. [Jaz] Well look, so now you’re explaining to me, I’m the patient, you’re explaining to me. [Zak] You’re the patient. Okay. So what I’m thinking in my mind at this point is, I need to relate everything that’s happening to Jaz’s world and Jaz’s life, okay? And the reason why, to answer the question kind of in the context of whoever asked the question, is, that I’ve found in the past in some different practice types that people approach their problems reactively. So you have to put yourself in the context of where you are, what type of demographic you’re typically looking after, and what they have come to accept as normal. Okay, so if they’ve been seeing a dentist for 20 years and it’s patch up with GIC every single time, you’ve got to think instantly in your head, okay, whoa, slow this down because there is no point you coming along and thinking big clever stuff that you learned in textbooks, which has no relevance to their life. They don’t have the time, money, effort for it. They don’t give a damn because they’re used to waiting for stuff to break and hope to their cross their fingers that there’s something left to fix. Okay. [Jaz] And I just want to add to this one specific point because I work in a practice that has a well known capitation plan, right? So, people pay a monthly fee and everything’s included. They just have to pay the lab fee, right? So this is something that’s probably there in anywhere in the world. You have something like this now, get this. Sometimes I’ll say to a patient, okay, you need a crown or whatever, but they’re so used to having patch ups that even though it’s costing them a real absolute bargain, it’s a fraction, there’s only paying the lab fee compared to what a private patient would pay. It’s for them. It’s not about the cost or the fee at all. It’s just they’ve actually, they’re accustomed to getting patch ups. They’ve found these patch ups to be successful, painless, easy. And this is what they’re paying for. [Zak] And they use it as their insurance policy. They treat that type of kind of approach as, I tell you what I do is I pay my X pounds per month and all I can do, that gives me the opportunity to phone up at any moment something goes wrong and I get it solved within a day or two. Usually without any hassle or stress. [Jaz] It’s not sometimes about the fee, because the fee for, in these patients, I’m telling them, you can have a crown, which is the best thing for this tooth, it’ll last longer, it’ll protect your tooth, and it’s not so much money compared to a prior patient. But they’re like, no, you know what? I’ve had patch ups all these years. So again, it’s a value thing. It’s it’s what they’re used to. Exactly what you’re saying. [Zak] It’s also to do with the fact that some of some people have got this in a monologue and a thing that you will never, ever solve, which is that they believe that’s how the world is. Some people believe that it’s OK to lose your teeth. The type of patient who comes to see you and they go, oh, haven’t I done well to keep my teeth for this long? And in your head, you’re like, no, actually, it’s weird that you lost any of them, to be honest. Because your values are different. Your training and your professional training means that you approach the world in a completely different way to them. And remember that they believe in what their parents and their grandparents and then whatever else went through and there’s only so much emphasis and value that they’ll place on your professional expertise, and don’t kick yourself for that. That isn’t something you’re going to fix. It may be in a very small minority of your patient base. You can turn them around, but it takes so many years to change mindsets. And some of that can be solved a little bit with you putting out, for example, your own content. For example, if you’re a patient, your patient base is something that I’m always looking at. Your blogs or maybe have a great practice newsletter or something. You can kind of extol the virtues of what type of dentistry you believe in. And then you might become the person in that clinic, the lady or the gent or whoever it is, whoever you are that they come to because they believe in comprehensive stuff too. And you know what happens is your patient base is self selecting. You actually get the patients you deserve because if you believe in comprehensive stuff, and that’s what you do every day. And actually, you can quite fairly say to somebody that if you want to have something patched up that’s completely acceptable to me, what I can do to buy you some time, actually, should we go back to the role play? Should we do that? [Jaz] Let’s do it. [Zak] We should have some sort of video effect at this point. Let’s go back to that for a second, because at this point, I’m showing you a photograph of this broken tooth, right? [Jaz] Is that what my tooth looks like? [Zak] Yeah, isn’t it crazy? I can’t imagine having a job where you have to look at this all day long. So shall I talk you through? And do you know what? All of this stuff lightens the tone. It makes, it sets the scene for you’re not going to get old school weird dentistry here. And that matters a lot to me. Perceptions matter a lot to at this point I might show the photograph. and I will kind of give you a summary. Can I give you a summary of just for two minutes based on what I can see? Would that be okay? [Jaz] Sure. [Zak] Great. So there’s three things that we always look at on every single tooth. Whether it’s in a photo and x ray and the x rays coming in just a second, by the way. So some of the things I’m telling you, I’m going to mold around what’s about to appear on the screen. Okay. But basically I’m looking forward. Is your tooth well embedded in its foundations? Teeth are kind of a bit like tent pegs in the ground. So imagine there’s the ground, this is an upper molar tooth, so the ground is here and your tent peg is well embedded inside. In fact, funnily enough, your tent peg’s got three roots, like this. So it’s quite well embedded, a bit like, when you go bowling, you put your fingers in a bowling ball like that. It’s kind of really well embedded, okay? It likes it there. But what can happen over time is the foundations can shrink away. Let’s turn it into one single root because it’s a bit easier. So the ground and the foundations can shrink away. I’m checking on the x ray in a second to see, has it got good does foundations. That make sense so far? [Jaz] Yes. Yeah. [Zak] So that’s the first thing, but really the main reason why you’re here today is chunking and checking there. What was that? [Jaz] In the most basic of communication skills at dental school that we basically had was you keep chunking and checking. That’s essentially what you’re doing. [Zak] And I didn’t get that training. That’s good. I like the terminology. Thanks, Jaz. Thanks for embellishing as always. I wish you’d do this podcast together. So that was the first thing. The second thing. And the main reason you’ve come to see us today, let’s face it, is because every tooth that we look at needs to be mechanically sound, okay? One thing that’s important that you know is that when a silver filling is put in a tooth, just like yours, can you see on the photograph that it’s the channel in the middle of the tooth? Did you know that it’s actually not glued in place? Did you know that? [Jaz] No. [Zak] Okay. So here’s something that a lot of our patients tell us. They’re unaware that a filling stays in a tooth in that way. Basically a filling has to stay in a little bit like it has to be deeper at the base and narrow at the top. So it’s kind of, if you look at it, looking at it side on, it’s kind of like a pear shape. Okay, and the pear shape matters because what you see on the surface means it’s deeper, lower down, and can you see how thin, so fragile, I always go into that tone, I don’t know why, but I do, it’s so fragile, the outer wall of the surface of the tooth, that I can kind of envision that was what was going on on the inner wall of the surface of the tooth. And, God forbid, you know when a bridge falls down? Like, literally a bridge over a river. Can you imagine that it wasn’t just the last car that drove over it that caused it to fall over. It was actually the fact that it was going wrong for quite some time. Does that kind of make sense? What I’m trying to say to you is that this tooth hasn’t just instantly broken because of a bit of chocolate. It’s kind of been headed that way over a period of time, okay? And there’s another aspect to this, which is that I need to look at the tooth biologically. Because when you have a filling inside a tooth, it needs to be sealed all the way around the edges because it’s a bacteria seal. And if bacteria get in and around your filling, they kind of get underneath, kind of, I know it sounds a bit horrible, but basically it means the filling is leaking. And that leakage is, doesn’t mean you’re leaking by the way, that leakage around the edges is the thing that can actually soften the foundations. And a lot of people come to see us thinking they’ve broken their tooth on an olive stone or something or chocolate. And probably the tooth of a filling has been deteriorating over time. So the filling’s kind of sitting on top of soft foundations. [Jaz] Oh, right. No, no dentist ever told me this before. You’re amazing, Dr. Zak. [Zak] Thank you. That’s very kind of you. Zak, by the way, I don’t give the dogs that. That’s weird. But, yeah, that’s very kind of you, Jaz. And do you know what? A lot of people really value the explanation because it matters in terms of what our options are next. I’ll tell you why. Can I show you a picture of somebody else who’s been in a similar situation to you? Okay, so here’s a picture of my iPad. So here’s a filling inside a tooth. Can you see how we actually, this is Jane who came to see me, always put context with somebody’s name on it. That matters because they can visualize that this is this person’s tooth, not just any old tooth. Okay. So this is a photo of Jane’s tooth when she had a silver filling in it. And actually we luckily preempted the breakage of this tooth. But can you see how that tiny wall there is starting to crack? [Jaz] Yeah. [Zak] So the tiny wall of the tooth is starting to crack. And what happened is that we realized this tooth was going to break at some point. What we decided to do was this. So we removed the filling, swipe on the iPad. Can you see there’s actually a dark brown foundation underneath there. And they usually go- [Jaz] Oh. [Zak] Actually to you. And thanks mate. To you and me. As in dentists, we know that that is not to do with, it’s probably not even active carious tissue, right? But we know that a tooth is underneath. But to them, it’s brilliant because it always gets a response. So this is deteriorating underneath. You don’t have to say going wrong in a period of time. And can you see that the wall of the tooth here is very thin? It’s so fragile that if I’d left that in place, Jane would have come back even a few weeks or months later. And she’s broken that bit of the tooth off as well. So swipe again. Here’s a photograph of what we did afterwards and what we’ve achieved for her is we’ve filled in the missing tooth structure. We’ve actually shaped down the tooth to some degree and put something strong on top. And that strong cap on top binds it all together. Do you know what a jubilee clip is? [Jaz] I actually don’t. [Zak] Okay, that’s weird. Okay, why did I say, I said weird a lot today. [Jaz] I’m going to have to start a poll on the community group to ask, do you know what a jubilee clip is? [Zak] A jubilee clip is for people that know how to do stuff in their homes. This will be people who like DIY and have actually got their hands dirty in life. Not you, clearly, because you call someone- [Jaz] I suck at DIY. [Zak] It’s kind of to do with plumbing and DIY and stuff. Anyway, basically, a jubilee clip binds something together, okay? You basically put it around something like a pipe, and you tighten it up to make it seal together again, okay? And people get that because what it does is it binds the whole tooth structure together, and that means every time that you bite down on the top, a little bit like having a helmet on top of a head. You’re going to bite down and the force goes through the tooth, or in your case, up a tooth, up through the tooth, okay? What’s been happening in your case, and the reason why it broke almost certainly, is that the flex and flex and flex every day of that little thin section caused it to break away. [Jaz] Okay. [Zak] Does that make sense? [Jaz] Yeah. [Zak] Do you know where I usually go with it at this point is the x rays come up? Let’s just assume for sake for the sake of argument because it’s going to get way too complicated and way past my bedtime, the tooth has no pathology on it. For example for argument’s sake. It’s just a fracture of the tooth It’s pretty straightforward is we’re just going to restore it. Okay, so can I ask you a question Jaz? [Jaz] Yes. [Zak] How much a risk taker are you? [Jaz] Oh, depends. Have to buy me a drink first. [Zak] This is only a first day. [Jaz] Yeah. You actually asked that question to a patient. [Zak] Occasionally. [Jaz] That’s pretty cool. I like that. [Zak] Occasionally. [Jaz] I see where this is going and I like it. And I have actually put this in a gambling form, are you a bit of a gambler? I like the risk approach much better. ‘Cause gambling has negative connotations. So I would say well, I wouldn’t know what to say to that as a patient. I’d say, a little, I guess. [Zak] Okay. So the reason I ask you that is because today what I recommend is I’m going to seal this section for you because we want to reduce your chance that that surface of the tooth becomes sensitive at some point. It’ll also make it a bit smoother so your tongue won’t keep playing with it. We always do that. I don’t know why us human beings do that, but we do it. Okay. And the reason I ask the question about risk taking is because it’s all going to come down to how quickly we get round to proactively helping you with this tooth. The longer we leave it, the higher the chance that other thin wall of the tooth is going to break away. So to finally, finally answer the question of whomever, thank you again for whoever asked the question. If you hate doing amalgams, that are M. O. D. P. s, that are unretentive as hell, that you have to put pins in teeth for, that, you know in your heart of hearts you should overlay the buccal cusps for, but you’ve also got 30 minutes rather than an hour and a half, and also- [Jaz] Or just a large composite, that way it should have been cusp of protection, yeah. [Zak] If that’s the case, then perhaps, don’t offer it. Or maybe offer it in such a fashion that you go, this is well, you could say, look, okay, slight facet to this. Quite often I will place a direct composite because particularly for tooth in a situation like this isn’t giving us any symptoms. I will want to restore the core, protect the buccal cusp with an overlay. By the way, shout out to Nick Sethi and Riyaz Yasser. If you’re interested in finding out more about how to place onlays. So go and have a look at their onlay course because there’s an awful lot of information that we don’t know about adhesives. And we’re not taught at dental school. So, I definitely recommend you look into that. And placing an onlay direct like that gives us time. It gives you the opportunity to reassess the pulpal health of the tooth. To reassess it periapically to have somebody come back for a complete health check so that actually you can maybe convert this person into a comprehensive thinking person, and you are not going to solve that on day one. [Jaz] Yep. [Zak] So I guess that kind of answer the question, but I suppose what we’re saying is, if the person chooses the amalgam every time. Are we saying don’t do it? [Jaz] Well, I had a good think about this as well before I got you on. I was thinking, so look, I don’t mean this as a criticism to you, Zak, okay? But everything you’ve said sounds great when you are working with time. When you can really focusing and you have that diary time to build a report, although I don’t think you’ve done anything excessive or beyond, but let’s put ourselves in a situation where maybe in a public funded dentistry, NHS mixed practice, maybe a factor, maybe the difference is that this same dentist, so it’s the same dentist with the same values, the same hand skills, same language working in two environments and one environment, they seem to be taking up the treatment approach, which is best for them. And the one she recommends and the other one, they’re deviating from that. Maybe the difference is that in one practice, she has half an hour, whereas the other practice she has 15 minutes, which is it’s real well, right? Maybe it’s a time and the lack of rapport and the lack of having the ability to show the patient a photograph of an example case and to show them and you be able to give them the opportunity to use language like fragile, that you’ve got a fragile too. That’s one factor. [Zak] Okay, go on. What’s the other? [Jaz] But the other factor is, is how you present the option because you just made a great point there. Maybe if a large composite or a M O D B L amalgam is inappropriate and you’re just giving that option for the sake of giving the option was it’s not an appropriate option. Maybe you should say this tooth needs a crown and there’s nothing wrong with saying. [Zak] Maybe it would be so that we can keep this to take your teeth so we can keep this tooth in your mouth for a long period of time, hopefully years, decades, or maybe even the rest of your life if you’re very lucky. Then we need to do something strong and proactive, and that means we need to protect that thin wall, because my worry with this tooth, Jaz, is that if that remaining portion of the tooth breaks off, we could be in a situation where you come to see me and there’s no tooth left to rebuild. And if that’s the case, then, well, actually, let me ask you, how would you feel? And that question. [Jaz] Oh, I’d hate that. [Zak] Okay. So if that’s the case, then we need to do something proactive about it. So what you’re trying to do is kind of, again, contextualize that person’s goals, values, plans for the future. And if that person says, I’m never losing another tooth again, because that was a horrible experience and I hate the gap. And I’ve always wanted to do something about the gap, but everything just seems to go wrong. Let’s face it. Actually, I have said this so many times. If I hadn’t ended up in dentistry, I could very easily have been a terrible dental patient. I, my sixes are pretty heavily filled. Things could have gone pretty horribly wrong for me. And I could have ended up in a world where I hated dentistry because that’s not because I’m, maybe not doing the right things, but just because stuff happens and you tend to go down without getting too philosophical. We all go down a kind of directional path in our lives, right? It’s hard to remember what it was like to not know the stuff that we know and take the decisions that we’ve taken. You can’t backtrack. I find it really hard to remember what it was like not to know how to brush my teeth. Like, and to be honest, I didn’t really know how to brush my teeth until I was taught by a dental hygienist when I was in second or third year at uni. And. And that’s because I was a guinea pig patient, right? I had no clue how to look after myself and I actually probably wasn’t taught how to give OHI myself. But anyway, conversation for another day. The other aspects and things that I, to answer the question in a little slightly different way, if somebody keeps choosing the option that you think is the worst option of all of them, one thing that might be worth playing devil’s advocate with, and it does depend on how much, how in rapport you are with this person, is to ask, how long are you expecting this to last? Well, how long would you expect that to last? And they go, what do you mean? And that’s again the point at which you need to kind of rethink the whole situation because, if they, yeah, if they haven’t opted into the fact that we’re just space filling with this problem, then you need to kind of have them understand that actually when you take half a step back, look at your whole mouth, and if you’re chipping bits of teeth off everywhere, again, why do you think that might be? If you’re even watching this and you’ve got this far down the road of this, God knows how long supposed to be a podcast. [Jaz] By the way, I’m now having to convert this into a full PDP episode. It’s no longer a group function. [Zak] Sorry mate, how long supposed to be? 20 minutes? I don’t know, whatever. [Jaz] 10 to 15 minutes. My producer is going to charge me double the cost now to produce this is good. Let’s keep going now. Let’s do it justice. So it was going to be like, okay, how can we help this lady, this dentist who has a real world issue, and five, 10 minutes, boom. Some, some tangible tips, but you’ve actually gone way beyond that. [Zak] I can’t do it half. I can’t do it half fast. Sorry. [Jaz] You can’t. And you were going to whole hog. So we talked about the values of the patient. We talked about how we should potentially not only give them that one option, but then in a way you have your dentist that says, oh, but you know, GDC says you have to present all the options. Well, the GDC says that we are, we can and should give them a recommended option. The GC states that, you should give them what’s the best option. [Zak] It also states you should do what’s in the patient’s best interest. And that is a fundamental thing that we actually miss when we think about treatment planning, because we think about teeth in isolation. Teeth are not in isolation. Teeth are in people’s mouths and people have parameters. People have time constraints and funding constraints and they have context of their lives where they believe certain things to work in particular ways. Now, there’s only so much you can do in instilling the virtues of what you believe in their minds, in one solitary episode. So one solitary appointment, you can seal a tooth and make it biologically sealed. Try your best with a bit of Fuji. Classic bit of patch up dentistry to buy some time, but what I’m really doing there is bringing them back for a complete health check. And on a second appointment, you’ve got a better idea of how much they’ve won. Retain the information or some of which you gave him last time. Give him time to think about options for the future. Maybe I wouldn’t have given the full options about crowns and restorations or whatever on day one. I would have waited till the The complete health check, if you think they need longer, then maybe you, I’m not saying don’t work in a public health type clinic, but I’m saying maybe if you’ve got this, you’ve got this far down the road of listening to this episode, then maybe you are the kind of person that should be thinking about working in an environment where you’ve got so much more time at your disposal and technology at your disposal and invest in your magnification of photography, because if you can’t communicate with pictures, you’re so handcuffed. So for the future, that’s the direction that we’re going. [Jaz] That’s great. So also an opportunity for this dentist to reflect on there is a difference in these two environments that she’s working in, and that is one part of it as well. I was actually, I told you earlier in the, before we started recording that I spoke to a dentist the other day, and we were talking about communication. And one thing I didn’t tell you was it’s along the same vein and along the same theme of what we’re discussing about here, about how to talk to patients about the different options. And he was having the same issue. He was saying that I work in a run of the mill and just practice day in, day out. And my patients are just, they don’t want the private options, you know, fine. It’s a whole gray area about private options and just options. Let’s forget about that for a second, but they don’t go for the superior option. And then I asked him and I said, can you pretend I’m a patient? We actually did role play and can you present the options to me? And he said this, he said, We can do the big filling, it, it will help to restore your function. It will do the job. And that’s included or that’s, you know, 200 pounds or whatever, making up a figure. Or you can have this all singing or dancing option, but it’s going to cost you 450 pounds. Can you see what’s wrong with that? And I told him that, dude, the way you’re presenting is like, you actually just presented the better option, but then you sort of like, oh, but you know what is a lot more money. So I told him that instantly, here’s what you need to do. He needs to present them the best option first. Like, listen, if this is my tooth and for all the reasons I showed the photo I showed you, the tooth really benefit from protecting all the cusps and to actually put a cap on there will really mean you get the longest lasting result. This will cost 450 pounds and I think this will last you a long time. You have the other option of going for a big filling, but I don’t think it’ll last as long. It costs that much. Don’t you think I framed that in a much better way? [Zak] Do you know what you did? Is you used the but. So much more effectively. You used the but in such a way as to portray the negative implications of the worst solution. And that isn’t because- [Jaz] And Barry Alton talks about this as well, but Barry’s great at doing this. [Zak] And exactly that. You used a but in the right context and you timed that very well as well because you spent longer talking about the more recommended option, the more proactive option, and you skirted over the other option. And that isn’t because you’re trying to convince somebody that’s just that, in your heart of hearts that that’s what you’d have done. So say it, explain it. And, and having somebody understand how long it lasts and therefore how much investment you need to put into it to make it make that happen. Actually, one of the things we talked about again on the previous podcast is that, people forget that it isn’t just a time implication, sorry, a financial implication, but it’s also to do with how many repeats, repeat episodes with this tooth might arise over time. So it is that classic thing of you do something to try and patch something up, but you might be back with this tooth and paying the same amount again in however long, but actually the difficulty with teeth, unlike human, unlike buildings, for example, or building work is that a building, if it all goes horribly wrong, you can knock the whole thing down and start again. The difficulty with teeth is that once it’s gone, the bit that mother nature gave you is gone. [Jaz] I think that’s the fifth analogy in this episode. You’re always full of these crazy analogies. Not one of these analogies you’ve said on the previous two episodes. So there we are. You got these great ones. I mean, wow. I mean, again, I think we have now answered that question, of this dentist who’s feeling as though that the patients are choosing inferior options. So I hope I hope that helped you. I’ll message you once this is out so you can give us your feedback. See if you found that useful. I’ve changed my mind. I think I will put this a group function because we helped him answer a question. We did it in just a super comprehensive way. [Zak] Comprehensive dentistry. Demonstrate comprehensive answers. What can we do? I’m sorry, guys. I just talked too much. I need to go and get on with my life. [Jaz] No, no, no, no. But it was, it was good. It was good. It was useful. And you know what? I think what this shows is that this is such a mammoth. Topic and we couldn’t have done it justice in 15 minutes. Again, thank you so much. No, no, no, no. His name is John. Anyway, thank you, Zak. Thanks again. Always, just in case we are live somehow, thanks for tuning in guys. I don’t think this worked out. I need to complain to these people, Riverside. Anyway, Zak, thanks so much for coming on and helping out. As always, we really appreciate your time and your expertise, and I hope to see you more on the Protrusive. [Zak] Let’s do this. Cheers, mate.

Dec 14, 2020 • 35min

Getting Started With Dental Implants – Is it for me? – PDP051

Dental Implant courses for Dentists are a significant pathway in terms of commitment. Have you ever attended a Dental course and not applied the knowledge…and then a few months or years later – you felt it was an absolute waste? For example, I did a laser course last year – I have hardly touched a laser since then – its my own fault and I take ownership of that…but what if the stakes were higher? https://youtu.be/rXYARG13AEQ Is it too soon to start Implants…? Need to Read it? Check out the Full Episode Transcript below! Implant courses are not a small investment and I know some Dentists who have invested heavily in implant training…but they never quite got going. Whatever the reason, it’s sad. This is why I recorded with Implant Dentist Dr Hassan Maghaireh who is going to help us over 2 episodes to cover this mammoth topic. In this episode we look at getting started with implants – is it for you? https://youtu.be/dSgGnoTyC1c Should you be placing Implants? Stay tuned for a very clinical Part 2 where we will discuss case selection, implant assessment and Ridge preservation for Dentists. This two-part series aims to help you even if you are not placing or restoring implants, we’re going to cover the fundamentals and scratch in itch we have all had since qualifying from Dental school with limited exposure to Implants! In this Episode, I asked Hassan: As you do not get to place or restore implants at Dental school, how can you know it is the right path for you? I know many young Dentists who dabbled with implants and then stopped placing implants – how can we ensure this does not happen to more dentists? There is a school of thought suggesting that with implants, you should either go all in, or do not touch them. How and where does the GDP fit in to this? Is there a place for ‘dabbling’ in implants? How can we start safely and positively? In this episode we promised you some downloads and resources: The ADI Whitepaper on Bisphosphonates The BAIRD Implant Course starting in October 2021 Wex for Refurbished Photography Equipment If you enjoyed this episode, you will also like Transition to Private Dentistry which changed my life. Click below for full episode transcript: Opening Snippet:You're absolutely right. I mean, it's sad. I'd also teach the one of the universities masters. And I can tell you people did MSC in implant dentistry, and they're not placing implants. And it's sad because I know they have the knowledge, but they did not get the after sale support... Jaz’s Introduction: Have you ever been on a dental course and not applied the knowledge and because he never got to apply the knowledge, you felt as though it was absolute waste because really, if you didn’t get to apply it, you didn’t get to treat a patient with that new technique you’ve learned, it really goes to waste. So sometimes, you know, we do these courses, and they can cost a lot of money. And we don’t get the best out of it. For example, I went on a laser course last year, I’ve hardly touched a laser since. So I feel it’s a waste. And I know it’s my own fault. And I take full ownership of that. But I think sometimes the states can be even higher beyond just a laser course. Imagine doing implants, for example, and investing heavily in implant costs. And they’re not cheap, let’s be honest. And imagine doing that. And I’ve got some friends who have done implant pathways and programs and have not been able to put it into practice. That can be a costly mistake is one way of putting it or a costly discovery that actually maybe implant is not the right path for you or whichever path you’ve done or invested in isn’t best for you. That’s why I’ve got Dr Hassan Maghaireh with me today for this two part episode. The first one is a mammoth topic, right? The first one is, how to know if implants is the right path for you and how to get started within dental implantology. And Part two is assessing your patient for implants. Who is the best patient for implants? What is their requirement for space dimensions, bone, delaying the implants versus immediate, all these sorts of things that will hopefully cover the very fundamentals. Even if you don’t place implants in a moment that you’ll be able to gain from these two episodes. Just a bit of news before we dive into the episode. Occlusion 2020 was a massive success. Thank you so much for all of you who took part. It didn’t feel like a zoom sort of conference if you’d like it felt more than that it was so much more energy. The chat was on fire. It was a lot of great banter, actually. And it was so so great to see everyone there. And the beauty of it is that replay function or redo think online education really is the way forward in dentistry. Who would have thought five years ago that so many of the courses in education can be delivered online. So it’s really great. And thanks so much for supporting us with occlusion 2020. And thank you to you guys listening right now for helping this podcast grow. And I’m always in a good mood to say these positive things because it really puts a smile on my face. For example, recently, about a month ago now a German dental student reached out to me and told me I always have favorite English podcast. So Sofia, thanks so much for listening. And all of you I get loads of messages of gratitude. And I really love that and it’s very great to read those messages. Sometimes a message like you rekindled my passion for dentistry like oh my god, I can’t get over that. So please, let’s keep going. If you don’t mind recommending me to a friend or a colleague who hasn’t heard about the podcast, that’s how the podcast grows. That’s how I can have more varied interesting guests. So I really appreciate all the hard work you guys have done in helping to promote my podcast organically. And funnily enough, I found out that the Protrusive Dental podcast last month was the number one ranked podcast in the category of medicine in Qatar. So shout out to all my listeners in Qatar you took me to number one baby. Hopefully, Qatar is done but hopefully the world next. The Protrusive Dental pearl I have for you is dental photography related. So whether you’re still to get started in photography, or you’re taking photos already, I think you can gain from this. It has to do with equipment, right? Like if your biggest barrier is the expense of buying a camera. Firstly, let me say it’s totally worth it no matter how much your camera costs, dental photography will really elevate your work or bring you so much more satisfaction as a dentist, so just do it. However, I know young dentists, you know, one or two years out and you feel as though it’s a big investment to make all at once. So my advice to you would be to consider buying your photography equipment secondhand. Now when I bought my camera seven years ago, I got it from Gumtree or if in the US Craigslist or whatever, you can buy used camera and camera gear from a photographer, for example, who’s looked after their equipment really well. But now because they’ve upgraded they essentially can sell their equipment, the older equipment that is really valuable to you at a much discount price. Now, as dentists, we don’t need a particularly fancy camera body, okay, the body itself can be fairly basic, the lens should be good, and the ring flash should be adequate. So really, there’s no reason to break the bank over all this and you can buy used models. And even on websites like in the UK, we have wex, w-e-x, where they have refurbished items. So I would totally explore buying equipment, whether it’s due for renewal, or your first purchase, secondhand, or as a refurbished item on these photography websites. And the sooner you get started taking photos, the better. So that’s my pearl for you today. Let’s jump in with the episode with Dr Hassan Maghaireh with getting started with dental implants. Main Interview: [Jaz]Dr Hassan Maghaireh. Welcome to the Protrusive Dental podcast. How are you? [Hassan]Hello, hi, Jaz. Thank you very much for having me. I’m very good. And good morning to you and all our colleagues listening to this nice podcast. [Jaz]Yeah, thanks for tuning in, guys. We appreciate it. And today I’ve got kind of, can I call you Hassan? [Hassan]Yes, please do. [Jaz]Hassan is someone who I’ve seen a lot over the years on the social media presence, and his passion for implants and teaching really stood out to me. So that’s why I reached out to ask him because a lot of the listeners were like, Can we just have a bit more implant stuff, especially when it comes to a journey of implants so hustling. If you don’t mind we’re gonna cover a couple things today? One is getting into dental implants. And two is just you know, if you’re looking for your first couple of cases or if you’re looking to refer, you know, what is the basic sort of requirement, suitability, assessments, can you place it in smokers? What about timing of extractions? Obviously, in a podcast like this, as you can only scratch the surface I’m sure there’s so many nuances, right? But any direction you can get a dentist that would be great and Hassan. Can you just please tell us a little bit about yourself? About your working week and how you got into implants yourself? [Hassan]Well, thank you very much, Jaz. Basically, for me, implant dentistry is one of the most rewarding aspects or branches of dentistry. And I strongly believe that every single dentist has a duty to know something about implant dentistry. In fact, as we all know, GDC here in the UK makes it mandatory for every single dentist to offer implant option to their patients, even you know, if they think you know, a patient won’t go for it, to never judge a book by its cover. Should always offer implant dentistry as one of the treatment options. And I strongly believe that you know, people who like to go into implant dentistry, they’re going to find it very rewarding providing this start right. What goes, what starts right, goes right. Why do I say that because it’s so easy to slip into implant dentistry through the wrong doorway or through the wrong entrance and then start to mess up your career, and you lose fun. The way about implant dentistry, let’s admit it, maybe in UK and maybe other countries, undergrads don’t get enough education, about implant dentistry. Hence, every dentist you know will need to pursue a career in implant dentistry through some post continual education or continual education after graduation. And that could be either through masters if they want to get like into research and thesis. Or if they just want to reach a level where they can be say implant dentist, there are so many good courses, continuing education courses, which according to the general dental Council of the United Kingdom has to be a long course with integrated mentoring scheme. And that course needs to be completed with an assessment, hence only then someone can say now I’m safe to do implant dentistry. [Jaz]You mentioned that Hassan because straightaway that leads very nicely to the first overall question I want to ask which is basically when we do our undergraduate studies, like with a lot of dentistry, we scratch the surface I mean I know dentists who have done one molar root canal or even dare I say no molar root canals and they’ve got a BDS Hassan, Okay? So don’t even go like don’t even think about implants. If they have done maybe seven extractions and one molar root canal, this is the state Okay, and I don’t know how much worse the pandemics and make everything right. So we’re qualifying with way less experienced than we used to then and you don’t get to dabble or get your hands into implant dentistry. So how can you be sure it’s the right path for you and to even begin to think it’s now worth investing some money into, into the path of learning because if you quite correctly said the way to learn implants will be through a private courses or masters just like you said, but how do you know is the right thing for you? Are there certain traits that you see in someone in a clinician you think, you know what they may have a fruitful career in implant dentistry, or a certain type of individual, a student maybe should focus on something else, any sort of light, you can judge, you can share on that? [Hassan]I thinkJaz, it’s a decision every single person will need to make you and I know, let’s talk about dentistry in the United Kingdom. At the beginning, once you graduate, you need to make that decision. Are you going to be NHS nine to five dentists who just you know, happy to settle? Or are you someone passionate, wants to take the challenge one step forward? Do some more challenging cases? Wanting to spend more time with your patients not wanting to keep your patients in house, even wanting to, you know, upskill and upgrade your CV so you can get better jobs later on? So this is the first question every single graduate needs to make. You know, Where do you work? Where do you see yourself five years down the line? Now, should you decide that you know what NHS dentistry is not for me, I want to be someone different. I want to be above average, then the second question is, right, which part of private dentistry you think you can be enjoying that? Okay, now we know jack of all trades, master of none. So you need to somehow develop passion in one aspect of dentistry. I mean, I’m not saying don’t do the rest of dentistry, but just developed passion, where you sort of start to attend evenings, open evenings, Congress’s lectures. And if you find out that, do you know what, this is something I see myself doing in the future. This is something hopefully, in five years time, I’m gonna be doing that with passion, with confidence, safely, then you could make that decision. All right, let’s go into implant dentistry. Before going into implant dentistry, it’s always wise to find someone you look up to like a mentor or someone in your city where you know, you refer some patients to before and say, pick up the phone and say, Can I come and shadow you for a day or two, please? I’m not sure about implant dentistry. And I know that you’re someone who gets implant dentistry regularly, I just want to come and stand behind your shoulder and see how things work. I’m sure you’re going to find lots of people will come in you. And only then you could say, right, this is for me, it’s time to invest. Let’s take it forward. [Jaz]I think it’s great. You mentioned the role of shadowing, it had a huge role. In my career trajectory. I shadowed lots of great dentists. And that’s the reason I’m today I’m a general dentist who likes to do ortho, likes to treat tooth wear and stuff like that, because it’s a dentist that I shadowed. And that really influenced me, I also shadowed Implant Dentist and I went down and did place some implants on a course, which I shall not name, it’s an international one. And I didn’t have a great experience. And I think it was due to the education I received and that point, and I do think if I could go back in time, I would have picked a different sort of route for getting into it. But now I’m enjoying myself because I’ve got a diploma in orthodontics now, I’m doing more of that. So that’s how I went about it. But really, I think you raise a good point that if I summarize it, you have to kiss a lot of frogs before you find your prince charming, basically, you might have to go on that endo course, you might have to do some endo in practice, and then start making some dentures and maybe shadow a prosthodontist. And then eventually, maybe shadow someone who place implants. And trying to figure out which one or two micro areas within dentistry really resonate with you the most. And I think it’s so great that you mentioned the role of shadowing, which by the way has been complicated by COVID. Unfortunately, there have been a few dentists who have messaged me you want to shadow I missed a few dentists I want to shadow. And because of the whole COVID we just don’t know whether to go or not. But obviously, this will pass. But it’s a great advice you give to find someone in your city, potentially someone you refer to. Shadow them and see if that’s a career for you. Is there anything you want to add to that progress? Before the next question, Hassan. [Hassan]Perfect point where you’ve mentioned, I mean, obviously COVID is temporary, and hopefully it will not continue. But you know, you don’t have to invest in courses, maybe congresses, conferences, and don’t look at it as a waste of time. Because you as a dentist has a duty to develop basic knowledge about every aspect. You know, so a patient comes in and say, am I suitable for an implant? You can’t say just to be honest, I don’t know. You have a duty to know the basics about implant dentistry, at least, you know, to be able to answer these questions. So we have in the United Kingdom, ADI, ITI. They’re both two big organizations and they offer annual congresses and conferences. And I think every dentist should go and give it a try. And only then you could decide this is for me or not. [Jaz]Brilliant. The next thing I want to ask you then is that there are some dentists who end up doing some implant training and investing their time and money into it. And then they don’t fly with it. They don’t run with it. Happens in anything like, you know, you have some people who do an orthodontic diploma, and they don’t do as many orthodontic case afters, they do an endodontic program, and then they decide not to sort of not specialize or they don’t make their practice limited to endodontics. Because they just don’t get around to doing it. And they spent all their time and money into that field, for example. So how can you ensure that if you want to do some implant training, what’s the way to make sure that you can hit the ground running, and get some cases under your belt? And actually not then just give up implant dentistry a few years later, despite investing time and money? [Hassan]Jaz, this is an amazing question. And as you might know, I mean, we run a course here in Leeds, through the British Academy from time to start in dentistry. And I get a lot of people calling me asking about the course. And actually, the more important question is, what support the delegates going to get after the course. Because there are so many good courses here. And you know, there are the differences can be minute between one course and the other. But what really makes it or break it for you is what support you’re going to get after the course. And I think every person who’s going into ortho, or implants or endo, continuing education, try to link yourself to a group in that field. And only then after the course, the discussion, the mentoring, the encouragement comes from the family. So in the [?], the Bridge Academy, we like to feel like we’re a family. And we have annual meetings where we can encourage each other. I mean, whenever someone has a challenging case, we have a mentoring scheme, integrated mentoring scheme, where someone can come to your practice, and help you to do this challenging in case. You’ve got a simple case, we have this platform where people discuss these cases together. So I think in general, in dentistry, whether it’s implants, ortho or endo, whenever you want to look into course, especially if we’re talking about a serious course leading to course certificate or diploma, you need to be asking the question, what support I’m going to get after the course? So I can start to enjoy, you know, get the reward of my investment. You’re absolutely right. I mean, it’s sad. I’d also teach the one of the university’s masters. And I can tell you people did MSc in implant dentistry, and they’re not placing implants. And it’s sad, because I know they have the knowledge, but they did not get the after sales support. [Jaz]I guess that’s it, Hassan. Thanks so much. The next question I have then is there’s a school of thought with that. With implants, you should go all in because to me, there’s so many systems, so many complications, surgical and restorative, that if you just dabble an implant, you will never reach your true potential or you may not be as successful as someone who just dabbles. So where do you think the the humble GDP fits into it? Firstly, do you believe that? And how does the GDP then dabble? You know, maybe a GDP places six implants a month? Is that a decent amount? Is that okay to practice in that sort of field where you’re placing that number? Or does it really need to be either zero or 50? [Hassan]Yes, 100%. Let me take just one step backward. Now, as a general dentist, you have a choice of going into implant dentistry, as at three levels, let’s say level one, which developed the knowledge and I think this is now becoming mandatory, every single dentist needs to have enough knowledge. So whenever you’re doing a consultation with someone coming to you with the failing teeth, or missing teeth, you need to have the knowledge talking to your patient about implant dentistry as an option, and I strongly believe this is mandatory. Okay? Now the next level is to refer your cases to someone you trust, so they can place these implants and then you restore them in house. And the advantage of that, that imagine you having a central incisor missing tooth, you’re gonna want to refer that for an implant, but the adjacent front teeth needs some veneers or crowns. So it will make sense for you as a general dental practitioner to have one impression for all of them, you get the nice matching color, the everything all in one scheme. And also, you as a general practitioner will have the knowledge to be able to follow up this patient, okay, but you need to be trained to do that, you know, training how to restore implants and link yourself to someone you trust, where they can place implants up to the standards you expect. Now, the third level is to say, right, I want to provide the service, in house service for my patients, where I don’t want my patients to go somewhere else, because like it or not, you know, I’m a dentist who accept referrals from colleagues. And I think I might regret saying this later on. But patients like it, when they have all the treatment in their own practice, you know, for a patient they develop over the years, they’ve developed this comfort zone, this trust relationship with their dentist. And when you say, when you go to them and say, do you know what I’m gonna need to refer you to see someone else in another practice. So then this is completely unknown, and they’ll take your word for it. So it will be nice and amazing if you use for them, the dentist they trusted over the years who can continue this treatment. So you as a clinician need to make that decision. Where do you see yourself? Now, the moment you said, right, I’m going to start placing implants, then we forgot another three levels. According to the ITI classification, which is available on the ITI website for free, you could feed all the information about the case on that website, and then you’re going to get a classification whether it’s simple, advanced or complex, mean, no one would expect you to go and jump into complicate complex cases within the first three, five years of your implant career. So what I mean by simple like a case where it’s a lower molar, we’ve got loads of bone, away from the nerve, simple flap, no challenges, you could place that implants. Now, obviously, you need to have the training to be able to do that simple treatment. And then you do simple cases, by yourself for the first few years, couple of years. And whenever you have an advanced case, rather than referring this case to someone else, you could call your mentor and your mentor can come to your practice, and you and your mentor do that advanced case together. So you’re learning one to one through this mentoring session, your patient having treatment in house, so no need to, you know, disturb the patient journey. And you know that you’ve done the best of, you know, of treatment for your patient. Now, the third level, which is complex, and that’s when you mentored or someone really advanced in their training, we’re talking about atrophic jaws, about science of grafting, that’s when you can refer your patient. But these are not very common cases, we’re talking about 10, 20% of the cases. So personally, I am a big advocate for every practice to have their in house Implant Dentist. And if you that associate, or that practice owner, who has passion for perfection, for surgery for you know restorative work, I think you should go for it and give it a go. And yes, you will hear people telling you, it’s either all or none. My advice, it shouldn’t be like that. It’s gradual, like anything else in our life, we don’t go all or none, you don’t go from no driving license to driving Aston Martin, start with a Ford. And then you go up until you reach your dream. [Jaz]When you start moving up again. And you start doing more complex cases that you have the mental common, and you do the case together. I think some of my best learning experiences as a student, as a learner have come from that sort of arrangement. Like I remember being in the DCT position in Oral Surgery at a Guys hospital. And I had this complex surgical wisdom tooth. And I was struggling. So one of the registrar’s came and held my hand and she was retracted the cheek and she was telling me what to do as I was doing it, you know, hold it like this, hold it at that. And those have been the most powerful learning experiences for me. So I think that’s a really good point, you make that and that can be applied to any field of dentistry, if you can have someone to hold your hand, not just like over Facebook and send them photos and give you advice because that is really valuable as well, by the way, and by email relationship, but what I actually mean is that someone being by your side and seeing the patient together, and for them, just give me those little little micro tips that will just make your dentistry go a long way. So that’s a great point. And the last question to wrap up this theme of getting started in implants is the following, when we qualify, at what point should you decide? Okay, now is the time, I know you mentioned that level 123 which I really liked by the way, and you I think the way you described it so good because you can do level one very soon after qualifying because it just the core knowledge which we need to have even acquainted GDC but let’s say you want to start taking things again forward. Here’s my perception, my perception is you should be able to take teeth out comfortably enough before you even start think about placing implants. Because for me, that was around about three to four years afterwards. Now when I see any sort of extraction, it doesn’t faze me as much before then I was like, I’m not gonna be okay, am I not? Now I reach a position after the four year point where I thought, okay, now I can do some simple surgicals, happy to section and elevate. Whereas some dentists might jump straight into the deep end without even mastering extractions. For me, that’s how I was once taught is a good point to consider about the surgical aspects of implant dentistry. What do you think about that? How do you know is the right time? And do you need a good restorative background? Before you start going into level two and level three of the implant pathway described? [Hassan]Okay, that’s another very good question we always get from people who are passionate, they want to do something as quick as possible, but then they want to check, is it a good time for them? Or are they doing it too early or too late? Now, my advice would be after you finishing your dental degree, obviously, you’ve got to have one or two years of general dentist experience, dentistry experience. And you’re absolutely right, you need to have some knowledge about restorative techniques in general. You need to know how to take a tooth out, and not only taking a tooth out, you need to be learning and focusing on how to be gentle in taking teeth out. Because when it comes to implant dentistry, it’s all about the bonds all about that maybe a plate, which is in 87%, less than one millimeter thickness in dentin [inaudible]. So you could see we’re talking about very thin structure. And it will make or break your implant case in the future having that labial plate intact or not. So absolutely with you that you need to have good skills, the minor and all surgery skills, good some restorative understanding. But on the other side nowadays, you know, people like me and other co directors of other courses, whether it’s University lead or private lead, we acknowledge that and we started to integrate this as part of the education we offer to our participants. So our implant course is a 24 day over eight months. And in a part of this 24 days, we do lots of hands on teaching and taking feedback on managing little tiny, simple flaps, suturing techniques. So we take people assuming they haven’t ever done a suture before, they haven’t ever done a tooth out. And we sort of put that as part of the course. Now you could decide to learn how to do Oral Surgery by yourself and your patient by after taking 100 teeth out, or you could come and attend a one day course, which saves you the trouble of putting yourself and your patient through the stress and the trauma of trying to take a tooth out. So again, the question is, you know, you need to look at what sort of things is going to be covered in that course. I mean, in our course, it’s an implant course. But we also have a full module on occlusion, because we acknowledge the importance of occlusion in implant dentistry. Exactly. [Jaz]I was celebrating on there. For those driving, they didn’t see that I was very happy to hear that. [Hassan]He was jumpingup and down. So yes, definitely. Because, you know, to learn an implant is not only about this crew, it’s all about you know, stabilizing the map, stabilizing the whole structure, the pink structure, the bone, the adjacent teeth. So some courses will just teach you how to place an implant and other courses will have more like holistic approach where you go from A to Z. Look at the whole thing. And I would like to think in my course, or in our course, we covered all that. One of the brightest graduates we had were people who came to a request two years after graduation. And I mean, I wish I can mention someone called [delegate’s name]. [Delegate’s name] came to me he was the youngest participant. [Jaz]He’s very dear friend of mine. [delegate’s name] is a very dear friend of mine. And yes, I didn’t know it was your course that he did. That’s brilliant. He’s loving it. Amazing. [Hassan]And now, you know, he’s at his young age, he’s a mentor. So what I’m trying to tell you, it’s up to you to decide when you want to start and I go to people say because I do have some of my colleagues and very respected colleagues, they say, you cannot go into implant dentistry too early. You have to be 5,10 years of experience before giving into implants and I beg to differ because imagine yourself 35 years old this is I would like to think when you’re 35 you should be at the top Okay? If you’re certified with five years or 10 years experience in implant dentistry, it will make a huge difference compared to if you were 35, with one year experience of implant dentistry. So the earlier you start, you know, and you do the course doesn’t mean you’re going to finish the course and go and do full arch. Now you do the course and start with the simple cases. And that put you the first two steps in that pathway. And then from there, you develop your passion, you attend conferences, courses, continual advanced courses. So by the time you’re 35, you can do full arch with confidence. And that’s what I would prefer to do if time goes back. [Jaz]That’s a great way to look at the pathway. But I’m so happy you mentioned [ ? ], it’s unexpected, actually. It’s so great to celebrate the success of one of my dear friends. And I mean, if you ask him, he’s very humble, he will say success. That’s the wrong word for me, you know, he’s very humble guy. But I remember because we’re in the same you know, we’re best buds. And I remember what he was saying, so soon at dental school, I want to go to implants. But he’d been thinking about that for a while. And he went into it, knowing that he’d be one of the youngest, least experience. And he was very grounded. He said, that Look, I know, I have so much to learn. And the way he took it, he, I remember, he actually got extra mentorship, he actually, you know, I believe he paid for it, or whatever you need to do. But he did it the right way. He went the right way about it. And I love what he’s doing now. And he’s dedicated. He’s got a purpose. So that is a great case study. And I’m so glad you mentioned him. So it shouldn’t put anyone off if you’re too young, but you have that desire, and you have the willingness to put the hard work in. It’s all very achievable. So I think that ends this part one in a very nice way. So this was all about getting into it. We asked some questions like, at what point, what core skills you need, what to look out for, is it right for you. Any closing words on this segment Hassan? Before we move to the next one. [Hassan]Jaz, you’ve just mentioned an important thing and you said he did the course but you had to invest more. And this is the other message, you know, please don’t be diluted or deceived thinking that you’re doing the course, that’s it you’re going to be a perfect implpant dentist. Any course whether it’s even master’s degree, or one of the private courses like the [12 course] which we do over 24 days, which is an intensive and we offer patients as part of the cost our delegates even that it’s only your first step, you need to be willing and ready to invest. You have to invest into mentoring after the course, you have to invest into attending like advanced soft tissue and bone management courses after the course. So it’s a continually, it’s a marathon rather than a sprint. If you ready and if this is something you want to go, go for it. Don’t let anyone stop you pursuing your passion. Otherwise, you might as well just leave implant dentistry to another colleague. [Jaz]Well said and another great point that you reciprocated there about having the need to continually invest more and learn more advanced techniques. And a great example I can give you is I’ve got lots of good friends of mine who have Mclindent in prosthodontics or Mclindent in periodontics. And guess what they go abroad to America to Brazil or to wherever to do advanced soft tissue courses. My prosthodontics colleagues, they’re the biggest CPD junkies I know even though they have you know this, they made it, they’re prosthodontic specialist. But no, they’re still going for these advanced courses techniques. They’re continually investing in themselves, so it doesn’t stop. So I’m sorry, if you’re listening to this, and you’re thinking, oh my god, it never stops. You need to actually see that as a beautiful thing that you know, otherwise you get bored, you become stagnant. This is the beauty of dentistry there’s, you know, there’s not a single day that goes by they don’t learn anything new and that that will never stop. So I think that ends is part one really well. So Hassan, thanks so much for covering for us getting into the implant journey. [Hassan]Thank you, it’s a pleasure. Jaz’s Outro: Protruserati, thank you so much for listening all the way to the end, I always appreciate you listening all the way till the outro. Really appreciate that. So hope you found that useful with Dr Hassan Maghaireh. Watch out for part two of this where we actually get a little bit more clinical, how to assess your patient and the spaces whether they’re suitable for dental implants. So catch on that one. The is an update in terms of social media. We do now have an Instagram page, it’s @protrusivedental. So I’m going to use my own Instagram for my own things now. If you follow the podcast, you like the content and you want to keep in touch with the content, join the @protrusivedental Instagram. Give us a follow and we’ll follow you back. Thank you so much as always and I’ll catch you in the next episode.

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Dec 9, 2020 • 12min

Dahl Technique and ‘Maryland Bridges’ – GF001

This is the very first Group Function and we are tackinling RBBs! I will take questions from the fellow Protruserati – I will use your help to come up with some helpful solutions. TLDR: You can do Dahl RBBs, but it doesn’t always mean you should. A little prep of enamel will not be THAT detrimental for the tooth. https://youtu.be/VtRlzodts8c Need to Read it? Check out the Full Episode Transcript below! Thank you Aaron for helping this episode happen as our first question! It is about a technique dear to my heart – Resin Bonded Bridges! Firstly, if you know nothing about the Dahl technique, you totally need to listen to the episodes with Tif Qureshi on Dahl Part 1 and Part 2. It CAN be a good way to place Resin Bonded Bridges in a way to eliminate any preparation for the occlusal surface – in young patients it can be very successful. However, it just seems a shame to prop someone’s bite open on just ONE tooth and allow what naysayers refer to as ‘unpredictable orthodontics’ to work it’s sweet magic. I am totally fine with a little prep – staying in enamel (which is so key!) – every case is unique so treat on it’s merits. In a younger patient, I am more likely to consider that approach. I hope this helps! If you find this useful – send it to a colleague. I cover Dahl RBBs extensively in the Resin Bonded Bridges CPD Online Masterclass as well as Zirconia RBBs. Click below for full episode transcript: Opening Snippet: You know sometimes when you get asked a question and then you help to answer that question or you know someone who knows the answer and you connect them and then the topic that you discuss becomes so helpful, so useful. You kind of wish that 'hey you know what i wish more people had access to this' because i'm sure if this person benefited from these answers that many others will also benefit from these answers... Main Topic: So this is why, this is the first ever group function okay? So i’m calling this series group function because it’s us, you and i working as a group. You guys the listeners, myself, the previous guest of the podcast, the future guest podcast and those on the Protrusive D,ental community facebook group we’re going to ask questions, we’re going to answer questions. They’re going to share answers, we’re going to try and be i guess a fly on the wall when these helpful conversations happen. So for the first ever group function, someone messaged me yesterday with a question his name’s Aaron Raju. Aaron, thanks so much for the question and he gave his consent for this to be go on an ama so i can ask me anything but of course i’m calling this the group function. So what Aaron asks is to do with resin bonded bridges so aka maryland bridges you know i don’t like that term but anyway maryland bridges and using maryland bridges as part of the dahl technique. Now if you are totally unfamiliar with a dahl technique you need to end this episode now and go back to episode 16 and 17 where we are joined by Dr Tif Qureshi and we talk everything and anything about dahl, about how it works, the mechanisms, the indications, contraindications. So this is a really important background knowledge to have, to be able to answer this question and resin bonded bridges are something very dear to my heart. I’ve got a little mini series online on rbbmasterclass.com so i placed hundreds of resin bonded bridges. I’ve published on this technique in dental update. So Aaron thanks so much for the question basically i’ll read it out “Dr Gulati..” Well first you don’t need to call me Dr Gulat. I am Jaz, you know that. Hope you don’t mind answering quick query. I read your papers in dental update regarding resin bonded bridges. I have a case where a resin bonded bridge is used to replace an upper right five with the upper right six as an abutment with the wing overlying the palatal cusps and the palatal surface. This was no prep and the plan is to dahl to reestablish posterior occlusion long term. I realize there is also a potential to create an anterior open bite as a result of raising the occlusion posteriorly. Have you experienced any kind of potential issues in your experience? And to avoid this i was considering a minimal occlusal preparation in the future to leave the palatal and lingual surfaces untouched. Kind regards, Aaron. Aaron thanks so much for the question. Let me break that question down into his different components so we can answer each one. So it’s it’ll flow better. So firstly the situation is we have a resin bonded bridge, it’s a cantilever resin bonded bridge, it’s from a first molar as the abutment tooth and it’s replacing a second premolar so it’s a cantilever design and it’s resin bonded so it’s not a conventional bridge, it’s a resin bonded bridge. Now the question is when we over lay onto the occlusal surface so half of the occlusal let’s call it the palatal half of the occlusal surface. Now this is a good thing to do generally because you’re maximizing the surface area that you’re covering of the abutment which is really important for resin bonded bridge because innately they don’t have much retention form. They’re relying heavily on the bonding. So it’s a good thing to do and also the other benefit of covering over the half the occlusal surface is if you put any pressure or force down the long axis of the pontic so the upper right five pontic okay? You put some forces up the the tooth as you’re chewing some food okay? Then forces will be acting on the bridge abutment and what the occlusal element of the abutment brings is that it allows your cement lut to be in compression compared to if you didn’t cover the occlusal and he only had the palatal surface the wing classic used to see this design quite a bit and they were not so successful is because when the patient now chews and they’ve got a food bolus on their secondary molar and they bite together. Now what’s happening is that shear stress and tensile forces are acting on that cement loot and then eventually this can debond but by having the occlusal component, it’s allowing it to be in compressive stress which it can handle much better So it’s always a good thing to do where you can. Now the issue is if you’ve got someone with a perfectly well interlocking interdigitated posterior occlusion then you don’t have space right? So your options are A) you prep and you prep 0.7 millimeters so you definitely don’t want to get into dentine because that really reduces the bond strength but you should be able to do it but nowadays you want to be minimally invasive so this is why some people like to use the dahl technique i.e do not do any prep or very minimal prep and have your technician make the resin bonded bridge abutment in supra occlusion. So you bond it on, cement it on and now when the patient bites together because you didn’t make the space for it you’re open everywhere else, you’re not biting anywhere else except on to the abutment of the upper right six. So can this technique work? Yes it can. So i’m just gonna for those who people who are watching obviously those who are listening i’ll be able to describe it for those people who are watching i’m gonna put some still images from my resin bonded bridge online course and this will help to drive the the sort of vision home as well and the explanation will be clearer. Using the dahl technique as part of resin bonded bridge to replace a tooth is something i did a lot of in hospital both when i work at that guy’s hospital and at sheffield hospital on the restorative department for the young people post-orthodontic around about anywhere from age 15 16 up to you know even their 20s we did this a lot. We didn’t prep and we just bonded these resin bonded bridge in supraocclusion and they would sort themselves out okay over time you would get the posterior over-eruption or dental alveolar compensation so this image for those watching is that the teeth are apart it hasn’t settled but even as quick as four weeks later they do come back and everything is meeting quite nicely if not a hundred percent and maybe ninety percent of the way there and then with a further follow-up teeth are all into collusion, they’re all into static occlusion again and things are looking pretty good. So how does this work? Well the posteriors over-erupt or dental alveolar compensation happens there could be some anterior intrusion and also there could be a degree of condylar repositioning and all these and any of these things can be happening at the same time. So it does work but you have to pick your battles and as now you know, now work in private practice, I tell you i don’t do a lot of this anymore. I’m very very selective about which cases i do this for. So let’s talk about some contraindications. So the real world advice is firstly all the principles of dahl, you have to also apply it to doing dahl on a resin bonded bridge because dahl traditionally nowadays when we do it, we do some anterior bonding for someone who’s got localized anterior tooth wear and then we allow the several teeth contacting at the front only and then allowing dahl to work its magic condylar repositioning, anterior intrusion, posterior eruption and then eventually everything is settled right? And this is fairly predictable especially in a younger patient but with the resin bonded bridge unless you’re doing like a long span anterior resin bonded bridge like in the situation that Aaron just spoke about, with dahling of just one tooth okay? That’s pretty extreme right? So all of the patient’s contacts all the chewing will be on the upper right six everything else will be open is this a good thing to do? Well I think Aaron told me the patient’s about 27 so yes fairly young and that should be fine but are there any risks? Now before we come on to the risks there are some things that apply universally with dahl like for example avoid dahling anyone with an anterior open bite because hey if they were receptive or susceptible to anterior overruption and whatnot and an intrusion then their own anterior open bite would have sorted itself out already right through eruptive forces but it hasn’t. So avoid AOBs, avoid intracapsular disorders with tmj. Do it on people you like and trust because it’s kind of something that you may be seeing them over again for if it doesn’t go to plan. Avoid severe tooth wear because they probably need a full mouth rehabilitation as Tif says dahl is very much reserved for interceptive like when it’s not too late, when you can do some edge bonding and you can recycle these as you go along so every eight to ten years do it again and really it’s a great way to keep someone going but if they’ve lost too much tooth structure or if they’ve got posterior wear, significant posterior wear that’s not a dahl patient, that’s a rehab patient. You also want to avoid it in someone with a reduced periodontium so imagine this patient that Aaron spoke of obviously 27, unlikely to have severe perio problems but if the upper right six was periodontally compromised then really there’s a fine line between doing a dahl and and just putting something at increased risk of occlusal trauma. So you have to be careful with the reduced periodontium and of course age is significant. So the younger you are the more predictable it’s supposed to be and one more thing that if you ever do a dahl always think about the axial contacts like where are the contacts happening and if the opposing tooth is having the contact along the long axis or not so you don’t want teeth display and flare out you try and want to design everything in your wax up and you’re planning to allow all the forces go up the long axis of a tooth. So Aaron let’s actually answer your question, it’s totally okay to do this but i don’t do it so much because it’s annoying for the patient and if they’ve got a perfect in well interlocked interdigitated occlusion already a little bit of prep for them to have a new tooth is not the end of the world okay? And that you can still stay in enamel for that 0.7 millimeter thickness and a lot of these cases you have a look and actually in some areas you may need to prep a little bit and other areas may not need to prep so much. So actually a lot of these cases don’t need as much as 0.7 millimeters perhaps you can actually do a lot less as well. Are there any risks of creating an anterior open bite? Well this is a very broad question because when can an anterior open might happen in restorative density? Well in this case it would happen where if they potentially have a large slide between their MIP and their centric relation contact point then let’s say you now prop them open on their upper right first molar as part of the bridge abutment and then what happens their lateral pterygoid muscle relaxes and suddenly their mandible goes all the way back, it’s like they’ve completely forgotten how to bite together and now yes they could have an AOB how can you screen for this? Well you need to check where is their centric relation contact point position, have they got a large slide perhaps you could use a leaf gauge to check what their first point of contact is and that might be useful for you and of course if they’ve got a poor posterior stability then nothing’s going to help them to slot back into their mip. So these are all the other things that we look at to predict if someone’s going to be high risk. There’s loads of other things that go on as well because if anything changes in the temporoomandibular joint then that can obviously change the way that our teeth occlude. So i think it’s a low risk of doing it but it’s still a risk nonetheless and every patient’s different and you should screen for this and do your usual occlusal check.

Dec 1, 2020 • 57min

What Every Dentist Should Know About Managing Dental Anxiety – PDP050

When Mike Gow first told me that he helped place dental implants on patients WITHOUT local anaesthetic, I thought he was lying. Then I found out they have also done a sinus lift without LA…what?! You read that correctly! Mike Gow has centred his practice around the management of nervous and anxious patients. Don’t you think we can learn so much about management of dental anxiety from someone who has achieved the above? This is exactly why I brought him on as my guest of honour for Episode 50 (50 not out!) and you will love this, gem-packed podcast with valuable ways to help us become better Dentists to anxious patients. https://youtu.be/dkMByGXwI1A Full episode with Dr Mike Gow only on Protrusive and Dentinal Tubules Need to Read it? Check out the Full Episode Transcript below! The Protrusive Dental Pearl is to check out Anydesk (it’s free!) to gain remote access to your work computer in a secure way, so you can access X-rays and treatment plans any time, from any where! This has helped me on so many occassions! Also check out the 1 hour free training on Teeth Whitening by Dr Payman Langroudi of Enlighten Smiles. https://youtu.be/jO0bIetHLtY We discuss: How and why he found himself in a situation to hypnotise patients and place implants without LA Mythbusting about Inhalation Sedation Top tips in making patient feels calm and cared for (gold) Gow Gates vs Akinosi – which ID Block alternative is better? How to have a thriving practice centered on anxious patients The powerful secrets of managing dental anxiety https://youtu.be/uqiXh6QUjXw Inhalation Sedation is massively underutilised https://youtu.be/LevjbyjOTIM Hypnosis is powerful! Mike’s resources as promised: ISDAM Website ISDAM Facebook page His practice, the Berkeley Clinic And of course, Mike on the news!: https://www.youtube.com/watch?v=D04uduXkYJ0 Dr Mike Gow also runs InterDental TV for the latest in Dentistry. If you enjoyed this episode, you may also like Dr Libi’s 2 episodes on Paediatric Dentistry! Click below for full episode transcript: Opening Snippet: I see myself like, cocktail waiter, okay? The patient presents and tells me what kind of you know we work on what kind of thing is needed. And now it's up to me to decide how much of this is going to be pharmacological, how much behavioral, how much technological, and we make this mixture that's unique to that person... Jaz’s Introduction: Managing anxious patients is not only one of the most difficult things in dentistry, and sometimes they can be very stressful encounters, but they are actually some of the most rewarding experiences sometimes this defines us as dentists, a dentist who cares, attentive who can really give people hope. People lose hope. And that’s part of the anxiety. They won’t know if they will get along with you. But they won’t know these patients. If they can never trust another dentist again, they’re too scared of pain. They’re too scared of just general dentistry. And I think if you could master the art of treating the anxious patient, you will be so so so busy, profitable, or more important, your value and your sort of self worth as dentists and enjoyment and fulfillment can really really increase and that’s why out today on this episode, Protruserati, PDP050, 50 Episode 50 raising my bat. Thank you so much for sticking with me all the way to 50 episodes. I’ve got an amazing person. This clinician, Dr. Mike Gow, if you’ve ever met him, I met him in Switzerland course few months ago in , this guy is just something else like, Here I am, right? I’m placing local anesthetic, sometimes when I’m placing retraction cord, right? So I take the temporary crown off. And I need to get scanner impression to go to a definitive crown for example, and I’m placing local anesthetic for retraction cord. Yeah, I’ll put my hand up. I do that sometimes. Right? Where as this guy, Okay, Dr Mike Gow. He’s worked with dentists alongside him. And through his hypnosis and just amazing management of anxious patients, their team has managed to place implants and do sinus lifts WITHOUT local anesthetic. Yeah, you heard that right, right? Without local anesthetic to do a surgical procedure, and place an implant. That is amazing. I’m not saying you guys should aspire to that level. But don’t you think we can learn so much from Dr Mike Gow. And just even as a GDP if we can learn a few tips from this episode, which is absolutely jam packed full of it. It will really help you in the management of nervous patients. We asked about Mike’s journey, how you got involved with nervous patients, what his top tips are, he explained what he was feeling like just before he’s about to operate on this patient when placing the implants without local anesthetic, like, that’s a big ask. And a lot of these were being televised and filmed. So there was a lot of pressure for him and his team. But it’s just amazing the outcome and we sort of find out what kind of patient is suitable for going as extreme as that. Yeah, not everyone is suitable. And it depends on a few factors, which might covers fantastically. So I’m really excited to share this episode with you. The Protrusive Dental pearl I have for you may change your life in a massive way. Like it changed my life in a massive way, right? When you’re sometimes doing treatment plan that is at home, and you need to just see an x ray, or you need to see exactly what the conversation was with a patient, you need to read your notes, right? And let’s say it’s a weekend sometimes I’m spending weekends doing treatment plans as you know from the previous episodes. So how can you access the notes it’s been something that really bugged me for a long time. So we use them in the UK a lot of people use SOE Exact and when no matter what system you use, you can download something called anydesk. Now anydesk will allow you to access any other desktop or computer or laptop that’s got anydesk involved and it’s like completely secure. So you’ve got these like long keys, passwords, encryption, all that sort of stuff. And then now you are able to access your work computer and if your work computer is on you can then log into your dental management, patient management software. And you can look at your X ray, you can you know find out emails of patient so you can email them the treatment letter. And that literally really helped me so much in terms of saving time in ways you couldn’t imagine. And also so I’m not constantly hassling or bugging the receptionist to send me this email or send me that piece of information or show me this x ray. So now I can just do it myself. You take the burden off the reception team. So if you ever wanted to know how can I access that information while out and about or at home or at different practice, I would download anydesk on your laptop or computer and also the work one and it’s really easy to use. So I really hope you enjoy anydesk. I’ll put the link for it on the protrusive.co.uk website on the under the Show Notes for this episode, but also on the Protrusive Dental community Facebook group which has been just amazing recently, so much activity on there, people are really embracing the term Protruserati which is awesome. I’d like to thank enlightened whitening for their support in sponsoring this episode. And they’re a premium brand of whitening that we use. And it’s just phenomenal, the patients get a really great response, it’s more about the feel that they get that hey, I’m actually using a quality system, the tray design is just on point, it’s a really like thicker trays, which have is a superseal effect. And so I whenever I fit these trays, I’m always impressed at the seal that’s achieved. I was really impressed the first time I use enlightened a few years ago that when the pack came in the delivery, there was like a cold pack with it as well. Because of course, we know that it’s so important to keep your carbamide peroxide or hydrogen peroxide cold, right? So we instruct our patients to keep it in the fridge. So I was impressed even in transit, these gels are being moved around with this cold pack to keep the gels at the right temperature. And I think that could be part of the secret if you like as to why Enlighten, it performs so well and why people get such great results with it and why they can give this B1 guarantee. Whether you use enlightened already or using an alternative whitening brand. I think you can learn a lot from Payman Langroudi, he does a one hour training on teeth whitening. And of course, you’ll get to learn a benefit specifically about what makes enlightened, unique as a premium brand of teeth whitening. So if you go to protrusive.co.uk/enlightened, you’ll be taken to the page where you can sign up for the one hour free training with Payman, who will becoming on podcast soon, because I want him to talk about these things. And I want to make it controversial. I’m gonna probe him and probe them and try and get out and gonna find out is the light, we know people use the in-chair lights on the teeth, Is that even worth it? Like you saw kind of know the answer. But what’s the sort of history behind that our practice is still doing that? What makes whitening more efficacious? Is that the right word? How can we do more whitening like whitening is such a, I want to say, easy procedure. But it’s like it’s a reversal procedure. It’s so safe, and it can really, really uplift patients and give them a much improved smile compared to doing invasive procedures. So it’s something worth checking out. So go to protrusive.co.uk/enlightened to check that out. So again, thank you to Payman and the team Enlightened for sponsoring this episode. And we’re gonna dive right in with Dr. Mike Gow. Main Interview: [Jaz]Mike, welcome to the Protrusive Dental podcast, how are you my friend? [Mike]I am very well, thank you. How are you? [Jaz]Fantastic. And I’m really, really excited to talk about all the themes we’re talking about today. I just think it’s crazy. Right? I’m going to say it now. I think it’s crazy that you can do treatments without local anesthetic. And I’m so jumping the gun a little bit. But I mean, you’re sort of claim to fame. For me, there’s room for bringing you on, is that an amazing accomplishment if anyone doesn’t know, and we’re sort of setting the scene here is, I mean, here I am using local anesthetic to place a retraction cord, right? And you have to have been involved in sinus lifts and immediate implant placements without local anesthetic. And we’ll talk about that today. And we want GDPs and dentists all over the world to learn techniques to manage nervous patients. But what you achieved with that is just mind blowing. Before we jump into that, just tell everyone about a little bit about yourself where you practice. You have a beautiful practice in Glasgow called the Berkeley tell us a little about just you. [Mike]Yeah. So yes, I’m I qualified in Glasgow in 1999. And actually got a really keen interest in in anxiety management right from the beginning of my career, even as a student, I was I was interested in anxiety management. I did my dental while Lexus and hypnosis as well back in those days, and I’ll get into that story a little bit more shortly. Over the years I’ve trained I’ve got masters in hypnosis apply to dentistry from University College London, postgraduate certificate in the management of dental anxiety, as well, Yes, and but you know, my practice is that the vast majority of my patients either are or have been anxious at some point in the past and that’s really the main core of the work that I did with anxious. [Jaz]What attracted you to that? I mean, you said from very early on as a student but what why that, why not orthodontics why not, you’re essentially everything to a very large number you’re there everything, you are there orthodontists, you are always going to be doing the ortho, you’re the oral surgeon, you’re a lot of services to certain people who will probably refuse to go to anyone else. Because, you know, when you have an anxious patient and they like you, they’re you know, we know that they will stick with you. So what is it that? Is it Did you know that hey, this is really important in my career that can be my USP or is this some other factors that made you, you drew you towards the management of anxious patients? [Mike]Definitely. I wasn’t, I guess business minded enough at the time just to realize that actually, it was a great USP to have. What it was actually there was a patient of mine as a dental student who was on the student clinic who shouldn’t have been she was terrified. All I was doing was making a set of dentures. And I still remember to this day all my student colleagues, you know, complaining about patient management and you’re struggling to do certain things clinically. But at the end of helping this particular lady, she was so great. If all that had got her through her treatment, she actually gave me a little Parker pen, this lady was not well off, she was a little old, classical widow, you know. And at the end of the treatment, I got this Parker silver Parker pen with Michael engraved on the pen. And she gave me the biggest hug and said, You’ve changed my life. And from that moment on, I thought, that’s what I want to do. I love dentistry. I do love clinical dentistry. But I love that feeling of changing somebody’s life and with phobic patients, you know, often people that haven’t been to the dentist are often decades, you know, they have no social life, they’re struggling finding work, they’re struggling to find a partner that will confidence, pain, unable to eat, and have very low expectations, they think their life cannot change. And to be able to take somebody through that journey to a point where they’re out of pain, they can chew, and we can smile again. And you know, it’s just, you know, it’s a privilege and an honor to be part of that journey with somebody. So that’s where I get my [buzz] And my kick every time is from how it changes people’s lives. [Jaz]I can definitely relate to that buzz I mean, I think all dentists are all dentists who mean well, who have a kind heart and gentle hands, who the kind of dentist that puts topical anesthetic, you know, there’s some who don’t, and some who do and I just automatically divide those two groups. And I think those who do, you know, maybe I’m saying things I shouldn’t be saying. But I think those who place topical care more than those who don’t, that’s just, [Mike]Here’s my thing, about topical, since you raise it. It is first of all, you’ve got to put it on for at least 90 seconds. So make sure this stuff works, give it a chance. But see, but by using topical anesthetic, you’re telling your patient you care, and you’ll go the extra mile. And for that minute and a half, you’ll buy appreciation, you buy the patient’s comfort, it’s so worth doing every time even if the patient’s not nervous. [Jaz]That’s exactly my mantra and a you know, so anyone listening out there, who don’t use topical, just use it, it just makes sense. It shows that you’re a caring dentist, it’s a no brainer for me, you probably have a, Mike, and just tell me just because it’s fun to know, where it is the furthest a patient travels from to come and see you. [Mike]Oh, my that question. I get patients from all over Europe, I actually saw a, sadly I had a patient who was due to see me from France, but of course they’ve not been able to come. So I think probably European is the farthest but again, this is one of the things Yes, patients will travel. But part of why I want to do that I don’t want to create a patient who believes that I’m the only dentist that can ever treat them, you know, it’s great for my ego, you know, it makes me feel nice. If that’s the case. However, it’s not very useful for the patient, if we go into lockdown, or there’s a pandemic, or, you know, I’m ill or something. So a big part of the journey I take the patient through is to rebuild their own confidence, their own ability to see how dentistry can be. Once they know how dentistry can be and that they have control over it. And you know, I will frequently recommend patients to see other dentists and especially if it’s someone I know, I’ll take them on the first part of the journey, get the majority of the treatment completed, you know, go other patients that will travel from England to see me, I find out where they are. And of course dentistry is a small world, I will know somebody local to them who I knew was an excellent dentist. And I say look, you can see, Jaz, he’s a great guy, he will look out for you. And then they’re not having to come and see me every six months. So yeah, patients travel, but I’m not for a minute seeing that that’s how it should work. [Jaz]That’s very admirable. The fact that you you know you look for that arrangement that you want to build up their confidence that they can see anyone and that’s the real hallmark of patient. Dentists that really cares about their patient going forward as well, because quite rightly said that you don’t want them to become too dependent on you. And I think it’s great that you take them through that process. And that’s amazing. So talking processes tell me you how do you get to a point where you even have the thought of doing a sinus lift without any local anesthetic? Like I’m afraid of the rubber dam clamp to pinch the palatal gingiva and then to sort of feed it and your like all the surgical thing. So tell us, you know, tell us a story behind that happening. Wow, I mean, I can only fathom all the different skills that you need to do that, but how do you do it? [Mike]But I think that, you know, I guess one of the skills is just having the bravado to say let’s make this happen and do it because, you know, as you know, you can use local anesthetic and the patient may still feel something. You know, one of the questions that people often ask me is what would you have done if one of those patients said had felt something? Well, guess what, that’s what we do every day. You know, we’re in that scenario all the time, the patient might feel something at any point, it was exactly the same. And so I guess, you know, first of all talking about pain management. Pain is unique to every individual who’s alive. It’s a very, very complex thing. You know, not only physiological, but emotional expectation, history, there are so many things wrapped up. And not only the experience of pain, but the interpretation of actually what that means. You know, the word pain in itself, actually, the origins of it means punishment. And you get words like penalty, and penitentiary, and all these kind of words from the same origin. So it’s a very, it’s associated as a very negative thing. So the first part of that journey when preparing a patient for something like that is to say, look, here’s the procedure that we are going to do. And the reason why we are doing it is to achieve your goals of promoting your health, promoting the aesthetics, you know, listening through all the reasons why they’re doing it. Now, during that process, your body will give you signals to tell you that there’s danger, something’s happening, there’s a surgical thing. However, you know, that this is a whole constructive, it’s all healthy, we’re doing a good thing by doing that. So you can interpret that signal [inaudibe]. So that’s kind of part of the introduction to how do you interpret the signals. Now, if you watch a lot of people talking about pain management for, you know, surgical situations, using hypnosis, the mistake that’s often made is the talk about seeing you will not feel anything. Okay? Now, I would never even see this if a patient was having local anesthetic, or you won’t feel anything. Because you do, of course, you feel something. But you’re going to feel pressure, you’re going to feel vibrations, you’re going to feel x, y and z. So yes, you’ll feel something. But you’ll be surprised how comfortable it is. Now, actually, if anybody ever watches the video that I did with [Phil Friel?], which was the immediate implant placement, and it’s on YouTube, [throat], the procedure, I’m seeing her loss of pressure, you’re feeling pressure vibration movement. At the end, the interviews says, hey, was that, you know, what was it? Was it painful? And she says, No, no, it was just a kind of, and she looks for words. And she says, that was a kind of pressure. And that’s the word side is using and feeding the whole time interpreting it differently. So first of all, for an extreme procedure, it would be quite difficult if the patient was extremely anxious, because that anxiety would drive the pain we know the more anxious somebody is the more pain that they interpret. Now, if you take an MRI scan, the fascinating part of pain research shows that this is not just the person seeing, I feel that painful. When you look at the functional MRI scan, their brain is firing. And these are the cases sometimes where you know the patient’s in the chair, you barely touched the tooth, or you take out a bit of cotton wool, “Ah that was sore. What did you do?” Okay, now, the chances, I mean, maybe there’s a accessory nerve supply, maybe there’s something else going on. But there is a chance that the patient has actually generated a pain response within the brain. Despite there not being a physical reason why it should happen. The pain is just as real as just as painful. So, you know, the big mistake would be to say, you couldn’t have felt that. [Jaz]Honestly, I’ve had these patients whereby literally, I’m hovering the needle above the buccal cusp of premolar about to give the infiltration like ahhh, and you know, you think oh my gosh, you know, but these are often you know, in my experience, very, very anxious patient, these are the ones that you’re taking out a lower molar, for example, and you’ve given four ID blocks and three articaine infiltration is going lingual, and then just as you’re putting any pressure on that they’re screaming, so my natural instinct, most dentists will think, Hey, you know what, this patient’s just full of BS. But are you suggesting that actually that there are, there is activity in the brain that matches up with real perceived pain? [Mike]100% I mean, first of all, never made the assumption that there’s something that you’ve missed in there, there could be an abscess, there could be [inaudible] could be a reason why they are genuinely feeling something. But I do believe in a lot of cases, especially in very anxious patients, their anxiety drives the expectation and experience of pain, but it’s very real, it’s psychologically generated a bit. It’s just as real as physiologically generated. And that’s, you know, that is something that we have to be super super aware of. [Jaz]Was it NLP? Did you use NLP or, or have you sort of done a program learning about NLP? Or is it purely your sort of hypnosis background that you’re able to get a patient like that. And also I want to know is would you be able to take me for example, I’m not mentally anxious, so he said, I think I am. And would you be able to condition me to potentially have a extraction, for example, without local anesthetic, and not that way that I want to go too much in that direction, because I want this to be really helpful for GDPs. And most of us are not going to start doing this. But I think there’s so much we can learn from what you do. [Mike]And here’s the thing being hypnotizable is mainly about somebody’s creative imagination and their creative ability, as well as expectation and motivation. Though somebody who’s who’s highly phobic highly anxious and is able to generate the experience of pain, despite the fact you’re doing very little is probably quite hypnotizable. Okay, because they’re already doing it. They’re doing it negatively. Okay? So for those patients, I know that yes, hypnosis can help. Now, could I hypnotize you? I’ve got no idea. I would need to know a little bit more about you. On a general assumption, if I know that you are creative, artistic, all those types of things, then I would guess, yes. You know, if a patient presents and says to me, Mike, I’m a professor of mathematics at the local university. Could you hypnotize me? I’m thinking Probably not, because he’s going to analyze everything. And rather than going with the creative experience, you’re going to be questioning what’s happening all the time, and it actually stops you engaging with experience. And someone says, I’m an artist, musician, they tend to be far more hypnotizable. But actually, as I see if someone says, I have a phobia of spiders, flying, water, the dentist, can I be hypnotized? Them the answer is yes. Because you’re already doing it. So it’s a beautiful self selecting group of patients. If someone comes and says, Mike, I have a phobia. Can you hypnotize me? Yes, it is the answer. [Jaz]That’s crazy. Because automatically, I assume that those two patients that you done an immediate placement, sinus lift without LA, I thought, hey, these are not the extremely nervous ones. They’re probably just normal guys that you sort of said, Hey, you know, it’d be really cool to do this. But actually, what I’m understanding now is actually you need that patient who generates those sorts of connections, neural connections that are amenable to hypnosis. So those two patients were, you know, most patient, most dentists would see them as phobic patients. [Mike]Not necessarily one of them actually was quite anxious originally, the other wasn’t, you don’t need to be. You don’t need to have anxiety to be hypnotizable or phobic, you just need that creative ability. And most people who are anxious for phobic have that. But you don’t have to have the anxiety element. There’s plenty of creative people that don’t have anxieties. So it’s more the creative ability. That’s important. [Jaz]Brilliant, so that now I want to get the learning done here. So you’ve talked about these amazing experiences. And if you send me the YouTube link, I’m sure lots of people want to see this. So I’ll put that on the show notes on protrusive.co.uk, so people can check it out. I want to know, what are some pieces of advice that you can give to dentists listening right now to help us tomorrow, manage anxious patients because anxious patients, phobic patients can be a blessing in terms of you know, their patients for life. so rewarding the great feelings that you get, the hugs that you get, the life that you can change, but they’re also the reason you run 45 minutes late, you have to get the tissues out and give it to your patient. The nurses roll their eyes, all that sort of stuff. They’re also they generate a lot of emotions in dentists. [Mike]I think you’re right. But each of the things you’ve mentioned there are things that you would address. So first of all, you know, creating an ethos among your practice of caring for the patient, and actually understanding that these are a really rewarding group of patients to help. And I think, you know, scheduling them at the right time, good communication with care coordinators, you know, all of those things go on massively, and it gives everybody it’s not just me that gets the job satisfaction, it’s the whole team can genuinely, you know, invest in this and feel like they’re, you know, they’re part of changing this person’s life. So make it a team thing, rather than just being about the you know, the connection themselves would be one thing. You know, so ensure that the staff is here and you’re also getting the training and communication and you know, Sedation techniques and whatever else you’re going to offer. And I think having time and flexibility would be the second thing. So I would always avoid if I know somebody is very anxious, I would always avoid squeezing and, you know, for me still the hardest patients manage is a phobic patient NPN squeeze them for 15 minutes. I mean that that is hard. No matter how many NLP or hypnosis courses you’ve done. That’s still going to be very tough because a patient will pick up on the smallest cues of you feeling under stress or pressure or trying to rush at something and the whole thing can just spiral and get at a time quite quickly. So time is really important. And then train, you know, this is one of the things I found interesting when I first embarked on my journey, it you know, dental anxiety management seem to go in one of two directions. So either you were a Sedation Dentist, or you did the behavioral, you know, CBT hypnosis can have side effects. And actually, I found these two different arms very rarely interacted and talked. And it was either the sedation clinic or the hypnosis clinic. And for me, you know, it’s truly to help a phobic patient, it’s about selecting the right mixture of all the things that we can do. You know, we’ve got clinical techniques, you know, injection techniques, learn how to do an Akinosi block, learn how to use computer controls, injection systems, like the ones and make sure you can get it. So there’s very little point in me talking a good game and relaxing a patient and can get it to fit. And so all of that is important. Technology that we have from CAD CAM scanners and impression dentistry is huge as well. Training and pharmacology, so training and sedation techniques, inhalation IV sedation. In fact, that terrified me, I was interested in being understanding the psychology of anxiety. But I knew if I truly wants to help anxious patients, I had to train an IV sedation. And it was one of the best things I ever did. Because, you know, in the right case, IV sedation is phenomenal. And then even on the behavioral side, you know, you have cognitive behavioral therapy, hypnosis, NLP, basic relaxation techniques, communication skills, all of these things come together so that when I’m presented with a new patient, I don’t just think phobic patients sedation, I see myself like, cocktail waiter, okay? The patient presents, and tells me what kind of, you know, we work on what kind of thing is needed. And then it’s up to me to decide how much of this is going to be pharmacological, how much behavior or how much technological, and we make this mixture that’s unique to that person. You know, some people, it’s a pint of vodka, it’s you need IV sedation, and we need to get this stuff. And but it’s always going to be a unique mixture for that person. So that I think is probably the biggest message that I have for people is, you know, train and as many of these different little branches and [ingredients?] as you can because the more things you’ve got to reach for the you know, the, the easier the treatment is going to be for the individual. And that’s part of you know, a few years ago, we developed the International Society of dental anxiety management. And the whole thing about that was trying to have a guess a platform and a place where people could learn lots of different things. So last year, we had a conference, and we had people teaching injection techniques, people teaching rapport skills. It was just wonderful. So that’s the type of thing that again, gets me excited. And there’s nothing you’ll notice yourself doing teaching. It’s nothing more exciting than another dentist coming back saying that thing that you told me I used on this really phobic person who had been struggling with and they’re now okay. And that’s hugely rewarding as well. [Mike]That’s fantastic. I really love the cocktail waiter analogy. That’s just phenomenal. I really love that. What percentage of your day is sedation? What percentage of your day are you actually delivering intravenous sedation? [Mike]And I would say I would actually put that as a percentage of the week more than a day because I maybe have a session a week or every couple of weeks, I don’t do a huge amount of IV sedation, maybe using an equation a little bit more. Especially just no IV sedation. It’s just a bit more complicated with, you know, chaperones and around Coronavirus, it’s just a little bit harder. But I find maybe once a week or once every couple of weeks and generally these are new patients that are needing a high volume of surgical treatments. So multiple extractions or multiple CMD chrome placements, you know, using the TRIOS. So we’re, you know, yes, the big disadvantage really with IV is the patient has no memory of the treatment. Your patients can seem rubbish because I don’t want any memory of the treatment. But if they have no memory of the treatment, then they’ve actually got no foundation to build their future experiences on seeing that was actually okay. So great to get things started. But it doesn’t necessarily help to cure the phobia in the long run. [Jaz]It doesn’t take them through that process of becoming less dependent on you. But it’s a good starting point for maybe a surgical procedure that they’re not maybe something that you probably want to do on their sendation as well, and when you take them through that journey, and they become more trusting, and they can open themselves up to other treatment. And you’ve probably got, obviously, as you said, your whole practice is geared towards that, which is amazing. So Mike has wanted to touch on inhalation sedation, A couple of years ago, I thought before then that inhalation sedation was just for children, right? And I got beat down on Facebook, by some eminent educators in inhalation sedation, like this absolute rubbish. It’s actually used for adults. And that’s when I learned, hey, whoa, there is actually a place for inhalation sedation for adults. So tell us. Can you bust that myth for us about inhalation sedation. And how much of an impact, how much can actually help your patients? [Mike]Inhalation sedation, I think is probably one of the most underused anxiety management tools that we have at our disposal. I believe just now, I may be wrong. So please let me know if I’m wrong. But I believe we’re the only clinic in Glasgow that is offering it at all. And it’s so effective. I mean, it’s great for kids works very, very well with kids, but for adults as well. It’s perfect for shorts, minimally invasive procedures. You know, I don’t know if you’ve ever experienced Nitrous yourself before? [Jaz]I have dental school, they give us a in fourth year, they give us a little go, you know, and it felt amazing, I felt like I was four points down, but not in like, it kind of four points down, but you know, you’re not gonna get a hangover and you feel fresh. It felt really good. [Mike]It did. This is how I explained it to patients. And if it’s a parent of the kids, you’ve got to be really careful as well. So I talked about it being a happy drunk feeling. And I made sure to explain to the kids that with alcohol, you can feel sick, violence, you can get depressed and upset. But with happy gas, it’s called happy gas, because it makes you happy but it’s I mean, it’s gotten me out of many, many difficult cases in the past, you know, it’s occasionally even cases big [10 for IV], where we’ve not managed to find a vein, the patients then being able to proceed with inhalation and actually got on Okay. It’s very, very safe, very, very easy to use. And, you know, it just makes me think why would you not have this? It is not that expensive setup and in practice, very, very easy to do. And you can find training courses through SAAD or the likes of Richard Sheron, who offers training courses in inhalation sedation. [Jaz]Yeah, I’m glad you mentioned Richard, it was it was actually Richard Sheron, who would beat me on Facebook about that, but thank you, Richard, because you taught me something. And hopefully, people listening right now, who may have thought, Hey, you know, inhalation equals children, it’s not the case. Inhalation is widely used in those clinics, they use it on adults to a great deal of success. So moving on. Yeah, [Mike]I was gonna say, just very quickly, when my VT practice, we had inhalation station plumbed in. And that was a little town called calendar, which is up in past near Sterling. And I always remember my trainer, said this wonderful line to me what he said, he said he loved using nitrous oxide for his patients. He said, “You know, you’re anxious, and you’re difficult patients, they need it, that you’re good patients, they deserve it.” [Jaz]But that’s, so your vt practice, you’re vt there, and they had in place sedation as well? [Mike]Yeah, so I was, I mean, that was great for me, I was able to use it, you know, straight from the [?]. [Jaz]That’s amazing. I mean, that reminds me about the book [Outlie], you know, the fact that both Steve Jobs and Bill Gates are both born in 1955. And therefore, when they were a certain age, they were coming to computers, and then for you and your journey, like the fact that you’re already interested in that, and then you’re VT place having in place sedations that only, you know, send fuel to the fire. So it’s amazing. [Mike]If you read Matthew Syed, he talks about that as well [whitebox thinking], you know, becoming a table tennis champion, but actually, the top 10 players in the UK all came from the same street, because.. [Jaz]That was bounce. Matthew Syed Bounce [Mike]So but and that is that is true. And so then [inhalation sedation] as I say, it’s well worth doing and actually not and again, I would never say get into anxiety management for financial reasons. However, the fees for doing nitrous oxide are actually fairly reasonable as well. And not only do you get remunerated for what you’re doing, it makes you faster as well. So for a small amount of downtime at the start while the patient is starting, because it takes a few minutes for it to work, you’ve then got a far easier, more compliance and more relaxed patient and the procedure goes a lot faster. So there is a business model on that as well, which is well worth looking at. [Jaz]Well, I’m glad you mentioned that because then that can lead nicely to another question I want to ask about businesses Look, when you’re marketing because you’re amazing at managing anxious patients, you’ve built a whole practice around it. You’re trained and invested in your staff to come the way they handle phone calls, the way they greet them. I’m sure every All bases are covered. So now you’ve invest in your team and invest in yourself, how do you attract the right patient that will really benefit from you? Is it just purely word of mouth? Or do you do some marketing within Glasgow And how do you I mean, I’m sure, correct me if I’m wrong, but the patient from Europe and that sort of stuff, I’m sure there’s loads of word of mouth going on. But do you advertise? [Mike]We do a little advertising? No, I don’t need to do a huge amounts of anxiety management. What was interesting, actually, when I first came to the clinic that I know, in, and it was a bit of a leap of faith, I’d been working in a mixed practice until that point. And you know, while I trained and hypnosis sedation. So when I first moved to the Berkeley clinic, there was no list. And I thought, This is me, I’m going to establish, Jaz, an anxiety management dentist, and I really had no idea, is there a big enough private market to sustain this? When I knew that 30 to 40% of the population were anxious. But I wondered, are there enough of that population that are prepared to pay a private fee for it? And more or less instantly, you know, the books filled up, it’s, you know, there’s a huge market for anxious patients. And so with regards to marketing, you’re right, a huge amount is word of mouth. And a huge amount actually came from the website that I originally developed, I started a website, as soon as I qualified, called whatfear.com. And it was mainly patient education,. [Jaz]Which I would share was that, Mike? [Mike]99. [Jaz]Wow. So that’s really great. That’s so I mean, so early. I mean, I don’t know, when was Google started? I don’t know. But that was, that’s really good. [Mike]I was right at the start. So actually, there were lots of mental health and self help forums ended up linking up because mine was pretty much the only dental anxiety website out there. So it’s become a bit more businesslike and about me, rather than a general thing about anxiety, because there’s better ones stancil for your central.org is a great one to look at. And it has everything in there. So the website helps Actually, I got involved in helping on [inaudibe] so as answering questions to phobic patients, which of course is the free of charge thing. That’s difficult, because it takes a lot of time. But when you know, I still get patients who have read responses and things that I’ve written within the forum, helping other patients, then know that I’m, you know, I’m caring and sympathetic to anxious patients. Of course, then social media, latterly, in the West is a thing. But I think the anxiety forums is probably the main thing that generated a lot of the business originally. [Jaz]That’s really fascinating. So there we are, for forums, as they were and obviously now so much of it. So word of mouth, you’re probably the go to clinic for that kind of stuff, which is great. The next question I ask is, now we’re getting to a bit where we’ve got to squeeze all this content and people listening, and then we’ll find out more. So now I want to find some learning points. So your name is Mike Gow. And I know there’s something called Gow gates, did you come up with the Gow gates? [Mike]I wish, I wish. You know, the frustrating thing of that is I prefer the Akinosi block. The Gow Gates is a bit harder. The chap who came up with it, his name was Gow, he’s an Australian dentist and the Gow-Gates, the hyphen was his tutor, was his teacher. So Gow-Gates is in honor of his teacher. [Jaz]I didn’t know that. So can you just for those who don’t know, what is the difference between a Gow- Gates and Akinosi? And let’s just focus on one, let’s focus on the Akinosi because he said that you prefer it? Obviously, we can’t video demonstrate exactly what if you just give a brief description. But then more importantly, how if I want to learn Akinosi, I don’t know how to do Akinosi, what’s the best way for me to learn Akinosi? So just covered like the difference and then how to learn that. [Mike]Okay, so the difference the gow gates block is an open mouth block. And after it’s delivered, the patient has to stay open for a considerable amount of time. And often you need to kind of massage and try and move the anesthetic around. So you know all the time when I want an alternative block technique to an ID block. Part of it is a problem with access. There’s maybe difficulty in seeing landmarks so maybe the patient is a bit overweight, and or they have a large tongue, a gag reflex, so the open mouth techniques are difficult in these cases. And the Akinosi is a closed mouth block, which is what makes it sorts of [inaudible]. So you can use it with patients with limited opening, huge tongues, gag reflex. Pure anatomy. Most of us have probably given an Akinosi inadvertently at some point in the past when you’ve been anesthetized an upper eight, and the patient says my lips starting to go numb to the bottom. You’ve kind of done a high block by mistake. So to do the Akinosi, you’re still using the same needles you use at ID block, retract the cheek as the patient close, and you’re actually going in by the height of the apices of the maxillary molars, at the mucoperiosteum, that’s the height you’re going in, you advance the needle hub to aboat where the distal of the seven is. And you’re actually giving, there’s loads of YouTube videos on this as well. So you’re actually giving the block much, much higher. And one of the reasons it’s not taught to us at university is there’s no body contact. So there’s no guarantee of exactly location and where you are. So again, you need to make sure you’re aspirating, you’re not hit any structures there. I’ve never had any issue with it, I have to say, while I’m doing it, and again, because you’re not going through muscle tissue, as you do with an open mouth block, it’s far more comfortable as well. So if I know I’ve got a needle phobic case, I will sometimes that’s my goal, too, as well, because I know it’s going to be more comfortable. And the patient is not straining to open mouth while we’re doing it. So please definitely learn Akinosi. Learning, certainly that our YouTube videos to look at, we do have in clinical training where somebody supervising is of course that you know the ultimate way of learning and nothing. So certainly look on your portals, look online for your CPD courses and see if anyone’s teaching it, we may well run something through as at some point in the future, if there’s interest, we can get acquired, [Jaz]I’m sure there would be, Mike, you know never underestimate the basics. And people want to get the basics right. And I think there would be demand for that. Especially because, you know, I remember back when being a second year student, and how short we all feel petrified of getting our first ID block and your glasses steam up and you can’t see anything and your hands are shaking like this. And now I’m going to stage where you know, you can, most dentist can do everything with our eyes closed. But when he’s trying to do a new technique, even though it’s so familiar, can be really scary. Like, for example, I once read, and maybe you can tell me about this I once read, I think it’s like dental update, or BDJ, that a technique to get your patients to feel that Id block less is that you get into position, instead of you insert a needle, you get the patient’s turn into the needle. But even that I don’t want to change, I don’t want to change anything, right? So it can be quite scary actually, when you’re first sort of doing that sort of stuff. [Mike]Certainly with infiltrations, I’ll move the tissue onto the needle, but my worry was asking the patient to move their head is somebody surely going to shake head one day or, you know, you lose control a bit over so that would be my worry with that particular suggestion. [Jaz]That’s why I haven’t done it. But it was an interesting thing to read, actually. [Mike]I’m gonna say that the Akinosi is simple. It’s not difficult. It’s fairly straightforward. It is like doing an alternative infiltration, essentially. [Jaz]So I’ll find a good video on YouTube, and I’ll link it as well, because people like to see that sort of stuff. So we’ve talked about how you track the anxious patients, [Mike]you’re gonna say, so just [inaudible] this first ID block that I ever gave. And of course you are you’re trying to get rid of the shakes and amend possession, working out my landmarks, the anatomy, and see after the needle, find the bone and coming back. And it’s just as I started to press the plunger, a wasp landed in my ear. So I just very slowly withdrew the needle. And I still [conversation overlapped] [Jaz]Everyone always remembers their first time they did whatever you know your first ID block, I remember my first ID block very well. And so that’s a very unique story. I like that a lot. So last couple of questions. Now, actually. One is tapping back into that story of you doing these procedures alongside a colleague without local anesthetic, and depending on hypnosis, which is just again, just still mind blowing, right? You had some TV coverage, I believe we had like a TV set on camera people come in, how did that happen? And what was going through your mind during that because you know, the whole is a professional team. And if it goes wrong, then it can be very embarrassing. What was going through your mind? [Mike]Okay, well, first of all, there’s been a number of things have done so there was a progression to this story. You know, hypnosis is an unusual thing, as you’ve heard, it’s just one of the balls in the bag, you know, one of the arrows there’s lots of tools that are used, but because it’s more unusual, I’ve kind of become known as the hypnosis guy, but that’s just part of what what we do. And so, you know, I that’s, you know, I experienced some amazing things with hypnosis. And that same first year, when it was working in the clinic with tinnitus. There was a little lady that came to see me who had chronic pain. We couldn’t find the source of it. I referred her to the pain specialists. The company wrote a letter back saying it’s probably psychogenic, and she saw all sorts of pain specialists, had medication, and I said I’d done this basic training course on hypnosis and I said, you know, hypnosis can help. And she just looked at me and said, I don’t think so. Three months later, her husband came back and said, “she is crying herself to sleep every night. She’s in so much pain. Could you try hypnosis with her?” So of course, I got all my books ready roll up lots of techniques. And I was supposed to see her for her assessment. So she came in for this assessment. And on the day, she’s in tears, she said, I can’t stay for long because I’m so much pain. Let’s just go. So I said to look, can I teach you a really quick technique, and it took off about 10 or 15 minutes of visualization technique of imagining her pain was a number on the dial. I asked her if she could visualize the dial, and just turn it up very slightly. So the pain was just slightly worse for a few seconds, and then turn it back down to where it was, it’s really easy. If you focus on pain to make it worse, turned up, and then back to where it was. She could then turn it down by half a number. And then it’s still number. So we played around for 10 minutes with this idea of the dial actually went away. I then picked her next appointments, and I started folding the folded train me my dad’s who works in hypnosis, and I got all these ideas for the techniques and skills to come back in the following weekend said I commenced my appointment, but you’re gonna be a bit annoyed because the pains gone away. I don’t think I need this appointment. And I said, Really what happened? She said, Well, I went home and I was doing the dial. And she said, See when you get to zero, is it meant to click and just never come back? I said a yes. Yeah, that’s fine. So that’s what got me interested in. I mean, I, as an evidence based dentist, I’m thinking is this coincidence? It could have been any number of things? Am I, did I make that up? Have I ever seen this properly. So that’s when I decided I was going to study the Masters because I wanted to know the science behind it. And that led me to that. So once I had the Masters, of course, you know, there’s only a handful of folks in the UK that have a master’s in hypnosis, and that attracted the attention of some of the TV companies. So the first approach I heard was from BBC Three, and they say Mike, we were doing a program about the power of persuasion, could be film you extracting a tooth with hypnosis? And you know, I panicked and thought we’d be creative, be wonderful to show what’s possible. The first tooth that was extracted with hypnosis was back in like the 1830s 1840s says, it’s not a new thing. But that made again made me think why are we still reporting this as this weird new phenomenon we’ve had this skill for centuries, you know. And by also panicked about giving across the wrong impression of Dentistry of hypnosis. I didn’t want people turning up at my door saying, take my tooth out with hypnosis. So the first case i did was actually a filling. And the guy came in put the rubber dam on, we did the dental restoration using hypnosis. And I thought, I have proved that good dentistry can be done with hypnosis. A year or two later, we had another contact saying, We are doing a program called hypno surgery live. And there’s somebody who’s going to be having a hernia repair operation done live on TV, we would love to film you doing a Dental extraction to be part of the show. And of course, I said the same thing. We’ve been doing it for ages. Why do we need to be proving? I thought, you know what, if we’re going to do it, let’s do something a bit braver, a bit more 21st century let’s look at implant placement. And I research that never been done before implant placement of local anesthetic. And I thought if we can prove that you can place an implant with no local anesthetic. Imagine the power that as dentists we have, we use some of these techniques in combination with what [inaudible] you’re using the things together. That’s the real power of it. So I agreed, phoned up the defense Union, is this Okay? Anything I need to worry about? And they said no, as long as the patient’s comfortable, and your local anaesthetic on standby if you need it it’s fine. So that this case with our bedside here, the lady had a sinus lift procedure done, and then the implant was placed. And I thought, that’s great. I never have to do that, again, with placing implants, there’s been done. And then another TV company contacted us and said, we’re doing a program about alternative therapies would love to have an extraction done under hypnosis, if I’m never gonna get away from this extract, right? But I’d still like the idea of the implant placement showing the you know, the more modern dental techniques. So, I was I got involved with Phil Friel for this case, and he came in film and this is the one that is more widely known and viewed, the lady had to her two central incisors extracted and to immediate placement implants placed just using hypnosis and local anesthetic. For me, I thought, you know, as best me, I’ve proved that I’ve done it, I don’t need to do it again. And then just a few years ago, there was one more approach and it was horizon and horizon said, Michael would love to see a dental extraction. From my swan song with this, I’ll do it. So this case was a bit more interesting, the guy I’d never met before, so I had no opportunity to test his hypnotizing ability or prepare on. He came up with the production team from London. And I met him the night before. And then on the day, we extracted an upper wisdom tooth just using hypnosis. So I did my extraction just using hypnosis myself. So that was that when you asked about how it felt, obviously, during the, you know, these procedures, I think in the earlier cases, I was probably more anxious. So remember, you know, the one with , the one with Phil, you know, there is a degree of anxiety because you don’t know what a TV company is going to do with footage if the patient has a bad experience, you know, how does that affect the profession? How does it affect the perception of hypnosis? Actually, the day that we filmed with Phil, we had two patients, so we actually filmed two and they both worked beautifully. So they selected the case that they wanted to use. A degree of anxiety but as I said earlier on, I think as dentists, we are in that position all the time. Our bread and butter is we are doing something intricate and potentially painful with another human being. And it’s exactly the same. So I had, you know, other hypnotic techniques on standby. And these cases, were not cases where we couldn’t use anesthetic. So we had our anesthetic on standby if it was needed, we just prayed we just didn’t need it. [Jaz]That’s amazing. I mean, such a great thing, example profession, I think, and to do it in that in that way. I’m actually excited to share the video with everyone. So I’ve got just one quick fire question. And I want to find out how we can learn more, any sort of the sort of, to the organization that you have as well but wherever you think is the best next step for people who want to get more into either hypnosis or just managing anxious patients, but can you give us one quick fire gem in terms of a communication technique that you can give to any GDP that might benefit and be Yes, how can we learn more? , [Mike]Okay, so communication techniques, there’s language techniques, there’s loads, probably one of the best ones is you know, learn some language skills, avoid saying things like try to patients, try and relax or try and open wider because the word “try” suggests difficulty or you’ll fail. So for kids, just see I bet you can’t open any wider and you’ll get a huge wide mouth. Avoid negative language, you know, don’t think about an Elephant. Elephant is in your head. So don’t worry, that’s what hurts worry this is going to hurt so negative language is a hypnotic technique. You can use it intentionally if you like, but most of us do it the wrong way. So you know, translate things into positive language “relax, I think you’ll be surprised by how easy that you find us today” is a great a great tool. Training wise, for hypnosis, I would say go through you know one of the medical and dental hypnosis societies. In Scotland we’ve got the British society of medical and dental hypnosis, Scotland, and UK, there’s the British Society of Clinical and academic hypnosis. They offer online courses, they offer weekend training courses, and seminars and lots of really cool things. Again, for the general anxiety stuff, the organization that we set up called ISDAM so if you go to isdam.com, there’s also Facebook page for ISDAM as well. And actually, within that Facebook group, there’s experts in sedation hypnosis language and it’s great because often if a young dentist it’s a question and again answers from the top guys in the world at these things about managing the case and their suburbian practice wherever they live. And it’s lovely to see. So join the Facebook group as well. [Jaz]I that’s what I love about these Facebook groups. You know, you mean the one that you said I’m definitely join it and share the Word. But also there are some restorative groups or surgery groups and orthodontic ones and woven and there’s so much wealth of knowledge that we can learn from. So Mike, thank you so much for coming on and sharing your experiences, very unique experience to us as unique for you it’s like a normal for me and the others. But there are so many things that we learn from that and we also touched on tangents like the Akinosi and the Gow-Gates, communication techniques, and how important it is to have the entire team on board and those little micro gains that you can get. So thank you so much for coming on and sharing All that knowledge. [Mike]Thank you. And thank you so much for the invitation. And I guess as a parting word to the, you know, the guys that are watching here, this is a tough time in dentistry and all the things. Things are difficult just know and dentistry is difficult to say with the extra things that we need to do. And but you’re focused on the stuff you enjoy, and try and get more of the stuff that you enjoy and get some of the passion back because there’s a real risk in the profession just now. Of Us losing our passion, losing a vision of what it is we enjoy doing. So there’s lots of patients out there that need your help. And there’s some great work that you can do, just go for it. [Jaz]Amazing. Love it. Thanks so much. Jaz’s Outro: As always guys, thank you so much for listening right to the end. I hope you enjoyed that episode with Dr. Mike Gow. Wow. I mean, I just still can’t believe the kind of stuff you can do with just words and body language and suggestions and hypnosis. It’s just absolutely crazy. And hats off to Dr. Mike Gow, thanks so much for coming on and sharing that with us. Remember guys, my podcast is one the only dental podcast in the world where you can get CE or CPD via dentinaltubules.com. And so it’s great value just for that, you know, if you’re listening and you want to get your CPD go to dentinal tubules. To get that you just have to acknowledge the aims objectives and answer the question. So you don’t have to listen to me all over again, you just go ahead and answer the question. So it really can’t be any easier than that. And if you enjoy these episodes, could you be a massive favor and share it with a friend share it with a buddy. That’s how the podcast grows and that’s how I can find more guests and have the highest caliber and how the podcast grow. So I really appreciate that if you could thank you and join me for the next episode.

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Protrusive Dental Podcast

Episodes

Mentioned books

6 Signs You are a Comprehensive Dentist – IC010

Chrome Dentures Made Easier with Finlay Sutton – PDP056

Understanding Anterior Occlusal Splints Part 2 – PDP055

5 Lessons from Lincoln Harris – PDP054

Which is the Best Matrix System for Class II Restorations – PDP053

Implant Assessment for GDPs: from Space Requirement to Ridge Preservation – PDP052

‘My patients are choosing cheaper, inferior options’ – GF002

Getting Started With Dental Implants – Is it for me? – PDP051

Dahl Technique and ‘Maryland Bridges’ – GF001

What Every Dentist Should Know About Managing Dental Anxiety – PDP050

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