Protrusive Dental Podcast

As our level of Dentistry gets more comprehensive or complex, sometimes it is useful to write a treatment plan letter to your patient. In some practices, this is considered absolutely essential. https://www.youtube.com/watch?v=_sMt7QLaPCk Full episode with great gems from Dr Jorge Cardoso Need to Read it? Check out the Full Episode Transcript below! The problem with writing treatment plan letters to your patients is that….it’s not easy! It takes time. It takes thought. You need to come up with solutions to the unique and complex problems for our patients, and be able to present an estimate of fees at the same time. Not only that, but the letter should ideally be easy to understand, visual, detailed enough to be valuable but at the same time concise enough not to complicate it. Oh and by the way…after all that time and effort, the patient may not proceed with treatment. There goes that Saturday afternoon away from family, totally wasted, right? https://youtu.be/bo-fA-o4OC0 I found a solution. Kind of. It’s called MakeMeClear and it generates easy to understand, visual and beautiful treatment plan reports and letters. Once I got slick at using Make Me Clear, I still found it takes time. There is no shortcut/hack to good treatment planning. But there is a shortcut to creating wonderful letters that increase your case acceptance. Thank you, MakeMeClear! Protrusive Dental Pearl – Do the 21 Day Free Trial for MakeMeClear and do not make the same mistakes I did of not taking action! (It will be more clear when you listen to the episode). All of the Protruserati clan get 25% OFF the monthly or Annual plan with the code ‘protrusive‘! If your dental practice subscribes to MakeMeClear then all of the associates and Specialists can use the same membership. Let that sink in! Thank you to Jorge for this awesome deal. https://youtu.be/pfuG8Q08rck Click here to check out a sample report / example treatment plan letter produced using MakeMeClear. I am joined by Dr Jorge Cardoso, founder of MakeMeClear, to discuss: How and When to Write Letters to patients – is it always? What about when there is more than one option – how can you put that in a treatment plan letter without it being confusing? What is the role of digital smile simulation images? What is you give a ‘global fee’ or ‘ballpark figure’ but things turn out more complex than anticipated? So many great themes of challenges with comprehensive Dentistry discussed with Jorge. If you missed his eBook I gave out in the last episode, check out 16 Steps to get More Treatment Plans Accepted Today. If you enjoyed this episode, you will love Think Comprehensive with Zak Kara. Click below for full episode transcript:  Opening Snippet: One advice that I wish I knew that out when I was starting comprehensive dentistry is that the worst thing that can happen to you is to start to be successful in comprehensive dentistry. That's the worst thing. Because success in comprehensive dentistry brings a lot of complexity. Exactly what you said... Jaz’s Introduction: When you start doing more comprehensive dentistry, there comes a point where just giving a verbal treatment plan to a patient just doesn’t cut it and you have to start writing letters. Now, this can be a very frustrating process. Now, of course, there’s a couple of benefits of writing letters, it helps with patient communication. And I think it really does help the patient’s, hopefully if the letters are good, understand the plan more. But secondly, it’s good for consent. And it’s I know, it’s a shame to say this, but sometimes a letter is not just for the patient, it’s for some potential lawyers should something down the line not go to plan. So it’s both for the patient, and unfortunately, medical legal, especially as your plans become more comprehensive. Now, the problem with writing letters is that it takes so much time like I sometimes spend weekends locked up in my office away from my son and my wife, my family. And I’m just doing treatment plans. I’m actually just doing these letters, and I’m putting them in the right slot in the letter. And yes, you have your templates and whatnot. But it still needs some thought and some choreography within the treatment plans within your pages or Word document or whatever you use. So it takes a lot of time. And it’s particularly frustrating if your patient doesn’t read the letter, or you put all the effort in and you know, the patient never comes back and you’ve invested all this time, but you could have been doing something else. And that’s the biggest issue with that. So Protruserati, today I’m really excited to share with you something really cool. Something has completely changed the way I present my letters now why make my letters now and I’m so so excited to share this how to write crystal clear treatment plan that is that wow patients and are easy to understand. Welcome, Protruserati to Episode 49 of the Protrusive Dental podcast and yes, you finally have a name so the fans and listeners of the Protrusive Dental podcast, you are from now on henceforth known as the Protruserati. And so do a massive shout out to Karl Walker-Finch. That’s Karl Walker-Finch. Buddy, Thank you so much for the suggestion on the Protrusive Dental community Facebook group. And thanks to everyone who send in your sort of messages and emails and sort of suggestions. I love them all I really, really appreciate you. But the one, that one was Protruserati by Karl Walker-Finch. So thanks so much, Karl. The last few weeks have been a kind of funny for me, a family member at home has tested positive for COVID. And soon as I found out, I’ve been isolating. So I’m coming towards the end of my isolation, if you wonder why I’m suddenly making a lot more content is because I’ve been off. So I’ve been quite productive. But it’s also been great to spend more time with my wife and my son. And the usual things that you do. It’s like it is locked down for me because I can’t leave the home I am you know, it’s like what it was in the peak of you know, April. But it’s so much better because I kind of know when it’s finishing. So it’s pretty good. I’m more focus. And it’s nice to know exactly when I’m going back to work. So it’s not been too bad. And I’ve made the most of it, I’ve thought and thankfully my family member is completely fine. And we’re all in good health. And there’s nothing more important than that, because health is wealth. So because I’ve actually had more time off, I’ve also been working on the practice rather than in the practice. So I can now work on my systems, how I communicate to patients. So I discovered makemeclear, which has been just amazing. And don’t worry, we didn’t talk all about that today. And it’s basically a online platform where you can generate these beautiful looking very easy to understand really clear treatment plan letters and reports for your patients. And it’s just revolutionized the way I do my dentistry now, how I present my dentistry. Of course, last week with Zak, we talked about treatment plan presentation, but you still need to give a letter for these comprehensive cases. And I found no better way than making letters than with makemeclear. And I’ve got the founder Dr. Jorge Cardoso on the show today to talk about the genesis of makemeclear. And so the Protrusive Dental pearl for this episode is check out makemeclear, it’s makemeclear.com and sign up for the 21 day free trial. We’re talking this episode about the mistakes I made because when I signed up to makemeclear initially, you do the 21 day trial, but I didn’t actually act until day 16. I had to kind of ask George for an extension because what happened was that I found that when you actually log in to makemeclear, you actually have to do the charting of your patient. And I was massively turned off by this. I was like what I have to chart the patient again like they’re already on my practice management software. Now the chart the base chart again, and chart the treatment plan again, this is crazy. This is not time efficient I thought right? I couldn’t be farther from the truth because when you’re doing comprehensive treatment planning is something that I used to do when I used to work with someone called Dave Winkler who’s a really top guy. Hi, Dave, if you’re listening, who’s also good buddies with Corey Fran top notch dentist in London, and the way they do the letters, they do a tooth by tooth prognosis. So like, you know, upper left seven is in this situation, upper left six, so you’re counting for every single tooth. And that’s like the most ultimate level of treatment planning, or even the most ultimate level of consenting a patient so that they know exactly what’s the situation of every single tooth that’s like the gold standard, right? So when I overcame the fact that it’s a double chart, and when I actually produce my first plan, I was amazed. My reception team was amazed. And importantly, my patient was amazed. And I’m now doing about 15-20 plans now. And I tell you, I can’t get tired of these plans. They’re just amazing. So I want to share with you exactly the benefits of that. But even if you don’t take any action, and you don’t do the free trial or anything like that, you will learn a lot from Jorge. Dr. Jorge Cardoso. Today, he has a very comprehensive dentist base in Portugal. And I kind of asked him questions like, “Hey, does every single patient need a treatment plan letter? Or is it for certain patients? What about photos and simulation photos? Are they a good thing? Are there any downside to that? And what about when you make a comprehensive treatment plan and you give them a global fee then something doesn’t go to plan, tooth fractures, it needs a root canal, How do you account for that? Like, how do you become a better communicator for when things could potentially go wrong? And the fact we discussed in the episode actually is that the more Dentistry you do, the more complex you go, the more things can go wrong. And when they do go wrong, the more catastrophically they can go wrong. So we talk about those aspects of communicating with patients. And of course, me being of a certain ethnicity. I kind of begged Jorge Cardoso for a discount for the Protruserati and I can say he that he caved in. So anyone who signs up for make me clear, as a listener of the protrusive Dental podcast or as a Protruserati, you can get 25% off by using the coupon code protrusive, which is so easy to remember, just make sure you spell it right, because I actually see how people end up on my website and on Google, like half the people spell protrusive wrong. So spell protrusive correctly, please. So yeah, for those who are interested, and they like the software, as much as I’ve loved it, but make sure you don’t pay full price, use the coupon protrusive for 25%. Off. That’s for lifetime. So I hope you guys enjoyed the chat. And I’ll catch you in the outro. Main Interview: [Jaz]Jorge Cardoso, Welcome to the Protrusive Dental podcast, how are you? [Jorge]I’m very fine. Thank you, Jaz. Thank you for having me. I’m really looking forward for a chat with you. [Jaz]I’m super excited. [Jorge]I’m on social media, and it’s your really fun chat to follow. [Jorge]I really appreciate that George. But George today is about speaking about treatment plans. And I think the what we’re gonna discuss i think is gonna blow everyone’s mind because we’ve talked about this already. But I’m really, really excited to share this with everyone else. Because what’s happened since I learned about you and what you have going on keeping the secret a little bit, I suppose. But it really has blown me away. And I’m going to share my little journey as how I went on a high and a low and then a very much a high again, I’ve been telling all my colleagues at the moment, but I want to share this on a podcast. And this is huge, but the main theme, and the title really is how to make crystal clear treatment plans. So we’re gonna talk about that. But before we get into that, Jorge, please tell the people listening and watching where you work, your background, because I know you spend some time in the UK as well. Give us all that background for us. [Jorge]Well, my name is Jorge Cardoso. I got my dental degree from Porto University, which is in north of Portugal. That was in 2002. And in 2005, I went to the distance learning program at King’s College in London. So I did an MClindent in prosthodontics. So I worked through in Portugal and I lived there during the four years I did the MClindent. And then I eventually ended up spending like one week, a month working in London in central London. And then eventually I stay connected. I stayed connected to King’s College where I still do some lecturing. And my private practice is mainly comprehensive interdisciplinary dentistry, which is what I love. And this is also one of the reasons why I make the software was developed. So that’s it. I lived in Portugal and my clinic is five minutes from the ocean. So it’s a lovely place to live at work. [Jaz]That’s amazing. And I just want to touch on one point you made there. So at one stage you were doing your MClindent. But then you’re also commuting back to Portugal. Did I catch that right? [Jorge]Yeah, because the MClindent at King’s College you can do like a two year full time or four year distance learning. So eventually I had to spend in London about, I would say, one month every year during three, four years. So it was manageable. And also I could not afford not work. So I had to because I had just opened my practice. So I was paying the bills of my practice and also doing the distance learning. And it was very nice, because I’ve met a lot of amazing people that are still friends today. And it was one of the best professional experiences of my life for sure. [Jaz]That’s great. And I’m glad you know, you gain from that MClindent, and I’m able to balance working in Portugal. Family life, was that a challenge of balancing family and being away for a month at a time? How was that? [Jorge]Yeah, it was not that I was that mature way, because we went there for chunks for periods of time. So I stay like remember for a full two weeks and come back and stay again for full two weeks. But it was a lot of online work. We had a lot of assignments. And it was it was challenging, because I was just opening my practice hired work for I was at work as an associate for other practices. And I decided to work for myself. And the reason why I decided to work for myself, because I mean, you know that if you want to do comprehensive interdisciplinary dentistry, you have to be in control of pretty much. I also don’t say anything, everything, but pretty much the main parts of the treatment. So I wanted to open the practice and then invite people to come here and work and do like a lot of brainstorming local to be able to perform the dentistry in terms of the standards that I wanted. So it was challenging. It was very challenging. It was very, it was four years extremely challenging, because growing up practice, opening a practice and still studying it was the money, but I gained a lot in terms of literature knowledge, I gained a lot from that. And it was it’s still it is something that I still take advantage on today in courses and stuff like that. [Jaz]And now from doing that distance learning, does that give you a title of specialist? Or does that just give MClindent Prosth like am I right that you need an mrd? Or is that not right or? [Jorge]That does not give me a title of specialty, it gives me a MClindent But what because I don’t practice in London anymore. But if I wanted to, I think that the next step towards working specialty was much shorter. I’m not exactly how sure it was but it was shorter. [Jaz]So overall, with your prosthodontics training, and you told us that your interest lies in comprehensive dentistry. And it’s a topic I’ve talked about in a couple of episodes before about how to think comprehensively as a dentist. And when you can diagnose more, you can treat more and the bottom line of treating more is nothing for me anyway to do with finances at all. It’s for to do more dentistry, the root of what you love to change people’s lives and to make a real difference and impact because single tooth entry gets boring. [Jorge]And to have fun. [Jaz]Exactly [Jorge]Comprehensive interdisciplinary dentistry is extremely fun, all the nuances, all the engineering, all the biology, all the [inaudible]. It’s amazing how you have to contact with all the different specialists. And for me, it really lights me up being able to go to do comprehensive. That’s exactly as you said, I mean, single tooth dentistry, it’s important as you get out of the college. So first you learn to do a cavity then you do a crown, then one veneer, then six veneers. But all of a sudden you realize that most of the patients, most of the actual patients, you cannot solve the case functionally with only six anterior veneers, you need to understand more than you need to understand about full mouth. And once you understand about full mouth, you realize that’s one thing, there’s one big tool that you can use, that makes everything even more complicated, which is orthodontics. And most of the situations that we see today, they need some sort of orthodontic. So once you add prostho, ortho and perio, everything becomes much more interesting and much more fun. [Jaz]I totally agree. And I think 80% of my patients who I view and give me permission to view them in a comprehensive way and plan them comprehensively and accepted comprehensive plan, 80% of them would benefit from pre restorative orthodontics. Now that doesn’t mean that 80% will have orthodontics or accept orthodontics, unfortunately a bit lower than that. But I think the benefit even if it’s minor, 80% of your rehab patients will benefit from orthodontics. I’m glad you mentioned that. I mean, it’s no secret that I love occlusion and learning about these things. And that’s why it’s called the Protrusive Dental podcast, obviously. And I think that was for me the passport into treating bear cases because you need an understanding of how everything works as a system. So that was really important for me, I guess where I am in my journey now is that although I think I’m able to think comprehensively and diagnose broadly, the thing I’m missing that I’ve already discovered that you have is working more with specialists. I feel as though I try and do a lot myself. And I do think that the next level up for me will be to refer out and have a periodontist who I trust near me who I can send that work to, and I think work more multidisciplinary will elevate my level of fun even more. [Jorge]Absolutely. And one of the things that I noticed about your [inaudible], I think that you have the same feeling as myself, don’t you sometimes feel the urge, feel the need to tell other colleagues “Look how amazing this is, look amazing comprehensive dentistry is.” Because you still see a lot of single tooth dentistry. Number one is not the best interest of the patient. And number two, it’s much less interesting than comprehensive dentistry, and has ever seen in terms of, of teamwork. Well, it’s difficult, I have to say that, in the early years, especially when I started, when I want to do my first comprehensive case, it was difficult. And you really have to be really detailed in terms of communication with a specialist. So my advice to you is start to find a team that you can feel comfortable in communicating, it doesn’t have to be the best prosthodontist in the world, doesn’t have to be the best orthodontist, or you just need to have a group of people that want to grow together, and then want to have fun. That’s it. Because if you want to grow together, if you want to have fun, you will eventually be better. You will, of course do some mistakes, you will learn with the mistakes, and we will get better and better and better. I think if you find open communication, I think that’s the way to go. I think communication is the key because everything else. And it’s also very important to have people that are open minded in terms of feedback. I mean, let’s say I’m an orthodontist, and I say “Look, hey, Jaz I think that you should do this this this way.” And don’t mind, I don’t want you to take it wrong for me being able to decide some prosthodontic decisions as well I adult minded to also give you some orthodontic advice, because there’s a lot of ego in dentistry, and you want to find people that can break that ego barrier, and that they can learn with each other. That will be my advice. [Jaz]The whole time. You’re saying that last bit, I was thinking of that episode recently with Richard Porter, about emotional intelligence. And when you’re working in any teams and successful teams, that’s what you need to do. And what you said was being able to take criticism, being able to give criticism knowing that the other person is going to take it the right way. But wait we’re digressing a little bit because right now, I love that little background story we just had it was really fun exchange there. But I want to talk about developing as a comprehensive dentist. When you start diagnosing more, we need better ways to communicate with our patients. And I just felt at one stage in my career that hey, you know what, as I’m becoming more comprehensive, as I’m diagnosing more, as I’m communicating more verbally with the patient, I’m like, hey, this patient kind of needs something to go home and read, right? Because I can’t just tell him everything expect to remember it. And a lot of the buying decisions, and I hate using that term, but it’s true for someone to want to spend X amount of money with you to look after themselves, even if it’s like just biological dentistry doesn’t have to be aesthetic dentistry, even just biological dentistry, they need to sometimes just think about it and have some time to consider things over. So then I started to do letters, which I thought were important. So and the way I used to do it was like, if I have a patient, and I want to find out how you did it, and how you do it now in terms of At which point do you go for letters. And which point is your threshold. Like, do you have a threshold, for example, if today, a patient comes in and they just need one crown and a filling I’m okay with, hey, you need a crown, you need a filling, and I can have that chat in the chair. And I’m confident that I’ve given them a good value and understanding and they can retain that information and get some degree of consent as well from that. But when it gets to a certain level where it becomes a couple more crowns, changing a little bit more than that, maybe definitely if there’s some periodontal surgery involved, when it gets the layers of complexity get more and more at that point, I then need a letter. Now, what is your sort of protocol with that? And what do you advise to general dentist? You know, do should they give a letter to every single patient for every single treatment plan? How do you do it? [Jorge]Well, that’s a very interesting question, because you mentioned something that most of the dentists including myself feel a little uncomfortable, which was the financial part because the dentistry is a branch of medicine, right, but most of the dentistries done privately. So, if you want to do comprehensive dentistry, either you want it or not, even if you are not making that much profit for the dentist, you have a lot of materials, I mean the lab bill is usually very high. So because so the fact that comprehensive dentistry equals very high cost, it does not mean that you are making a lot of money, but you have to face one very important issue which is we are talking about a large amount of money. So if you’re doing, so to be very direct to your question is once the patient needs to spend more than $1000, or $2,000 depends on your own practice. I give them a very comprehensive letter for treatment planning this case may be. If it is a single tooth dentistry less than 1000, less than 2000. What we have in our practice is we have some pre printed sheets where we have a list of treatments, restorations crowns, which is really there, we just feel the total. On the back of that sheet. There are some guarantees of the practice policies, some important information and that’s it. But once you go after 1000, or 2000, or even if you just think it’s a difficult patient, you want some more information, you just go for a comprehensive letter. So my [inaudible] is a financial police when I think it’s very important that we as dentists, we should not be making dentistry for money, I think that’s the worst motivation that you can have, you will be miserable if you do that. But dentistry is an expensive profession, it’s an expensive work, even if you don’t make that much money for yourself, you will still have to charge a lot of fees because of staff, because of equipment, because of lab. I mean, that’s a whole lot of issues involved. But you have to be able to deal with that situation. And another very important here that we may be able to talk later, which is I never tried to sell anything, never. My thing is information. It’s never about selling dentistry. It’s about providing information with transparency. [Jaz]Absolutely. And I agree that now I’ve reached a stage and been like you actually where it is a little bit about a threshold of At what point they’re spending above a level that I think actually too is a significant investment into their health, and therefore to have some written information to just make it more professional overall. And the communication being crystal clear is important in that patient journey, I think so. I agree with you. You also touched on a patient who may be a difficult or a funny type patient. And sometimes there are some patients who just regardless of what they’re having a simple procedure, they just want all the information, the status of their health. And I completely see that as when I see those patients. And I think those patients also benefit with a letter. And also that can sometimes double up as consent as well. But we’re going to touch a little bit on that later. But you mentioned makemeclear. So let’s talk about Makemeclear. So for those people who don’t know, makemeclear is your baby, it’s Jorge’s baby, and is basically an online platform where and I’m saying it as a user, you’re the Creator. But as a user, I see it as an online platform where I can make beautiful treatment plans and letters to my patients who need comprehensive dentistry. Now, I have done it a bit like you so far on the eight patients I’ve used it on. I’ve used it for those who need a little bit more than just one filling. Okay? They need some work. And they find that so much value from that. So to give you to share some experiences about what happened in the first patient I started to use it on, it was a disaster, Jorge, okay. Because what happened is that I log in because you do 21 day free trial, right? I log in and my biggest barrier was oh my god, I have to chart this patient’s dentition again, right. And on the one hand, there was like, a devil on my shoulder saying, Oh, this is rubbish. You know, why do you have to try it again. But on the other shoulder, there was an angel because it reminded me of someone I used to work with Dr. David Winkler someone if you’re in the UK, you may know Dave Winkler very charismatic guy. I used to work with them in Windsor. And he was very important in my journey to comprehensive dentistry. And when he got me to write letters for my patients, this is what he made me do Jorge, okay? He made me take a screenshot of the exact software charting before and after the plan, okay, which is like the base chart. And the final chart, which actually, visually doesn’t really make much sense to patients that is there but then what I did is upper left eight dash, this tooth is an OK condition. Next one, upper left seven, missing tooth, next tooth, upper left six, this tooth has a large MOD amalgam, it is leaking a bit. So every single tooth, my tooth diagnosis was in that letter, okay. And I thank him for that, because it really made me think like, wow, I’m being very clear, a little bit too much. But because it reminded me of that it showed me the makemeslear is an easier way to do that. Because it’s all visual and I was able to chart then I was able to put my treatment plan. And then I click the Generate Report. And wow, the magic happens. So the first patient I use this on, and I didn’t wanna talk about finances, but this is important. It’s a significant five figure sum. Okay, and it just so happened that I saw a space for a new patient exam and I thought, okay, I’ll use make me clear. And then you email me ‘How’s it going? As I haven’t used it, I have to double chart right Baby, I did it. Okay. And the patient loved it. Okay? Patient love that plan. And she’s going ahead, I’m really excited to start her phase of treatment. It’s a full mouth rehabilitation. I might have send you actually, I’m not sure. And then that was my first experience. And then the second is that was that one practice. Now, Jorge at the second practice, here’s what happened, right? This was 4 full crowns two anteriors, two posteriors, okay? And he’s been like he knows he’s got these two root filled premolar is done by my endodontist. And he needs these crowns. He knows He says, I’ve got a big tax bill in January. I’ll do it. I’ll do it anyway. For crowns he needs, okay. His post crown recently came out, he needs it all done. And I made it for him. When I emailed my reception team to email the patient, okay. Then two days later, I had a message from my principal. Okay, let me read it out to you. So the patient messaged my principal saying Hap, so my principal’s name is Hap Gill. He says, “Hap. I have just received the training plan for my practice, and told Debbie that I have never felt so well cared, treated and informed in my life with any other dentist. And unfortunately, I have a long experience. You are brilliant. Thank you. And thanks, Jaz too please.” Okay. And this is the feedback that I got. Okay. Now, Jorge, before I let you talk a bit about your software and stuff. Let me tell you the funny thing that happened thereafter. So Hap sends me this feedback on our practice group chat, okay. And then I make a video I say, Hey, guys, you know what, I use this new software’s called makemeclear. I think it’s amazing, okay. And then Hap calls me and says, “Okay, when you send that letter, okay, it was like 16 pages. And it sounds very daunting, but it’s all very visual, right?” The reception team, they went crazy. Everyone was like, “Oh, my God, have you seen this plan that Jaz has sent?” They were talking to each other And then they told my principal, “Have you seen this plan? Have you seen this plan for the patient?” And Hap was like, “No, I haven’t sent it to me.” And he was thinking, Oh, my God, what am I doing open heart surgery like, This is crazy. And you know what my principal looked at the plan and he thought this is different. He doesn’t do it like this. Here’s more text heavy. It was very comprehensive. And so Okay, let’s try it. Let’s send it and so the rest is history. You know, the patient loved it. And that’s been amazing. So although I had to double chart, I think for me to help me treatment plan. And to present something that’s really valuable for the patient has been amazing. So the really the question here is, firstly, praise for makemeclear. I love it already. And two is, what will your struggles that led you to make makemeclear? [Jorge]Well, it’s fair to mention what David Winkler’s at Windsor, right? I was in his office when they were when [Jaz]I worked with him in Windsor. Yeah. [Jorge]And you know, I did exactly the same thing, I would go to my management software, I did a screenshot on the before I did the screenshot of the treatment plan. And then I would just attach it to the word document and then save it and then send to the patient. The problem is that I was losing a lot of time, but I was still doing the comprehensive treatment plans. But I was losing a lot of time. And that’s when it was it. I think it was like in December 2016, something like it. It was I think it was like three days before the end of the year. I said no, I have to do something. So I started drawing and designing a mock up in Keynote for makemeclear. And then we just talk to some coders, and we just did it. That’s it, I was just basically scratching my own itch. I never thought that would be become a business or software. I never thought about that. But what happens is that in terms of user feedback, there’s a lot of reluctancy. With that, with double charting, there is and some of the advantages to just stop that as well. That’s not for me. But what I find is that the dentists that are taking the higher value from Makemeclear out of the dentists that are doing more comprehensive dentistry, or let’s say things, in other words, then this that understand that in order for them to be able to perform comprehensive dentistry, they have to communicate well, I usually say this, if you’re going to buy I don’t know if you like cars or not, I’m not a big fan of cars. But if you are going to want to buy your fit, the brochure looks one thing. If you are going to buy a Porsche or a Ferrari or Mercedes, the brochure is different. And this is what makemeclear is all about. It’s being able to deliver a treatment plan that is professional, transparent, elegant and easy to understand. That’s it. [Jaz]I like your analogy of cars that because I actually had that same thought like when you go to a car dealership and you’re looking at expensive car, they send you home with all this beautiful documentation, right? So when I started being more comprehensive, making bigger treatment plans, I thought, Hey, I can’t send my patient home with no letter I need to explain so every like orthodontic patient of mine will get a letter. Every rehab patient for sure will get letter and makemeclear has just elevated my letter, I don’t think I’ll ever be able to switch back to my usual letters again, because I really enjoy the visual plans that are made. And hopefully as I’m saying this for those watching, I’ll be able to have some B roll video on showing some some clips from the behind the scenes. But I want what I mean I’ve talked about the software and I’ll touch on it later again. So people know how much I fall in love with them, telling them my principals, my ex principals so everyone’s checking it out now as well. But I want to ask you Next is even within the software as well you can help me, when you have a patient who has a couple of options. Let’s say option one is full mouth rehabilitation. Using crowns and bridges, option two is that with implants maybe? Or the other one is that you know what, we’re just going to conform to the, to your worn dentition and just make your Chrome denture. And it’s a compromise approach, but it’s still a valid approach right? In terms of letters. How do you do it? Like, do you would you put all three options in there? Or would you put your recommended one? And then put the other two in passing? Or just what I understand in your world, the treatment planning? How is that done? How is that handled? [Jorge]That’s a very good question, because it was exactly because of that, that we have in makemeclear, we have added the option of doing stages. So basically, what you can use stages in order to stage the treatment. So these are the basic treatments, these are the functional treatments, these are the provisionals. And these are the files, so you can do sub stages and have subtotals in terms of the value there. And you can decide to hide or to show the prices of the of each stage. And you can also decide to hide or show the overall price of the whole treatment. So you can do it in two ways. One of the ways is you can do like a stage one, but instead of naming it stage one, you just name option one, and you just describe it, and you can name it, option two, and then you just hide, you decide not to show the price of the whole treatment plan. So basically, on the title, you say option A veneers, and undisputable so these are veneers, the difference is this, this and this. And option B, these are resins and the advantage and a disadvantage like this. So the basically the patient said that they won’t be able to say to see option A and option B, option A the price and option B the price. Now, this works very well, if that change of option A or Option B does not make very significant changes on the chart. Because as you were saying one thing is implants and crowns. If you want to do that what you can do one very important to, you can just duplicate the plan. So basically, you do the charting, you do the option A. So one plan is Option A only. So then you go to the back office, to the homepage and you just duplicate that plan, you rename it and you just keep the diagnosis, and you only choose the treatment plan. So then it gets sent to documents. But usually what I do is, I always tried to make everything in one document, unless it is a very different treatment plan. So you can do it both ways. Yeah, the problem of implementing everything in [inaudible] that when you are changing the charts, because of implants versus crowns, you will be then presenting four different charts, which from the patient’s perspective, I think it gets confused. So in that way, it’s better to duplicate the first plan and then just work on the treatments and leave the diagnosis. I hope this makes sense to you. I don’t know if I explained it. [Jaz]it made perfect sense because I’ve used the software. So I didn’t know that you could hide the price per phase. So for those listening right now when you do and I encourage you all to use the 21 day free trial for makemeclear just to see for yourself and have a play around. When you do your charting, and then you’re making the plan. And then you select bridges, you select crown, you select fillings or whatever. The way I have been doing is phase one is like you know, basic restorative, recalls and stuff like that, the provisional crowns, then phase two and I say you know, 6 to 12 months later I will do my final crowns. And phase three is like a splint or something you know, so I’ll make three phases. But what you’ve taught me now is that you can hide the price in each phase and hide the overall price as well. And now it makes sense to me that you can within one document, present three different options because you don’t show the final altogether price because what you don’t want is three different options and give one big global fee adding it all together. Because that’s not accurate. We’re so that makes sense to me. So I’m hoping people who can visualize that. It will make so much more sense to you, if you’d go to makemeclear.com and start the 21 day free trial and just have a play around, see what we’re talking about. But that makes sense to me. So really, what I heard was you like to make it all under one plan, ideally, although there are some challenges if the charting is different, which makes sense to me as well. And then therefore the option to duplicate the plan is genius. Fantastic. [Jorge]I mean, there’s also one thing that you can always do, for example, let’s say I have basic treatments on phase one, and then phase two is different. It says option A and option B. That way what happens is that you may make high the overall price but you can also generate overall price. And then you can also edit the PDF outside makemeclear. And then what happens is so your price will not be 5000 to be, from 2000 to 5000 depending whether you choose for phase two, option one or Option two, but it’s very important, Jaz, that on the description of the stages, make sure that the patient clearly sees that’s options are option a veneer. Option B, resins. Option A, implants. Option B, crowns. Very important place the word option because they want from the sentence option. [Jaz]That’s another gem that because obviously, I had Adobe, the software and the full paid one or whatever. So I’ll be able to open the generated treatment plan and actually do a little edit myself which it makes so much sense. I can’t believe I didn’t think of it. But yeah, I like that. So you then give a broad range of fees, because it obviously will depend ultimately on what they choose. So thank you so much for that gem. Within makemeclear. And I mean, all my treatment plans even before makemeclear, had patient photos on there. So I like the fact that you can add a document with a photo template and you’re able to have these likes or grids where you can upload your photo that was amazing. But just general treatment planning advice? Do you provide smile simulations in your treatment plans? And who do you use? Do you use a company? Do you do it itself? Tell us more about that. And do you give any sort of disclaimers with that? [Jorge]Yeah, so basically, what I want to add as much images as possible because I think that patients they want a combination. Most of the patients they want the combination of charts, simple to read text with the appropriate pricing, and also image especially of their own case of sort of images. I mean, Crowding, most of the people, they don’t they have no idea of the amount of crowding that they have or the condition of some of the fillings on the backside of the mouth. So that is very important. Also, do I use smile simulations? Absolutely, yes, use smile simulations, if you notice on one of the templates, one of the image templates have makemeclear, there’s a template for smile simulations phase before and after. And there’s pre loaded method says this is just the simulation, final results can vary depending on each case. And which program do I use? I use smile cloud from [inaudible], it is amazing software that you can use we use smile designs for the before and after. So that is I use that on reductive cases. So let’s say you want to do some reductive in your veneers, or you want to do some reductive crowns, so you cannot do any editing mock up. But whenever I can, I prefer to use a mock up. Sometimes I do it directly in the mouth. Sometimes I just give impressions to the dental technician and that he does the mock up. But I love to use mock ups for the patient to videos before and after, of course videos, you cannot ever makemeclear collect images. But sometimes I send technically and I also send a link to show the patients, the videos that we have that. It’s also important that you have to take into account local regulations in terms of privacy and stuff like that, even though makemeclear is a software that is approved with the regulation everything, what you do with a document, of course, you have to be as careful as with every other document that has some patient information, we have to look at local regulations, of course. [Jaz]Thank you very much. And you talked about the 2D simulation, which obviously, we found out you’re a fan of but you also talk about the 3d, which is the mock up in the mouth. But I noticed that is very interesting. That sounds like in some cases, for the additive cases, you do the 3d mock up and take that videos and photos and then send the treatment plan makemeclear. Tell us about your workflow. Do you get the patient to cover your wax up at least? Let’s talk a little bit about those, you know, staging or when you do because because it’s a very, it’s called a motivational mock up because it’s highly motivational. So it makes sense to do it first, then I like your is a genius idea to send them the video, it makes even more sense to me that hey, you know, to use an app or something to get the two video before and after side by side. That’s a pretty cool thing to do as well. But if you have that information at the same time as sending them the plan, that’s a good idea. But how do you do it? What’s your workflow? [Jorge]So that’s a very, very interesting question that I get asked a lot by students, and it depends a lot on your own personality. Well, let me give you an example some of the most outgoing personality in terms of dentistry, they just tell this patient, the patient comes in for the first time he said, Well, I like to do something, I’m not even gonna charge you for that. So basically, it’s some impressions or oral scans. And basically, they asked dental technician to do some aesthetic mock up. And in most of the cases, they have an agreement with a dental technician that they will not be spending too much time on the wax up on the digital wax up. It’s not a functional wax up, it’s just some buccal veneers. And then you just do a key and you just sneak on index and on the second appointment, you place it in the mouth, and then you start talking about treatment planning and money. Well, I think it can be very effective. I think it’s mostly respectable, but I think for me for my own personality. It’s a bit salesy, you know, I mean, it’s not very, I prefer to do Following, I prefer to ask it, to tell the patient Look, the patient comes in for the first appointment. On the second appointment, I will not charge it, I will not charge it. And what I will do as well, what I am thinking is about this, this, this, this and this. On the second appointment I talk. First I talk about the treatment plan, and then I placed the mock up and then do the recording, I don’t want to be talking about,.. [Jaz]But I just want to check, maybe misinterpret. So you will see the first patient for the comprehensive diagnosis and new patient examination. And then the second appointment is that to explain the treatment plan or is it’s purely for the mock up? [Jorge]To explain the treatment plan. To explain the treatment plan and also show them the mock up. And on that second appointment, I myself I assume the costs of the mock up. But remember, Jaz, that mock up is only an aesthetic mock up, what I don’t like to do is I don’t like to the patient comes on the second appointment, they get placed a mock up, and then they just start talking about money with a “Oh, in order to get this result. It’s this this this.” So I want to be able to, I want to provide more information, I want the patient to understand why am I going to do a mock up for them to realize what we are talking about. I don’t want to play something in the mouth And then to start off because I think it’s a bit awkward. It’s I mean, I don’t want to have I would not feel very comfortable to have someone placing something inside my mouth without explaining the why that will happen. I understand the emotional dentistry part of that and understand that. But for my own personality, I don’t think it does work. So to sum it up, I think it depends a lot on your own philosophy and personality, there’s a lot of combinations, you can do it directly without spending money from the dental technician but spending share time and it improves your skills with composite. You can do it indirectly in the lab, but then you have to negotiate with the lab “look, I want you to be able to do me mock ups, aesthetic mock ups only for the six or seven or 10 into your deep, but those are only aesthetic. So let’s agree on what’s a reasonable fee. So that that I can either charge or not charge the patient, but also be vulnerable to the fact that they will not accept the treatment plan and I might lose that money.” So there is no way I’m going to do a functional mock up, a functional full mouth mock up without the patient have access to the treatment. So if I do a mock up with lab costs, it has to be real. And it’s only a aesthetic. And you can also use only 2D, if you don’t feel comfortable about 3d you can only use 2D me. I think it depends a lot on your own personality on the philosophy of your own practice. What I never do, I never charge the patient a second appointment. And I also know I know if it happens out in UK or not. But here in Portugal, there’s a lot of dentists and clinics that are doing treatment plans for free, which is something completely for free, which is something that I don’t agree, because I think that when you are doing something for free, do it very fast, and you are not going to do it well. It’s impossible to do comprehensive dentistry, a good treatment plan, doing it for free, because you’ll be losing a lot of time. It’s almost impossible. [Jaz]So I agree with you. Absolutely. I agree with you about a comprehensive exam requires so much energy and time and, you know, expertise that yes, it shouldn’t be offered free. But I just want to hone in on the real amazing gem that you shared, which is a real takeaway that I learned just now from what you said as well is to negotiate with your lab, in a non confrontational way. Now you’re probably buddies, a lot of us listening, and on very good terms with your lab, and just explain what you’re doing, why you’re doing it, and get them to see the benefit that hey, this may improve case acceptance. And guess who you’re going to be doing the indirect work with, that laboratory, obviously. So I think there’s a good relationship win-win with a lab like they can give you a significant discount on an incisor facial mock up additive, so it’s not a functional, they don’t need to worry about the occlusion just make it look nice. So they can clip on, if you like or just with Bis-Acryl. But also, is something fun to show the patient on the day as well, which I think is genius. But you on that second appointment when you’re about to place the silicon key. Do you have, you already made your makemeclear plan at that point. Right? Okay. And then you will follow up with the plan with the videos maybe from that appointment? [Jorge]Yes, I showed them the plan. And I said, Look, there’s one very important sentence that I use all the time and it relates to the question, well, should I talk about money in the beginning? Should I talk about money in the end of the explanation? For many years, I talk about the money before explaining the treatment plan and some people have given Well, that does not make sense. You have to talk about where to go through treatment plan. But sometimes it takes 10 minutes to go through the treatment plan and some patient are just they’re just waiting. So I think there’s a balance. So I usually say, Well, you know, I mean, you have what, ideally what you should do in your mouth, it’s almost the price of a car. So the treatment, and I’m gonna present you as an approximate price of this. And look, I am not here selling you anything. My goal here is purely giving you information. So my goal today here is providing you accurate information. And in these sorts of cases, sometimes I would advise patients to go for a second opinion. So I’m going to give you all the information, what is happening in your mouth, what will happen if nothing is done, and what can we do and what will be my proposed treatment plan, and then you can decide at home, think about it. And if you have any doubt, just call me. So now and after that I go through treatment plan. And so basically what I do, I lower the pressure, I lower the stress levels. So if I am on the patient shoes, the patient said, Well, this guy’s not sending me anything. I may accept it. I may not accept, but let me listen to what he has to say. Because all the pressure, all the expectations go down. Okay? So we can have a conversation, a transparent conversation like to normal people, because businesses should always be in a win win situation. And I don’t want to scare the patient for 10 minutes, Dentist talking about this, this, this and that. Well, now it’s 20,000. So I think it’s fair to talk it in the beginning. But I accept the critics that said, No, you should talk it at the end. And once I say that, well, now I’m going to place it in your mouth, something I want to do a short video, if you have a studio, do it with a studio, if you have even a cell phone is okay, just recording the cell phone the before and after, place it on the keynote, exported the before and after and sell it together with the treatment plan. I also create the treatment plan and deliver it to them, some patient they don’t want the paper Of course, some patients want the paper. Some patients, I think it’s important what you say in the beginning, they want to have something that they can take home and show their families. Look, I went to this dentist, what do you think about this? Do you think I should spend this amount of money? Well, let me see. So sometimes they in the [inaudible] reading a treatment plan. Because it’s like you said, one of the reasons that you click on the report and everything generates itself because there are some automated descriptions that appear. I mean, if you lose a tooth, this is what’s happening. And this is all automated, but you can also customize it. So I think for me, the best way is to I would I charge the first appointment, I collect the data, the second appointment, I will not charge I have an agreement with the lab. In some cases, it is possible to do the 3D, some of the cases with additive it’s only the 2D, but I try to play around with that, in my opinion, even if even if you spend some money on the wax, the wax up at the end of the day, in a statistic way, you will always be benefiting from that financial, always, because the amount of treatment plans accepted by your patients will absolutely In my opinion, if you are competent, and if you are honest, they will improve and you will have more and more patients for you. And another very, very important thing, even if they don’t do it, because they may not be financially prepared to do that. They will advise you, they will tell their friends and look at this guy, very professional, very elegant treatment plans. And there will be lots of of referrals from families. [Jaz]I 100% Agree I mean that that little message that I read out from the patient, I my first patient at the second practice, or I work at one day a week and look at the message that he sent to us saying that, you know he felt so cared for. And totally whenever someone mentions, hey, I’m looking for a dentist, he will think, Hey, I know a very comprehensive dentist who is very good communicator. But just want to highlight three important things I just learned from what you said, Okay, I want to just highlight it for the listeners again, because I think they’re just gold. What you said basically, A) is that I didn’t know that within makemeclear that you can edit the bits of for example, for those who haven’t used makemeclear when you do the diagnosis for missing teeth. I didn’t know you could edit the diagnosis. So I’m going to totally go and edit the different diagnosis in my own language, my own style. So I’m Oh my god, I’m so excited to do that. I sound like a massive geek. I know. That’s one. Number two is I like the fact that the way you communicate money to the patient, is that you explained to them upfront in a way that they can bring that guard down because if they’re all they’re worried, worried worried, oh my god, oh my god, how much it’s gonna cost? how much gonna cost? And you’re telling him all this stuff they’re not taking in. But if you can tell them and I love the way that you told them, You anchored it to a car, right? And then of course, a car can cost 800 pounds, it can cost 80,000 pounds, right? So I like the anchor because it gives you a range as well like a car, it can be anything. So I like that it gives them an anchor to work with that also allows them to just get that out their system and then listen to what you have to say. So those are three little things that I got from you there. So thanks so much for sharing that. The next question, Jorge, I have is and we’re down to our last two questions. The next question is the more comprehensive dentistry I do, the more couldn’t go wrong during the treatment. So for example, no, it’s true, right? Like Imagine you’re doing like eight crowns, maybe one will need a root canal halfway through and maybe one as you remove the core everything will just break and you find out hang on this tooth is actually unreasonable or whatever, right? Like this happens, it’s part of dentistry, it’s part of comprehensive care. A) how do you communicate that to the patient? And B) just out of interest, Do you absorb that cost when something goes wrong? How do you like to do it? Because I know like one of my principals, Hap remind me saying very comprehensive dentist, has lots of big treatment plans and is very much a full mouth dentist. The way he does it is that he sets one fee and he I really like one sentence, he writes in the letter, which I’m probably going to automate and introduce into my makemeclear now that I know that we can automate it so much, which is that, hey, you know what, I’m giving you this global fee. And just understand that if any little hiccups come along the way Don’t worry that this fee is to cover you anything you might need, except an implant like that, for example, and I like that way because it gives the patient the peace of mind that you’re going to do everything but how do you do it, Jorge? [Jorge]Well, I like what you say because there’s this one advice that I wish I knew that out when I was starting comprehensive dentistry is that the worst thing that can happen to you is to start to be successful in comprehensive dentistry. That’s the worst thing because success in comprehensive dentistry brings a lot of complexity. Exactly what you said. I learned I saw one one presentation from Paul from the state and he said it single tooth dentistry is proportional. I mean, what you gain depends a lot on the amount and the problems depends on the amount of work that you do. Comprehensive dentistry wants to increase the vertical dimension. Once you place ortho, it’s exponential. This means that the amount of if you are doing 10 crowns in comprehensive dentistry with increasing vertical dimension [inaudible]. You cannot charge 10 times 10 crowns. You can’t do that. You have to charge provisionals, you have to charge articulators, you have to charge the try ins, you have to make yourself safe. And what I do I place, I always paint the worst case scenario. Most cases won’t happen. But I place the worst case scenario, if there is a tooth, that is doubtful, okay, so I also place in the playroom, we may eventually have to place an event on the stick with an additional cost of x. But if I have not mentioned that I absorbed the cost, I’d never, I always tell the patient Look, I never I would not like to play a game that someone changes the rules of the game in the middle of the game, I don’t like that. So I will not change the rules of the game, this is the amount. And from then on up to this amount of this worst case scenario, we will absorb everything if anything happens. And I also talk about about warranties, I guaranteed my word for it for some period of time, I think it’s this is controversial. But for example, I give my ceramics three to five year guarantee depends on a functional risk, I give my implants a five year guarantee, as long as the patient is coming for maintenance, I give my restorations a two year guarantee. And I do it for every single patient, I understand that dentistry is medicine, and each person is a person, but you have to be able to talk their language, they have to feel comfortable. And we Indian, one thing I always tell my team, if you are doing a remake of restorations, it’s the best marking that you can do if it’s within the guaranteee, it’s the best marketing maneuver. And you should be doing that with a very happy face. So we do the restoration, very happy face, you have a loyal customer for the rest of your life. [Jaz]I like that mindset. Because this whole thing about whenever you’re produced with a challenge, you should see it as an opportunity. So the challenge is the patient broke your crown after a year. But this is an opportunity to really wow a patient to show them that you care. And then they will sing and shout from the top of the world for a second time. Hopefully, that hey, you know what this happened, but they looked after me so well, like all the best customer service places obviously have that. And I like the what you touched about. You will cover everything up to the point of the things that you mentioned in the letter. So yes, for example, my principal, he mentioned about hey, you know, if anything go wrong, Don’t worry, we got you. But then I think if you mentioned things like but for this [inaudible] root canal, I want you to budget for this amount, because in case it needs it, and suddenly I learned from Lincoln Harris as well actually that actually every deep filling every crown he does, he’ll always give the fee for the root canal to go alongside it, it really just like you said, gives the worst case scenario. So I think that’s a great answer. So now we’re down to the last question before we just have a little chitchat, which is what are the ways that you used to present treatment plans before makemeclear? And what’s the number one thing that patients have told you since you design makemeclear and now you’re using that? [Jorge]Well, I think the number of questions and agitation from people has dropped dramatically. I have received letters from dentists, customer that use the makemeclear said Well, I’ve had the lawyer that call me say look I have never seen such a well written dental contract as I’ve seen you, because lawyers they are very sensitive to letters and stuff like that. If you do if you present a comprehensive treatment plan to a lawyer so ah this guy really knows what he’s doing. And the amount of respect that you spent, that you get from patients is huge. Like I said, even if they don’t accept it, they will they will refer you. Absolutely. You will be referred to I have no doubt. So what was happening before and what is happening now. First of all, I feel my stress level is high up until the moment that I do the treatment plan and sent to the patient. Once that happens, that stress loss. Why because after that, I only need one thing, execution. So the most difficult thing is doing the map. If I know the map, if the patient knows the map, and he accepts it, then we just have to execute it. But the level of stress diminishes, was also one thing very important is that with makemeclear everybody, especially if you divide the treatment phases, everybody knows what they are doing in which stage of the treatment plan which is something very, very important. [Jaz]This is so good. Because it now that I’ve been making the letters and I’ve been breaking into phases, I’ve been thinking, hey, when I come to do the treatment, this going to help my nurse so much, know what I’m doing what to set up for each appointment if you like. And also, you know when you’re in a busy and practice, see some of the patients, and then Mrs. Smith is coming she’s you know, a more comprehensive plan. And you’re like, wait, what are we doing today? We decided we’re doing, where are we? And when you have it documented in a letter like the one that you can produce with MMC. It’s not just for the patient, it’s actually benefit for you as a dentist because you can Okay, we’re on phase two, somewhere around the middle. So that’s a really great point you raised there. And I think this might be a good point to say to those listening is that please do the trial for the makemeclear and see for yourself. But don’t make the same mistake I did. Because the mistake I made made was I got scared by the double charting. But I want everyone to see it as an opportunity to A) be as comprehensive as possible and B) when you do the charting there and really is it gets quicker and quicker. I’m on like a patient 8th now. And I’m pretty quick now. Because once you know what you’re clicking stuff on the left and apply to the right, it becomes quicker and quicker. And the second thing is that when you’re doing the treatment plan, you’re doing the whole thinking process. So every patient you get you treat comprehensively you have to sit and think and you have to think okay, am I doing a crown or a filling? Okay, how much am I raising the vertical dimension, if you do all the hard work, then just like you said, when you’re producing letter, and you produce a beautiful letter, just like you said, the rest is just actually carrying the dentistry out. So the hard work is done as part of making treatment plans. And it’s part of communicating with the patient. So everyone, don’t be scared of the double charting get good get slick it and my plan for the future is to teach my nurse how to do it. Because to be fair, one a part of my workflow is when I take my full photos, sometimes when I’m speaking to the patient, my nurse has already rotated the photos and she is now doing the charting already on the system. Because I can check this caries and whatnot already. Medical legally the charting so you can be do from the photos, basically. And I think to use the MMC visual format, I am confident that my nurse will be able to do my charting for me as well, then I need to go and make the plan. So everyone, don’t be scared of double charting, use it on your patient, generate the report, send in the report and just you know, see how amazing is now. Jorge, you have been very kind to offer those who listen to Protrusive Dental podcast a discount, I really appreciate that. So the code is protrusive. And that will get them 25% off. Is that right, Jorge? [Jorge]Yeah, if you can use that you can use a 21 day free trial. And we also have a special special offer for you being such a kind friend for makemeClear. And if you use the protrusive coupon, you’ll have a 25% discount, either on a monthly or on the yearly plan. [Jaz]I mean, that is amazing. I mean, put it this way, the first patient that I gave the plan to and she’s accepted. And since then I’ve given seven other plans. And one I got the feedback and obviously in 2021, he’s going to head that plan as well. So if you just get one comprehensive plan, how much is one comprehensive case worth you, when you get that approved Because maybe the difference was that letter and how good it looked and how professional it looked. But also saving the stress going in the future in terms of following where you’re on the journey. I think it’s amazing value. And honestly, Jorge, thanks so much, 25% is a massive discount. So really appreciate that. So the code again is protrusive and only for those who listen to Protrusive Dental podcast. Jorge, The other thing that I actually watched one of your recordings on YouTube that you did with another podcaster I think and you guys talked about well actually he meantioned it, That, if you have makemeclear as a principal as a practice, then all the associates, all the dentists, all the specialists within that practice, can use the same account, which, for me, like you’re doing yourself out of a lot of business a lot of money, I think, personally, but I think wow, what it makes it even more like whatever, comparatively low fee it is when you break it up against five dentists using it and using it consistently. I mean, that’s amazing. Thank you for making that happen, I guess. [Jorge]So the thing is that you basically, you will only be limited by the logo that you place on the front page, if the logo is the same logo in the practice. I mean, you can use it for as many dentists, as many users. Everybody can use it. [Jaz]What I’m doing at the moment, Jorge is as I’m an associate, right? I’m associated to connect. Okay, so the way I use it is I have my own dentist logo. Okay? And then what you’re able to do within that is I’m able to change the address of the practice, as I send out the plan. So that’s what I’m doing the moment but I can totally see it. Like if, for example, if tomorrow, one of my practices took on makemeclear, which I think Hap probably will, because he was amazed by the feedback of the patient. And then of course, the Richmond dentist logo will be on there. And then all the other dentists that all the four associates that we all can use that as well. So it’s really a great deal in that way. I think. So that makes sense. [Jorge]Yeah, you’re spot on exactly. We have users that are dentists that are working several practices, they use it for their own. So they just changed the address of the practice, they have their own logo as a dentist. And we also have practices that all of the dentists that work in the practice use makemeclear with only one account. So you can use it both ways. Basically. [Jaz]Brilliant. [Jorge]You can access it anytime simultaneously, you can access it, as long as you have a desktop that you can access with internet, you don’t need to install anything, it’s all done through the browser. So it’s very easy to use, we always wanted to make it simple to use, we don’t want to over complicate it, because there’s a fine balance between the features and simplicity. And we always strive for the simplicity, because sometimes the most complex things are and sometimes they don’t really have that much you want to have something that can really make your life easier. [Jaz]Jorge, once a patient’s accepted a treatment plan, right? And it is comprehensive dentistry. What I like to do is every phase I like to send them like a table almost. Appointment one, what I’m doing, how long it is, and then the next appointment, what should the space be between that so it takes me a bit of time, but I do it for the patient, but I do it for me and my nurse as well, because we know exactly how long the appointment is, what we’re doing, and I can follow that journey along as well. A) do you do this for your patients? And B) do you see any any value in that? Or do you think I’m wasting my time? Or is there any other way that you’d like to do it? [Jorge]I think this is the you have to, what the patient wants is practical information. So what the patient What will he want he wants to know? How long it will take the appointment specially if it’s a longer appointment? for example, I say well, this is these are the basic treatments. This is some restorations. If you want I placed on these descriptions of the stage, if you want we can make this in a full morning or a full afternoon we can take care of everything. And then let’s say for example, we place the implants on phase one surgery, phase two crowns over the implants. So, what we say on phase two is this, this phase will only take place six months after phase one and it will be needing like three or four or five points. So, as with your question, absolutely, you have to provide as much practical information as possible and be very simple in that information. So, this will be like a long appointment, this will you will have to wait for three months before going to stage two. So this phase should be done before the other phase or should be done after the two phase like to provide as much as practical information. So when you place yourself on the patient’s feet, what you have to do, you have to look at what you are reading and being simple to understand. So this is A, B, C and D these are the conditions from go from A to B but you have to be as simple as possible. Make it as simple and as concrete as possible with the most practical information of course. [Jaz]Jorge, thank you for coming on this journey and talking about a lot of different elements of patient communication and writing reports and letters and what should go in your letter and what about when you talk even about warranties and you mentioned all these other things that we didn’t scrape for and gave so much value. Any closing comments, my friend? [Jorge]Well i think that the reason why I created makemeclear is also because of a philosophy of communicating with patients and I think that dentistry in recent years is drifted into a lots of marketing. It’s a lot of easy and fast treatments and the reason why makemeclear was developed, it because I didn’t want that dentists that want to do comprehensive dentistry that the patient actually needs. I didn’t want those dentists to be into a disadvantages of the clinics or the banks that are much more salesy, that are much more aggressive in sales. So if you want to do comprehensive dentistry, please be hopeful dentistry that is comprehensive is beautiful, and you can do it at speed. But you have to develop communication skills, makemeclear is just one tool to help you become more transparent and more and to improve the efficiency of your communication to be able to the dentistry that you love. [Jaz]Amazing, Jorge, thank you so much for giving up your time. I know you’re so busy in Portugal in your clinic and stuff, but thanks for giving time to speak to listeners about how to make crystal clear treatment plans that’s going to woo the patients just like it has my patients and oh my god, I’m so glad I discovered makemeclear and I’m really excited. My principals can see it. I mean, when I come into work, and I made a new plan. I want to show my nurse, I want to show my principal, and the patients are just completely wowed by this. So thank you for making makemeclear. And thank you for making it all clear. I really appreciate you having on stage, Jorge. [Jorge]Okay, well, thank you for having me. It’s a pleasure for me. Sometimes I feel that comprehensive dentistry is something that is going into extinction. And especially with guys like you that are a lot into functional dentistry and are spreading the word of how fun functional and comprehensive dentistry can be. So I thank you so much for having me. And I hope that we can collaborate more in the future. Okay? Thank you so much. [Jaz]Thank you. Jaz’s Outro: Protruserati, thank you so much for listening all the way to the end, I really appreciate you. Do check out the show notes on the website where you can download an example report that’s been generated. So the URL for this episode will be www.protrusive.co.uk/treatmentplans and let me know how you guys get on with a makemeclear. Remember, don’t sign up for it unless you’ve got that, you know, a string of patients that need that treatment plans that if you’re going to take a two week vacation, not like anyone’s going anywhere, but maybe when you listen to this in the future. And you think hey, you know what, I’m going on vacation. And then unless you’re actually doing some treatment plans on vacation, don’t don’t sign up because I wanted to get the maximum benefit from the trial period, which I sort of neglected initially. But when I came around to making these plans, it’s been amazing. And I hope you guys enjoyed the chat with Dr. Jorge Cardoso today, and hey, next episode will be Episode 50. How about that? Okay? So I raised about to 50 PDP episodes, but I’ve got a few other things. There’s something called group function coming out. So I’m coming up with some called group function, which will be the third arm of the podcast, which is where when we ask questions as a community, so anyone in the Facebook group that asked a question, sometimes it’s a good way to answer the question, working as a group. So hope you like the name group function, and I’ll catch you in the next episode. Thanks so much.

Do you make ‘shotgun’ treatment plans? A shotgun treatment plan is like a shotgun wedding. It is rushed, on-the-spot and poorly consented.. https://youtu.be/mAnXcTUdFuM Shotgun Treatment plan vs being Comprehensive I am back with a Fan favourite – Dr Zak Kara who absolutely bamboozled with his communication gems from episode 10 (must listen if you have not already!) In this mammoth 80 minute episode we dissect how to PRESENT treatment plans to patients. Should we use their chart? Should they get a quote for extensive work at Day 1? Should it be at a second visit or all at their first visit (after all…this what they expect from us, right?) Do we need a separate consultation room (LOL)? https://youtu.be/cFHE2nnCM5E FULL episodes only on the main website and on Dentinal Tubules for CPD/CE Protrusive Dental Pearl 1: ebook Download for 16 Steps to get more Treatment Plans Accepted Today Protrusive Dental Pearl 2: Thank you for Mini Smile Makeover Composite Course and Enlighten Smiles for sponsoring this episode! Need to Read it? Check out the Full Episode Transcript below! I talked about my favourite composite instrument I learnt about from attending Mini Smile Makeover – it is called the CASI 3C and it is the perfect non-stick instrument for anterior bonding. Those in the UK can get this from Enlighten Smiles, and those in the USA or Worldwide can get it from their Cosmedent supplier. https://youtu.be/Ob9srJZu3hM The CASI 3C We also discussing about getting comfortable talking finance with patients – what are our limiting beliefs about money and fees? Is that holding us back? It did haunt me for many years… Do we need to give exhaustive documentation afterwards? What is the point of all this? What is the patient and you do not share the same ethos and values? This is the App Dr Zak Kara mentioned he uses: DDS GP only on the App Store What I loved about the episode was learning why Zak DOES give an itemised plan for Phase 1 treatment, but not Phase 2 or 3: https://youtu.be/plIpA6AjtBg If you gained value from this episode, be sure to subscribe and share it with a friend! If you enjoyed this, you will of course love Zak’s first episode on Protrusive: Think Comprehensive! Click below for full episode transcript: Zak: Jaz, the other thing is that it's not just because I'm a caring, sharing kind of guy. It's actually quite selfish without being a nasty person about it. I don't want to treat people who are a pain in the ass. And if we haven't got a connection at appointment two or appointment three, well, I'm cool with cutting all losses at that point, because I don't want to have to get to appointment 10 and find out. Jaz Gulati: How do you like to present your treatment plans? And I mean that like, in terms of your body language, and your verbal communication, and your written communication. Do you just say, hey, you’re gonna need three appointments and it’s a crown and the splint and that’s it? Or do you like to take a screenshot of their chart and you print the appointment schedules with the fees there? Or do you like to just present verbally and that’s it? Or do you like to invite them back for a second visit? We can show them all the photos and present them all the options. And they walk away with 78 pages of a plan. Now, none of these options are wrong or right. It really depends on. Your workflow, but I really want to tap in to Zak Kara’s workflow because he is someone I admire so much. I do believe he has mastered the art of treat ment plan presentation because he spent so much time focusing on this one element and of course he is a massive fan favorite. So, Protrusive Dental Community, I still don’t have a better name for you yet. Welcome to episode 48 of the Protrusive Dental Podcast. I’ve got Zak Kara on today who 38 episodes ago. So episode 10, he came on and wow, like his episode was so popular. That’s like an almost like a gateway drug for the rest of the podcast. Like once you listen to his, you get hooked. That’s how good and that’s how big of an impact it had. And for a long time, it was second in terms of the most listened to episode. Just behind restorability with a restorative consultant. But then of course over time it’s actually became the number one spot until of course Jason Smithson come and came along and we talked about onlays and vertipreps and then Jason just blew everyone else out of the water. So that’s that. But hey, Zak is a massive fan favorite. You may have heard me mention his name so many times before and I’m so stoked to share the episode we recorded in lockdown actually with you all today as you would expect, with an episode about treatment plan presentation. We do talk about how to present your fees, when to present your fees, the different ways to do it. Do you, I mean, I like to sometimes give my patients a ballpark figure for phase two and phase three, whereas Zach didn’t like going down there too much. And it was just an interesting variation and how some of the difference, subtle differences that we all adopt. And I picked up loads of takeaway points from this episode, a quick shout out for those of you listening from Texas in the USA and West Midlands in the UK. For some reason, you two places in the USA and UK are almost like pockets of super spreaders of the Protrusive Dental Podcast and a lot of my listeners come from there geographically. It’s very interesting. So, shout out to Texas and the West Midlands. Community, you’re in a bit of luck. Protrusive Dental PearlsI’ve got two Protrusive Dental Pearls to share with you today. One is quite a relevant one to do with treatment plan presentation, and I’ll tell you that in a moment. And the other one is some very good news I have to share with you as well as a fantastic clinical pearl I’m going to give you. So the first pearl is an ebook that I’ve shared on the Protrusive Dental community Facebook group just search that on Facebook if you’re not part of it already and it’s an e book. And it’s an e book by someone called Dr. George Cardoso who has almost become like a friend of mine now. I’ve been chatting to him quite a bit. He’s actually next week’s guest on the podcast. His e book is titled 16 Steps to Get More Treatment Plans Accepted Today and oh my goodness is full of absolute gems. So I want you to check that out. Almost like something it will prepare you for next week’s episode and I think you’ll get more value from next week’s episode if you read that ebook, it’s just brilliant. He’s the founder of Make Me Clear, which is an online platform to be able to generate really beautiful looking but very educational in a patient friendly way, treatment plan reports and letters for your patients. And of course it ties in very nicely with today’s episode. It’s just one way of presenting it. So do check out the ebook on Treatment Plan Acceptance on the Protrusive Dental Community Facebook group, and I’ll also add it on protrusive.co.uk/treatmentpresentation. So it’s all there for you in the show notes. The second Protrusive Dental Pearl I have to share with you is the clinical one, and it’s also tied in with some really good news. The podcast has a sponsor. So I want to say a massive thank you to Mini Smile Makeover and Enlightened Smiles for sponsoring Protrusive Dental Podcast. This means so much. And for those of you who know Payman Langroudi , he’s actually a fan of the podcast and he’s got a great podcast himself called Dental Leaders, where you go one on one with different leaders and they interview them and their journeys. I’ve really enjoyed listening to those episodes. So check that out, but really a massive thank you for the sponsors, because without this sponsorship, I cannot grow and add on different softwares and equipment to really enhance the experience for listeners. So, it’s an interesting way of sponsoring because the chat that I had with Payman Langroudi who is head of enlightened smiles and mini smile makeover and I found that he’s a fan of the podcast and then he approached me and I said this sounds great and I said as a sponsor he would do I said hey, what do you want me to say? How do you want me to pitch it and the most beautiful conversation happened Payman said to me, “Jaz I’m a fan of the podcast. I trust you. You already came to the mini smile makeover course last year and you already use Enlighten. Just, I trust you. Just carry on.” So, never before has a sponsor allowed a sponsee to be so expressive. So, thank you not only for the sponsorship at MSM and Enlighten Smiles but thank you for letting me do it in this way, where I get to share with the listeners, what I like. And it’s something I genuinely believe in. So let me share with you guys a really cool instrument that I bought from Cosmodent. So if you’re in us, you can get from Cosmodent. If you’re in the UK, you can get it from enlightened smiles website is called the CASI, C-A-S-I instrument. Now, the reason I love this one so much, and I first learned about it at the mini smile makeover course, which I went to in London about. I got some almost a year ago now. And it’s just fantastic because I’m not a massive fan of buying these instrument kits because what happens with these nonstick instrument kits is you have only one or two instruments that you’ll probably end up using and then the rest of the seven or eight instruments go to waste, right? So one thing that actually Payman spoke about over a year ago at that course was that he likes to buy one instrument and maybe buy two or three of those, of that one instrument because it’s the one he uses all the time. I’m still someone who uses just a microbrush and a probe for his posterior composites. That’s all I use, right? But for anterior composites, I like some good instruments. And this CASI has just been amazing. I like this. I like the shape of it. I’ll tell you why. Okay. The one side. Okay. It’s really good to actually adapt composite on like veneer it on. So allow it to just flat pack it on, but it’s got a lovely curve to it which means that instead of using my finger, which I sometimes do, I use my glove finger as a palatal matrix. I know some of you are vomiting in your mouth. I apologize, but this is a better way of doing it than my glove finger because it’s got this lovely contour. So you can use it to sort of make your freehand palatal stent for an incisor and the other instruments. So it’s a two in one. The other side of it is just perfect. It’s like an IPCL with a curve and it’s just flexible. And it’s just so perfectly shaped to shape the interproximal contours and get your line angles in. So I know that for anterior composites, it’s just the one instrument I need. So, check out Enlightened Smiles or Cosmodent if you’re in the U. S. If you want to get the CASI instrument. The one I have is a 3C, which is suitable for central incisors and canines. I didn’t buy the lateral incisor one because I just feel I can use this or a flat plastic to be frank and honest with you. But it’s a great instrument. So thank you so much once again to MSM and Enlightened Smiles for the sponsorship. And I’ll put a link to that instrument, which I like to use. So it’s something that I enjoy, not something that they’re pushing and that’ll be on the website. So I hope you guys enjoy the podcast episode with Zak Kara and I’ll catch you in the outro. Main Episode:Zak Kara, welcome again to the Protrusive Dental Podcast. You are a fan favorite. Zak: Ah, has it unlikely. Jaz Gulati: A hundred percent. You’re 12 listens away. So I dunno if you saw last year the most listened to episode was Oz Alani. Zak: Was it? Jaz Gulati: And I keep checking again, like, you know how far you are ’cause you were second, and you are now 12. Zak: You are now in lead board. Jaz Gulati: I should actually, you’re 12. Zak: Am I really from being, from being what? Number one. Jaz Gulati: You’re 12 listens away. Okay. That’s from last year. Jason Smithson came along and just literally blew, blew, blew the competition away. Yeah, as you do. Zak: I’m no Smithson. I don’t do this. I’m not hard skills. I’m soft skills. Just- Jaz Gulati: Well, that’s exactly why I had you on that. Out of the 20 odd episodes I’ve done so far, you listened to the podcast. You must have heard your name, you must have, your ears must have been burning. Zak: Literally, I’m out running, I’m out running with you in my ears. And it’s always like, Zak, I’m like, what? Why? I mean I appreciate it, I’m really honoured, I’m really honoured that people would listen. And I’ve had some really lovely feedback, so thank you if you’ve messaged Zara and a few others in, even in recent times. And some of the students I used to teach in at Portsmouth, King’s students, who are coming down on outreach. Quite a lot of people just comment and say, I wondered if it was you. And then it became obvious as the podcast went on kind of thing. So, yeah, I’m honored that people would take kind of my opinion, with the gravitas that they do with their- Jaz Gulati: No, it’s a hundred percent deserved, honestly, that impact. So if you haven’t listened to that episode please do listen to it. I think it’s about episode. 10, I think in the series. That’s a great lot- So many communication gems in there. And that’s exactly why I brought you back to talk about something that is very dear to your heart, something that you’ve worked on. And I know there’s something that we should all be working on and that’s how we communicate to patients. But specifically, we can talk about for hours on that. So what can we fill an episode with for now is presenting to patients. Zak: Love to. And do you know what? This is definitely something that’s close to my heart. And the reason why, I’ll probably give a bit of backstory, one of the reasons why this came up, do you remember literally last week? By the way, should we give the context of the fact that we’re three weeks into lockdown right now recording this? Jaz Gulati: We’re three weeks into lockdown, I’m wearing scrubs. Zak: Which is, I’m here wearing a Jimi Hendrix t shirt, although Jaz just told me we were doing a video recording of this. So we can do a video cast or pod, whatever you techno people will call it. So I wanted to put some hair wax in, because I was like, I’ve literally got out of bed hair, and it was like a bit here and a bit, anyway, whatever. So I’m looking I didn’t- Jaz Gulati: I forgot to tell you about that, sorry. Zak: That’s all right, no worries. You’re the one who has to get up every morning and sort your bug out, so. Jaz Gulati: That’s it. But can I just say, the benefit of wearing the scrub for me is this. So, a week into lockdown and I was really struggling to get my work mode on. So I thought, okay, you know, dress for the occasion, okay, and that has really helped me to actually just crack on. It has. Zak: Do you know what? I can see that. I can expect, I can sense, one of the things that’s happening in my life is everything’s just blurring into one. And but it does, this limbo period just feels like that period between Christmas and New Year’s, doesn’t it? Where you’re just not sure what time of day it is. And the mad thing about it is, without going too much into rest mode, we are, I think, all sensing a bit more about what we, what our bodies really want to do. And how our minds work best. And I do, naturally. I’ve always been a night owl. I remember back in my Sheffield student days, as an undergrad, always doing my revision at 10pm when everybody else has gone to bed. I used to have a mug which had the Guardian logo on it. And the Guardian mug, which was the triple size mug. It was a mug times three in terms of volume. And I used to take it upstairs like a bowl. And I used to sit there with it, and I used to be drinking my coffee all night, and, yeah, be up till, yeah, ridiculous 6 o’clock, and not get up till 9 or 10. Jaz Gulati: I was the same. Me and my friend Clifton used to do all nighters at the IC. But, one thing that has changed me, is not only the baby coming along, that really changes your sleeping patterns, but, I read the book, Why We Sleep. Have you read that one? Zak: Yeah, actually, yeah, I haven’t read all of it. I got about two chapters in and I was like, whoa, I’m gonna die. So I’m not gonna lie. I’ve veered on to other bits of the time. Yeah, but you’ve loved it. Jaz Gulati: So far? I’m about halfway through and it just rings it home, doesn’t it? You know the importance of sleep and how we are all depriving ourselves and this knockdown period is an opportunity for most people to to catch up and I’ve been enjoying the odd nap here and there, which is very unlike me, but it’s our opportunity for our bodies to heal. Zak: You’re right. Challenge always brings new avenues. Jaz Gulati: And talking of new avenues now, people who want to, whenever the day comes, that beautiful day comes, when we can see patients again. We can be what you’ve been doing with Tubular’s Live Aid as well is basically gearing people up so that we can go back, re energize, refreshed, full of knowledge, full of new skills, soft skills. So the soft skill I want to really pick your brain on is presenting to patients. And I knew that this was something close to your heart a few years ago when you’d sent me a recommendation. This must have been two years ago now, to read that book by Barry the art of case presentation. Zak: Yep. Jaz Gulati: Tell us about that book and tell us about has that had a major influence on you and what else has had an influence in the way that you present to patients before we then come onto the question. Zak: I’m a firm believer that we’re all a patchwork quilt. We’re all a patchwork quilt of where we’ve come from. Who we’ve been influenced by. Sometimes some of the systems that you’ve just happened to have fallen into, like for example, you end up in a dental practice, a couple of years out of university, you’re surrounded by some colleagues who do things in a certain way. And you begin to believe that that is the way to do it. And no matter how much training you had beforehand, which, let’s be really honest, as undergraduates, very few of us were lucky to have tutors who really got this and did it, I would say, in a world class way. But really at the time, you’re kind of flustered by the whole kind of that thing that you do as a dental undergrad on a clinic. You feel like you’re riding a unicycle that’s on fire and the world is on fire and you have to chase the dental nurse who thinks that you’re the worst thing since God knows what, you know? You remember those days? And so dental school is very much about just having basic hard skills and you don’t know what you don’t know. So, the Barry Polanski thing came from a great author, by the way, great, great book. Haven’t read it for a few years, but I picked up on that because I spent some time at the Panky Institute in Miami, Florida. And Panky, if you don’t know, is a little bit along the lines of Dawson Spear, actually to be really brutally honest, my opinion is that Panky’s a little bit more dogmatic than that. A bit more old school than that. Maybe evolving in recent times. But their foundations are essentially based on what they call the three legged stool. And their three legged stool is personal mastery, financial mastery, and clinical mastery. And the philosophy behind it is that you simply can’t have one longer leg on the stool because something else will topple over. And to be really, again, brutally honest with those of you listening, I think dentistry has got it really wrong over the years. I think dentistry has been full of people who are hard clinical technicians who are really good with their hands, no doubt gifted way beyond what I’ll ever be and even aspire to be. Because the more I got to know myself and understood my values and my attitude to life and actually why I bother getting up in the morning, the more I realized the fun bit is actually the people and the personal mastery stuff. So yeah, the art of case presenting comes from that because, actually it’s probably quite a controversial word, maybe a word that you want to get into, but the philosophy behind it is basically that facts tell and stories sell. And the truth is that if you want to convince anybody to do anything, and I don’t mean this in a manipulative taking advantage of vulnerable people kind of way. I just mean this in, let’s say for example, your life partner, your wife or something. You want to have your wife, Sim, do something and you know it’s in her best interest, but you kind of just like, come on, I want to twist your arm, right? How do you do that best? You don’t just tell her to do it, or you suggest it. You even be, try and be tactful. One of the most successful ways is actually to make it part of a bundle of well, what better way to describe it than a story, give analogies, give representations and use metaphors. And that made me go back to my roots. And I did an a level in English, which is a bit weird for some people who- Jaz Gulati: I knew it. I knew you had this. Everything makes sense now. Why are you different? It just makes sense now. Zak: Yeah. So I did. I know in English and unlike most dentists I had, I just had this natural thing where I did love writing essays and I still like writing essays. I am not in a, not technical essays necessarily, but you know, I’ve been toying with this idea of starting a blog and doing a this and doing a that. And do you know what? I just wish I had 48 hours every 24, I’d do loads of stuff. Yeah, so that’s where really the soft skills stuff came from. Jaz Gulati: Well, on that note of facts tell and story sell, case presentation is the very close cousin, or even the sibling, or maybe it’s the very same as another important part, which is closing. Closing the case. Closing the, in quotation marks the deal. Zak: Now you you make me want to be sick. Jaz Gulati: I know, no, but here, I know, but this is true. Call it what you want, but this is selling. So the, one of the questions I wanted to ask you is, what are your thoughts on the phrase? Because I know you like to think differently, but what are your thoughts on the phrase, to sell is to serve? Zak: You’re so controversial. Look, this is the word sell. I totally, totally get it. It’s a really controversial word. And I think that’s because when you do, we will do this mental algebra all day, every day. We’ve all got this inner monologue, haven’t we? And we all do our little sums and we work out our equations and we go, okay, well, I think that equals that because all these things go together, right? If you work out the square root of how words make you feel. I think the word sell actually conjures these images of manipulation, deceit, vulnerability, people being taken advantage of. And I think one of the reasons why is because the noun a sell is, as we know, used in magic tricks. It’s used in an act it’s basically, it could be argued a disappointment. It’s a disappointment that’s usually resulting from being deceived about the merits of something, wouldn’t you say? Jaz Gulati: Yeah, absolutely. Zak: And so, the word sell has these negative connotations, but the verb sell is just semantics, it’s a trade, It’s an exchange. And whether you like it or not, that is what we do. We exchange, if you’ve gone to dental school and you’re listening to this, and you’re not aware that you’re trading your time, your skills, your services, the knowledge in your head for something, which is probably money. Then, you haven’t got your head screwed on right because we’re all doing it and there’s nothing wrong with saying sell, but as long as you’re not miss or abusing that word, let’s say. Jaz Gulati: So as long as you’re doing justice in an ethical way, but the reason why that term it helped me is because I also come from this background that selling is a dirty word. I wasn’t comfortable with it. I wasn’t, just for the reasons that you said, the noun, I think you put it beautifully. The noun of sell, it’s not so well perceived. And in my earlier years one, two, three, maybe even three years out of dental school. I’d find it really difficult to tell the price of something to a patient. I would find it difficult to, even though I know this a crown will be better for them than a large composite. Maybe it’s from fear of rejection, or value, or whatever. That I would struggle, but then something that Barry Olton teaches and a few other people. Zak: Bazza gets a shout out every episode as well, you know that? Jaz Gulati: He does. Yeah, literally both legends. Hi Barry. Moving on from Barry Polanski to Barry Olton, and Barry Olton really rang it home for me now to serve, to sell is to serve. So when you sell to someone, you would do, so when I adopted that mentality that actually by selling, let’s use the word selling, selling this crown to this patient instead of a large composite because the fact that there’s only a thin buccal and lingual cusp remaining and really in the long term indirect restoration, cuspal coverage. Although three times more expensive is definitely the best thing for that patient and well, that’s it. So that’s my old roots, isn’t it? Coming through, it’s expensive or is it you know- Zak: Is it a greater value? Jaz Gulati: Yep, a bit bigger, or as some of the gurus say, a bigger investment. Zak: Investing in yourself, investing in your health, investing in your future. No matter how you want to spin it, I appreciate that, yeah. No matter how you want to mould your vocabulary around this, the truth behind it for me is that our value is not in the carpentry. Our value is not in the mini arts and crafts. And I’ve said this for years, we are humans with empathy, and hopefully we make dentistry a comfortable and a seamless experience. And we’re not lifting things and hunting things. We’re not producing stuff or growing stuff. We’re kind of connecting people. And we’re nurturing relationships with people. And do you know what part of that is that you have to trade your care for something? And do you know what? Jaz Gulati: Just say it’s money, money. Zak: It’s money. It is. Give me your money. The truth is that in this disrupted world we’re living in increasingly. So let’s face it, whether we like it or not. Jaz Gulati: In these unprecedented times. Zak: Oh, stop. If you say unprecedented or webinar, I am actually going to strangle you through my screen. Do you know what? The deeper than the word selling the sales coaches, in my opinion, don’t really get it. Their motivation, if your motivation is deep rooted in fear because you’re afraid of being replaced or because you’re only concentrating on your habits and your skills and your knowledge. You haven’t gone deep enough to understand why you’re actually doing it, your values behind it. And then you can understand your aspirations. Then you can know your emotions. Then you understand yourself better. And you know what? Your attitude is a byproduct of all of that. Isn’t it? If your attitude is right, and you’re conveying the right message, you won’t worry about the words that you use because people will come flocking to you. Do you see? Jaz Gulati: 100%. And then when these people come to you on referral, and then let’s say we’ve had this consultation, and that just reminds me of a story. A few weeks ago I went to my old school and I did a bit of like speak to the Year 9s, Year 10s, and they’d come to your store and they’d learn about dentistry. Zak: Oh, you’re such a soft lad. I love it. Jaz Gulati: Had a morning off, I thought, let’s give back to the community. So I did that, and I didn’t know this nurse would be there. And this nurse came from a different region, and she had some connection to the school, and we were there together. And she was three years into dental nursing, and she worked in a predominantly NHS practice. And we just sort of for a moment, exchanged our stories. So her story was that she would nurse for someone who would see up to 60 patients a day. And I am a dentist who sees 8 to 12 patients a day sometimes. And then we exchanged, okay, how long is a usual checkup? Oh, about 5 to 10 minutes. So when I said, oh, a new patient consultation with me is around about 50 minutes, sometimes an hour. She was, literally, her mandible hit the floor. She was- Zak: For sure, her mandible. Jaz Gulati: Her mandible hit the jaw. Her mandible hit the floor because, because she was just wait, how do you, what do you do for the other 50 minutes? So, this is the complete paradigm shift that she had to have to understand my world of it. So let us- Zak: Yep. No, go on. I just, sorry to interject, but I think that’s really the root of why sometimes some dentists misinterpret one another. Because if you haven’t been exposed to a world where maybe you take longer over things, the perception might be that you’re wasting people’s time, you’re just doing it slower, and you’re just trying to craft a bit more, you know, ring a bit more cash out of that person. And I don’t genuinely believe that that’s true because if you are, you can legitimately look somebody in the eye and you can offer X solution to solve Y problem, pain, worry, distress, whatever you want to call it. If you can’t do that, you’re not serving them very, very well. So the answer to your question, selling. Is it serving? Is to sell to serve? Yeah, it is, but the sell is the semantics which maybe gets it misinterpreted. Jaz Gulati: Yeah, that’s very fair, that’s very fair to say. So, I don’t want this episode to be in specific is about the actual data gathering or information gathering part, the examination, the questions, because we’ve done a little bit about that. Also you went around to different tubal study clubs and you did a beautiful presentation about how to communicate to patients during that. But I want to do the bit where you’ve now, found out the patient’s goals, their wants and needs, you’ve done your complete examination, you have your diagnoses and you have maybe a couple of different treatment plans in your mind. Let’s talk about presentation. So first question is what percentage of these patients do you bring back for a second treatment plan presentation appointment. Is it always? Is it sometimes? How do you do that? Zak: Okay. I think really what you’re asking about is choreography. And I mean, choreography without making people shudder and think about like role play. Jaz Gulati: I’m gonna interject you there as well, Zak. You said roleplay, you said choreography. Have you read Nudge? Zak: Actually, do you know what? It’s right here. It’s sitting here in my bookcase. And I haven’t, no. It’s next on my list. Why? Jaz Gulati: No, listen to it. It talks about, gosh. Zak: You’re such an audio book junkie, aren’t you? Jaz Gulati: Yeah, no, I must say, and it talks about choice architecture. Which is you say choreography, but it reminds me of choice architecture. So for those listening, it’s the way that different options are presented. So whether you’re in a canteen or whatever, the way that the different food is presented at different levels, whether it’s your eyesight or below, it influences your decision. So it talks about in healthcare, how can we make patients pick the option that is the better option for their health overall. So I didn’t really come away with massive learning points on how I apply it to dentistry. Perhaps I need to listen to it again, but it’s very interesting. You say choreography, another way, choice, architecture. So let’s talk about, please tell us about your choreography role playing. Zak: So if you’re roughly, in my world, I invite everybody back for a follow up consultation, but I’m not dogmatic. Everyone’s got their own workflow, and by the very nature of the practice that you’ve fallen into, the colleagues you’ve had the way they do things, I actually started in my first, let’s say, private practice position a couple of years out of university. I was just picking up the ropes, learning the ropes. I was developing my own style, getting to know myself and what felt right in my hands, in my words. And it takes time to craft that, doesn’t it? Because no matter how much you look at yourself in the mirror and you say the words in a particular way, you get these kind of spiels that become normal to you. It doesn’t quite always flow until you hit the ground and you go, okay, right, I’m going to have to say this to this person in the way that I practiced. And you kick yourself after. And you go, I didn’t mean it like that. And you kind of look back and you critique, right? It’s all part of the growth that we all have. So, at the beginning, I used a shotgun treatment plan. And what I mean by shotgun treatment plan is I’d have a 45 minute new patient health check appointment. Check up, if you want to call it Jaz’s check up. And I essentially sat there and I used to do the examination and I’d put some photographs and radiographs on the screen and I’d start seeing things and I’d start pointing them out. Bang, bang, bang, bang, bang. Here’s my shotgun. And I would start putting a treatment plan together. And in classic, SOE exact software, it’d be an itemized treatment plan and boom, it’d be in somebody’s hands. Jaz Gulati: So the patient’s there. So you’re back is to the patient while you’re doing this on computer. Let’s talk about that for parts of it. Zak: Yes, at that point, it was like that. Yes. And a lot of dental surgeries, particularly when you’re a younger associate, aren’t really geared up for this, are they? They’re not really arranged in such a friendly way where you can actually have a conversation side by side a patient because the reason why I evolved this and it’s become how it is now is because why somebody chooses something often comes down to whether they know, like, and trust you. If they know, like and trust you, then what happens is they’re actually, you’ve gone up in their estimation one level and actually this happens beyond dentistry. The thing I always love to do is tell myself, nobody’s going to believe what you believe in until they believe in it themselves. So if you can have somebody come up with a solution themselves to the problem that you have highlighted. And they put the words, you’re not putting the words in their mouth, but they spit the words out themselves. Holy moly, well you’ve just nailed it right there, haven’t you? So I used to think dentistry was kind of reliant on talent and personality, but what I realised over time was that I’ve become now, reliant on set plays. You know like in American, American football, there’s set plays, there’s scripts, there’s ways that they’ve rehearsed and I choreograph this stuff and then I come along and on my good days, I put my salt and pepper on top and I do my talent and I do my personality and I do my charisma and suddenly you’re like, boom, I feel like freaking Spider Man today because there’s like just webs, boom, boom, everything I touch comes to, just works, right, and then on those days, it’s self perpetuating joy and you honestly come to work I can’t fail today, this is all great. And actually what happens is you produce better restorations, patients walk out the door and advocate you, they become raving fans, we’ve talked about that before, Paddy Lund’s kind of way of approaching things. So when you told me about the theme of this podcast, why do I invite patients back? I actually broke that down in my head. Why do I invite them back? Well, I enjoy bringing patients back for a presentation appointment because I don’t call it a presentation appointment, I just call it a follow up consultation. It’s for a few reasons, and one of them actually is quite a serious, important, medical, legal reason. And the reason is because, in my eyes, you can’t adequately consent somebody for x solution to y problem, because you can’t do that in one appointment, necessarily, in my opinion. Because it takes time for people to warm up to you. To open up to you, to trust you, to see you’re credible, you’re not a charlatan, you’re not a sell, you’re not an act, you’re really doing it because it’s in their best interest. And if you want to go even further, then you could say Montgomery level consent. You’re going to go with Montgomery level consent. That level of detail needs to be appropriate to the person or the patient, or any reasonable patient under those particular circumstances. But for that reason, it’s ironically pretty impossible, isn’t it? How can you possibly get to know somebody in a shotgun treatment planning type appointment? How can we know what’s reasonable for that person, or what’s unreasonable? Because we’re not blinking psyc I’m sorry, I’m not, I’m not psychic. Get to know somebody slowly and steadily, and my approach to it is that I at all stages want to mitigate my risks. I mitigate my risk by getting to know my patients. And I do that unhurriedly, I hope, and hopefully personably. And if you then do the extra salt and pepper, hello buzzer again, if you do your comfortable dental injection technique and by the way, Barry hasn’t taught me, I’ve never even met the guy, I’ve just spoken a couple of times online and seen some of his work online and things, but people are influences like that around you, mate, you see, actually, that is how you join the dots, boom, boom, boom, boom, and suddenly, that’s, for me, the real art of being a successful dentist. Jaz Gulati: Well, what I was hearing there when you said about the bringing them back for the reasons of consent is never treat a stranger is what the theme of that was basically to get over that. Zak: Didn’t just say that on his podcast. Jaz Gulati: Absolutely. So you bring them back. Because of the fact that one of the benefits is the consent, it reduces a risk overall. And then when you follow that up with your excellent work, but if someone’s listening to this, and they’re thinking, oh, you know what, when this lockdown finishes, I’m going to go back, I’m going to invite all my patients back for a follow up appointment. Well, you need to make sure everyone’s in on it, you actually need to it. Get your receptionist, nurse, you can’t just suddenly just, off the bat and not do it. Zak: Yeah, yeah, exactly. And do you know, this is the thing that takes time. Quite a lot of students who I used to teach, there’s one who I think of in particular, I won’t call him out because he might be embarrassed, but he always used to say to me, how do I start doing this complex work? The truth is that you can’t start doing complex work until your team trust you. Your team don’t trust you because they don’t know you. They don’t know you well enough yet. They’ve not seen you vulnerable. They’ve not seen you scared. They’ve not seen you elated and enjoy it. They just don’t necessarily, and why would you? Because there’s an awful lot of really not very nice, not very, very good dentists out there over the years, sad to say. But now, our generation are having to kind of bear the consequences of that. People don’t trust easily in our field. So if your team love you, trust you first, then they’re more likely to recommend you to your patients. And that’s how you increase your skillset, not only soft skills, but then you can start branching into more complicated treatments and so on . For me, really, the other reason, not only just consent, but the other reason is it’s really important you know, and a patient needs to know, what their problem is. It’s problem awareness. And that takes time as well. Until they can commit to a solution, they need to believe what we believe. They need to approach the dentistry in the way that I like to approach it, because I’m sorry to say it’s my house, my rules. And they need to know, like, and trust you, like we said. Jaz Gulati: They need to come up with a decision, but also gives you the time as a person who’s going to be sharing the different options with them, some time to actually put something together. Zak: Exactly, and if they don’t trust the fact that you’re doing that for the right reasons, then you actually might be a bit stuck. Because a lot of people at that point are sitting there thinking, imagine a new, from a new patient’s point of view, they walk in the door and they’re expecting a certain thing because they haven’t been geared up to, this is the way they do it in this clinic. And so what they do is they’re expecting an answer at the end of the appointment, where they might be sorely disappointed at that point, right? They might feel let down, they might actually feel that they trust you less. So actually you’re not wrong. If you go back after lockdown, let’s say, and you’re back into dentistry, maybe dentistry is going to change altogether, but who knows? That’s another conversation. You hit the ground running, put together these wonderful treatment plans, actually you might come across in a very- they’re quite the opposite way that you intend it. Jaz Gulati: Absolutely. You have to make sure this is all part of something bigger. The thing I want can I just do before you move on to the next one? Zak: Yeah. Next thing. The other thing that’s part of that, by the way, the choreography I say is kind of, if you break it down from a person’s point of view, a patient’s point of view, they know absolutely nothing about you. They’ve never seen your face rewind to the very beginning of the steps. What do they know about you beforehand, and what are you producing online, for example? Because that’s where most people look, isn’t it? Your website, your blog, your Instagram feed, God forbid. How many Rolex watches you’re wearing, and whether it shows your Ferrari logo and Ferrari badge or whatever, you know? Be very conscious that that sends a signal. And I hate to say it guys, but if you’re ultimately you wish to live quite a pretentious life where you’ve got logos and brands around you and you’re swimming in this world of stuff, you’re going to attract a certain type of patient. So beware, be wary. Don’t be just diving in because you think that that’s the way to do it. So you have to know what they’re going to get beforehand. You have to ask yourself why they found you. What are their expectation levels? What are the systems that you have as a team? And what are they slowly, slowly, get there, step by step. You don’t ask somebody to marry you on the first date. And that’s what a lot of dentists do. And that’s what I was doing first a couple of years out of uni. I was asking people to commit to extensive treatment plans, asking to marry them on the first date. Jaz Gulati: You mentioned about bringing them back every time. The way that I do it at the moment is in something you mentioned, the Panky, I can mention a lesson we can learn from the Dawson Academy. Which is there are two types of patients. There’s your general patient. And there’s your complete patient. So, my general patients, who I say, this patient, you need a crown and a filling, go see the hygienist, here’s your plan, it’s gonna cost you that much. Obviously I don’t say it in that way, but then, there’s your complete patient, which needs a whole lot more, and they need to really understand what they’re getting themselves into. And sometimes you have someone who has really complex needs, but their mental attitude and their goal is of a general patient. So, you have to suss out the patient as well. Zak: And they don’t know yet how they’re going to feel after you’ve started to help them, right? And you don’t know either. So for me, if you want to boil this down into a journey, it’s problem awareness first, because it is risk, sorry, it’s risky to make big decisions and maybe invest, if that’s the word you want to use, financially in something without knowing its value. So that’s first and then solution awareness and then they’re going to have some interest in what you’ve got to provide and slowly but surely they’ll come to trust you. And one of the ways that you can actually have a general patient become a complete patient, let’s say, if that’s the philosophy you want to use, is you can solve some of their relatively surface level problems with an affordable way, a minimal investment, if that’s the term you want to use, of time and money and whatever. So low stress. And what you’re demonstrating at that point is, hey, I’m a good guy. I know what I’m doing and I’m not going to push you. And that’s cool. You take your time at whatever’s, whatever’s right for you. Play the long game, play the long game. Jaz Gulati: And you also demonstrate that you’re someone who’s listened to that patient. Cause that’s what they wanted. Yes, they have needs. That should be met that are beyond what they’re even aware of, like you said, but it all starts with actually good foundations and getting that patient just healthy and happy and have their own goals met before you then educate the patient about actually and that’s a whole part of it. I just remember the other thing I was going to say, based on what you said about what is your online presence like, that’s what I was going to say. And a huge percentage of people before their appointment will Google you. So you need to make sure that what you’re projecting out in the World Wide Web is the same thing that you coherently want to- Zak: Has he? It’s not 1997, is it? Jaz Gulati: I don’t remember. Zak: World Wide Web! Wow, that’s the first time I’ve heard that in a while. Jaz Gulati: It’s a long time coming. Zak: I agree, completely. Jaz Gulati: Quickfire yes or no question. Does having a consult room make a difference to patient acceptance? Zak: Yes, but probably negatively. Jaz Gulati: Fantastic. Interesting. Cool. So then now we’re going to get into the- Zak: Ooh, I love that you don’t even want to delve into that because it’s so controversial. Jaz Gulati: It is controversial, you know? Okay, I’ll be honest. Zak: I call a presentation room or a consult room a hard sell room. Usually it’s a small room, it’s a cupboard, people feel locked in, they feel encapsulated, no matter how much you allow them to put pointing their feet to the door or use all these philosophies behind allowing them to feel like they’re in control. Oh, you’ve got a lovely screen and it smells nice and you look, there’s lots of ways to manipulate people, but I’m really sorry to say, I think in my opinion, it veers more if you’re going to call it a spectrum, I think it’s more of a hard sell than a patient being in charge kind of way of doing things. If it fits into your workflow that you have to use a separate room, then that’s a separate subject and a separate methodology. Jaz Gulati: Do it because you want to, because it’s something that you feel is a comfortable environment, rather than what some people do is because they read or heard somewhere that actually their case acceptance will go up if they do it in a different room. That’s not necessarily what should be the case. Zak: Do you know what, Herschel, if you listen, I don’t even know if Herschel listens and watches. He does- Jaz Gulati: Yeah, he’s a cool guy, man, yeah. Hi Herschel. Zak: He said something the other day which resonated with me, which is that in the first few years of his career, he thought the aim was to get people to say yes and he came a point, came to a point in his career where he just went, Oh, all right, I’m not just here to get people to say yes. No, you’re not. And you know, it takes some time, I think, to, to be burned a few times and hurt a few times and go, am I really bad at this or something? No, it’s completely fine to just hold somebody’s, treat it this way. Hold somebody’s hand through the journey of their their dental life. Their dental future, and if you’re a really committed, caring person who will stay in one location, like the Raj Ahluwalia’s, for example, of the world, who’ve literally been in the same room with the same dental chair. Jaz Gulati: Tiff Quereshi as well. Zak: Yeah, exactly. Guys like that who are giants. If you want to stand on the shoulders of giants like that, be less millennial. Just be a bit old school, be a bit kind of it’s not about me, it’s about other people. And you have to be quite vocational about it if you want to, I think, be the best you can be. Again, maybe I’m a hypocrite for saying that because I’ve contorted my career in lots of ways and moved countries like you have and worked abroad and all that sort of stuff. So, there isn’t an only hard and fast rule, but hopefully this will inspire you in some way and help you kind of think about what’s really right for yourself. Jaz Gulati: Well, beautifully said, but also echoing what you just said a few minutes ago is playing the long game. So let’s talk about the appointment. So now the patient’s back for the follow up appointment. What can you, because I know you’ve studied this in great depth, what can you teach our listeners about how to, I don’t know if I want to use the word successful, or a having a good or a appropriate treatment presentation appointment. Can you tell us about maybe, I don’t know, I have no idea which direction you’re gonna go in now. Maybe you’re going to talk about different personality types and how to present different personality types. Maybe you’re going to say about letters and photos or what, how do you want to now? I mean, the microphone’s yours, my friend. Tell us about presenting to patients. Tell me how to make me someone who is okay, ultimately, how am I going to get my patient? Zak: I was just about to give you a compliment Jazzy. I was just about to say, you’ve got really good at this because you allow your guest to take the reins. This is wonderful. And now you’ve started to go old Jazzy, where he just talks and talks. Jaz Gulati: I know, I know, I’m getting, but the thing is, I’m biting my tongue because I don’t want to. Well, how do you get patients to say yes, at the end of the day? Look, at the end of the day, look, I know you just said, Herschel said, okay, it’s not about getting patients to say yes, but a part of presenting is because you would have come up with a plan that is in the patient’s best interest, and it’s a type of dentistry that you want to be doing. Okay. And obviously you want to choreograph your treatment presentation so that actually it gets the patient to do what is the right thing for them that meets their goals in a way that is ethically, and that’s something that’s within as you as a dentist in your sort of bracket of complexity. So tell us about how we can ultimately choreograph this appointment in the best way possible. Zak: That was very succinct. Well done, Jaz. Can we have a round of applause for Jaz? Okay, so look, I think the way to think about this is, in everything in dentistry, start with the end in mind, right? But if you’re going to start with the end in mind, you then have to break down every step of the journey. If you want to present effectively to patients, we said it begins at the beginning with the awareness stage. So for me, I know what you’re expecting me to answer is literally when the patient is face to face with you in the room, how are you setting this up? How are you choreographing? Where’s the computer screen? Where do they sit? Do they sit on the dental chair? Do they sit on a separate chair? If they’ve got their partner with them or their friend or whatever, do they sit in, how does this actually literally work? But just pause for a second and think. The relevance of that is actually that you need to know where a patient started on their journey. When they became aware of you, what did they see? How much do they know about the solutions already? Because you need to customize this. And some of that information you can actually achieve, or you can receive, sorry, in some of the pre chat stuff. And I mean way back. I mean, for example, if your system is patient finds out about us online. They see your blog. For example, I’ve started recently during lockdown starting to produce some hopefully really awesome resources for patients where they feel like they’re in charge of the situation where they are starkly comparing the difference between what we do in a clinic environment versus direct to consumer, at home braces type solutions, for example. One of the things I’m working on at the moment is actually like a DSD, like a Facially Generated Treatment Planning thing like SPEAR used to do 20 years ago, 30 years ago. Why don’t we show patients more transparently what we see as dentists? Because if they’re seeing stuff like that, they’re instantly forming a kind of perspective on this is what Jaz and Jaz is about, this is what he does, and geez this guy’s valuable because he knows this stuff. And you know it pitches you in a certain pocket of their mind where they go, this guy’s a giver. Do you follow? So I don’t want to go too woolly about this, but awareness starts with all of that stuff. And if they’ve got some backstory about you, not because you’re trying to convince them, some of that actually might be a valuable resource because you can then say, okay, well, here’s your whatever you want to call it, facially generated treatment plan. This is what you came up with. What solutions do you think there might be? And that’s how you can start to mold the conversation, for example. The other aspects of it then, what did they receive from the clinic beforehand? Again, if you’re an associate, young associate yet, let’s say your first five years, 10 years qualified, you maybe don’t have your own environment where you can mold quite so much yet, but if that’s the case, then help me with my episode 10 numbers and get us the extra 12 so I can get to the top spot because we spoke about being a linchpin in episode 10, right? And being a linchpin actually comes down to you taking the reins a little bit and showing the team around you that you care about this. And the way you can do that is, for example, you could come up with email sequences. You can help to communicate with patients beforehand by having that phone call we spoke about. It’s all about moulding what’s right for the type of patient you want to receive at the end, and what they might need to see on that journey before they get to you. I, for example, then talk to a patient by WhatsApp beforehand. And I’ve got WhatsApp on my desktop now. So I’m literally like, old school MSN messenger probably before a lot of people’s time listening to this, but bang, bang, bang, bang, bang, bang, bang back and forth like that. Right. Jaz Gulati: And because do you have a separate number for like, just?- Zak: Yeah. Jaz Gulati: Cool. So you have a WhatsApp. And this is again, part of the pre appointment sort of chat, or this is-? Zak: Absolutely. This is way back. So, if you want to know my flow, it’s patient finds out about us, some sort of campaign, or they’ve found out about us from a friend, or a word of mouth, or whatever. It’s very rare for somebody to just walk past and enter, let’s say, if you want to call it a funnel, call it a funnel. If they want to enter that and just walk in off the street, then they actually they need to pre qualify themselves for why they’re there. And, without being too rude or harsh about this, one of the reasons why is, who’s it that spoke? Is it the Implant Ninja guy? What’s his name? Jaz Gulati: Ivan. Ivan Chakun. Zak: Hello Ivan, if you’re listening. Ivan, spoke about this and actually I’m just seeing as I wanted to talk about it. This is my really rough version of what I’ve just been working on these last couple of days of what I would call green flag, amber flag, red flag patients. Okay. And I’m trying to work on ways of kind of going, is this person my patient? So, and the reason why is because, lo and behold, start at the end, this bit. Sorry about all the rustling paper if you’re just listening to the audio version of this, but, Jaz’s like, God, I cannot produce radio with you. But the ideal patient for me, I’ve just jotted down a few points. Smooth treatment results as planned. Arrange appointments and keep them. Fun to be around. Make our day rewarding. Pay without asking and on time. Maintain the result for years with minimal issues, minimal relapse, home care, low follow up stress. So if I want- Jaz Gulati: A unicorn! Zak: Yeah, the unicorn patient. Now, how do I get the bloody unicorn patient? Well, I’m sorry to say that I’ve worked in some clinics over the years and a lot of practices don’t know, because they’ve not thought about it. They just let anyone in the funnel. If you let anyone in the funnel, what’s going to happen is that you get any old crap at the bottom, don’t you? And you don’t get the fun patients to be around. You have stressful life and a stressful career. And the importance of that is that you know what you’re going to get afterwards. And, like I was saying, if you’ve got a funnel, you’ve got to start with the right people to get to the right people at the end. Right? If you’re going to start having to filter people out, well that becomes time consuming, it becomes stressful, and it actually relies an awful lot on variables, and it relies on team members to say the right things, and sometimes those team members are not empowered to do it, and they feel embarrassed to do it, and they don’t know the right words to use, and so you end up with people halfway down the funnel who actually should have never got in in the first place, and only then do you all realize, holy moly, we’ve made a [inaudible] And that’s when you then get, like I was saying before, the patients who aren’t so fun to be around. The patients who book appointments and cancel them short notice and so on and so forth. But then it also comes down to the practice environment. It’s your location. It’s your facility. It’s what your team members say and how the stuff that really their own vocabulary, the stuff we were talking about earlier, pre first appointment. Some practices I totally appreciate have like a treatment coordinator type approach, or they have a consultation of some sort of nature where somebody can get to know a bit more about what they offer, or maybe now in lockdown, a virtual consultation of some description, maybe that would be a worthwhile use of your time. Jaz Gulati: In your case, it’s the telephone conversation, right? Zak: Yeah, for me, it was always a telephone conversation. Actually, I might, through all of this evolve that into a video consultation because I can get a lot more from a patient in that sense. I’ve even been trialling and testing out methods like SmileMate, for example, which comes from dental monitoring which is essentially a way of building some value about what you do beforehand, so patients can even send you photographs of their mouth. And yeah, the crap photos, they’re retracted with fingers and they’re an occlusal that’s out 30 degrees like this, rather than 90 degrees perpendicular, but- Jaz Gulati: Better than some dentists. Zak: And the truth is that, patients actually respond quite nicely to that. Patients actually quite like the fact that we’re different to most. Jaz Gulati: That’s called smile mate. Zak: It’s called smile mate. Yeah. Smilemate. com or something like that. I think so. Something like that. Yeah. So at that point, now I’m only just getting to the bit which I thought you probably thought I was going to start with, which is the first appointment, right? And then during the first appointment, we’ve talked already. We do about this. We do a discussion. We have a blame free, judgment free kind of stylish, we do our very best to signpost our way through the examination process. So patients are getting nuggets of information, but not trying to receive it all in one go. And then really the main crux of it is the second consultation where you come back to somebody with a piece of paper in your hand or in my world, a massive iPad pro screen, a PDF that you’ve been putting together with a risk assessment of stuff, but using words that actually matter to them. So, for example, I’m actually going to pick it up on my screen whilst we’re talking. The way that’s broken down in my world is goals and concerns, recommendation, overview, which gives them a kind of step by step, and it’s not stabilisation, phase one, blah, blah, blah. It’s not. It just says healthy teeth and gums, step two, diagnostic and further planning. Step three, a smile you’re proud of. Step four, a care plan. Jaz Gulati: I love it. Zak: Do you like that? Jaz Gulati: I really like the in patient’s own terms. I’m gonna be nicking that one. Zak: Steal away, no problem. And do you know what? That’s, that point you then, I said it before about problem awareness. That’s the point at which I then talk about my bespoke dental health report. Which is a bit wordy, I probably need to evolve that a bit. But it’s basically a way of demonstrating to somebody that they’ve got this red risk for this. Thing and this and this and this, and then you can dive in a bit more as well. So verbally, what I’ll do is I’ll talk ’em through this plan and I’ll tell them, and I’ll talk like this in Inform. Jaz Gulati: So make it really tangible. Look, you’re there. You’ve got the iPad screen. This is something you’re presenting to them on the iPad screen at the moment. And do they have their own printed version in their hand as well? Zak: No, I email it afterwards because I’m as green as can be. Jaz Gulati: Right, so you’ve got the iPad screen, you’re sort of, with your finger, you’re sort of scrolling down as you’re explaining? Zak: Yeah, and I’m in certain times I sort of launch into kind of pretty stock spiels. I have kind of like, I’ll go down a rabbit hole of let’s talk about teeth. Let’s talk about the health of every one of your teeth. Your teeth. When we look at teeth, it’s really important that we check them from a biological point of view. That’s, is there a hole in it? Is there soft decay? You might remember from episode 10, we talked about soft decay because patients don’t care about caries or decay. Soft decay. And then I talk about teeth from a mechanical point of view, chipping, wear and tear, broken edges, fracture lines, for example. And then I talk about teeth from the point of view of their foundations. And what I’m trying to get into the person’s head is that, particularly in a slightly more complex case, we need to tackle each one of these things step by step, so that the foundations around them, the mechanics of every tooth, And the biological health of each tooth sound because without all those three, again, three legged stool, without those three things, your tooth’s buggered. I don’t say that, but you follow what I’m saying? You’re trying to give it to them in tangible terms without overcomplicating it or too, you don’t woolly it up too much. Jaz Gulati: So I imagine at this point you’re showing them some graphics regarding each three members of those stools. Zak: Correct. And so I’ve got an app on my, gee, I don’t even know what it’s called, on my iPad. I’m gonna look that up and check it out for you, but it’s a really cool app. It was really expensive a few years ago, like two or three hundred pounds app, but it’s got some diagrams and stuff. It’s got some videos and stuff on it, which are quite useful. And then there’s a couple of other resources. Again, I’ve sent them over to you Jaz and you can stick them on jazz. dental or the Facebook group or whatever. And those types of things are so valuable because you can then actually show people in real world terms. This is what we’re looking at right now and you’re also adding credibility at that point. You can actually, the trick of what I’m doing as I’m showing them their problems, is I also have a set bank of photographs for X Condition, which are my work. Where I can say, as you can see with Jane here, she came to see us like this. And all I do is a very rapid swipe through of and this is what we did, and da, and da, and da, and this is her at the end. But we’ll come to that in a second. And what we’re doing is we, I don’t ever let myself get, hopefully I can say ever, 100 percent of the time, don’t go too far down the rabbit hole that you start getting sidetracked with questions. But equally, don’t be so didactic that it’s like a lecture. Because I used to work with a guy who is just literally like a robot in his new patient consultation and his presentation appointment. It is almost cringeworthy to listen to because you can tell the patient has switched off after 10 minutes and they don’t want to be there. So what’s the point? It’s not adding value at all, it’s losing value. Jaz Gulati: You need to show your personality and that you’re passionate, that you’re the sort of personality that’s going to be getting along with that patient and this is another opportunity for you to show that you are the right dentist for this patient, or maybe you’re not. But then that’s where you can find out. Zak: Jaz, the other thing is that it’s not just because I’m a care and sharing kind of guy. It’s actually quite selfish without being a nasty person about it. I don’t want to treat people who are a pain in the arse. And if we haven’t got a connection at appointment two or appointment three, well, I’m cool with cutting all losses at that point because I don’t want to have to get to appointment 10 and find out. And the presenting doesn’t actually stop there either. As you know, the present presenting the presentation of your treatment plan is an evolving feast. Although we’ve got it in black and white or in my world, purple and white on some of our treatment plans, you get through to solutions and you start delving into whether this sounds right for solving their problem. Hopefully they’ve told you the solution as you’re getting down that journey. But every appointment, appointment on appointment, you’re continuously managing expectations. You’re gauging your rapport with that person. You’re looking at whether they’re punctual, whether they pay their bill, whether you’re demonstrating your care with your pain management. You’re working out whether their treatment has worked in the recommended way and they’re caring for it at home. And ultimately then you get predictable results for predictable patients who actually aren’t just robots, who actually want to be around them. Jaz Gulati: They now have a pretty good insight in terms of what’s going on. And in the very beginning of that, you gave them an overview of, okay, we want a healthy mouth. Then eventually step four we want to be a care plan. I forgot the terms that you use exactly. But then how do you actually now tell the patient? Okay, so based on all this stuff that I’ve just told you about, this is what you have, and where we want to go, ideally, there must be some options, and sometimes there’s more than just one option. And the other day in the Tubules Live Aid with Riaz Yard, did you watch that one? Zak: Yeah, that’s exactly how we ended up coming to talk about this in the first place, because I commented on it too. Jaz Gulati: Yeah, we were talking WhatsApp, and so for those who didn’t catch that, so Riaz Yard, essentially the way he presents to patients is there’s a comprehensive most ideal plan so getting the gingival zenith perfect gingival surgery orthodontics several restorations and this is like the gold standard okay but that’s gonna be the highest fee for the highest value see why I did that zach see already he’s rubbing off on me but then some patients it will be something not quite to that level, but something that will still be fairly, I forgot the terminology, he used for that middle one. Zak: So it would be something like an acceptable result, let’s say. Or maybe it’s compromised. Jaz Gulati: Yeah, I think it’s compromised. Compromised, yes, because then instead of ceramic, you might be using composite in some places, for example. And then there’s a bare minimum, that actually, if you’re not going to have this, then you’re actually dangerous for me to treat you or I don’t feel comfortable treat you or it’s just ethically wrong. Zak: Maybe that’s the point at which you do what’s necessary to get that patient pain free and you refer to, I don’t know, a therapist in your team and that might be the patient then comes full circle later, a year, two years, five years later, and they’re suddenly ready Because they’ve got to know like and trust you guys as a team. So that’s one method. Are you basically asking what’s my method? Jaz Gulati: Well, I’m coming. I’m about to come onto that. But with that method, we need to understand that what Riyazian was trying to say was that, yes, there are these plans. One thing that will affect which plan is most appropriate for them is that all the plans will be clinically appropriate but the the main factor will be is the affordability. What can the patient afford and in real world that’s important So he will tell them the appointment beforehand or earlier on is that okay if you’re gonna go for a comprehensive plan it’s around about this region. Is that the sort of thing that you’re looking for the ballpark figure and then you sort of know which level you’re pitching out so you there’s no if the patient says look I can only afford 5, 000 pounds or the option compromise and I can’t afford the 25, 000 pound plan a, you mentioned it because the patient needs to know what the gold standard may be, but you’re not going to spend too much time on it. So that’s his method of doing it. Zak: The difficulty with that and with greatest respect to Riyaz, he’s a fantastic clinician. The only thing I don’t like about that is it actually, actually two things. One is that it means that it’s geared towards the fee. It’s geared towards finances, i. e. if you can accept X result because your finances say so, you’re opting into that plan. Well, I don’t like that for some reason because, for example, if I’ve got 25 grand in my pocket and I want your perfect no compromises, all frills, all bells and whistles plan, but I don’t, and I can’t consent to perio surgery because I absolutely will not have surgery in my mouth, I won’t have scalpels, I don’t want sutures, blah blah blah, I’m a TV presenter. Obviously I’m a TV presenter. And I don’t want to show blue sutures, even for one day or two days and I can’t get time off. Then it’s not acceptable plan to me. That’s not consent, consensual in the slightest, is it? It’s not certainly not an informed result, suggestion. The other aspect of it is that the people who opt into the bare minimum, you aren’t actually consenting thoroughly. If you’re not explaining what that does involve and what the benefits of it are. I don’t know in detail exactly what reality solution or methods involved. So I’m not knocking it in the slightest, but my way of doing it is, and I would recommend this particularly early on in your career, my methodology with it is have everybody focus only on phase one care to begin with for two reasons. Again, two, I love the two reasons, right? So first reason is that at the beginning. It actually, when you’re not quite so experienced and you’re not quite so you’re not so sure of your own results that you can achieve, it’s okay to boil it down into very straightforward steps one by one by one. Do you follow what I’m saying? Jaz Gulati: Yeah, so phase one is healthy mouth. Zak: Absolutely, which we can all achieve because if you’ve been to dental school, you’ll know that phase one is just, is biology, isn’t it? And yes, it’s mechanics to some degree, but you can pause on mechanics. Because you can provide a nightguard, let’s say, which will buy you some time. It will actually test, as you’ve spoken about lots of times in your other podcasts, it will test people’s compliance. It will see whether they are suitable for any more complex treatment solutions in the future. And it can be used as a diagnostic tool as well, so it’s like win win win. And then in the meantime, you’re also testing their compliance, their home care, and whatever else with regards to their foundations around their teeth, for example. Just rewinding ever so slightly, one of the reasons why on our second consultation, we combine that second consultation with a, we call it professional hygiene visit, scale and polish. If you live in a different world, if you combine those two things together, what you’re doing is you’re selling the benefits of all of that stuff that we stand for on day one. It’s like an opt in strategy. You are not allowed to opt out of it. And I don’t treat anybody who won’t accept a professional hygiene visit on day one. And the reason why is not because I’m an arse. I am a bit, but it’s also because I believe in longevity and the things that I provide, whether it is bare minimum compromised or gold standard, all of those things require some taking care of. And I’ll say it to patients in these words. As much as I love taking responsibility for my work and I really believe in how long it lasts, what you do at home is going to have a greater input on that and greater impact on that. Jaz Gulati: And that’s evidence based. Zak: Yeah. And it’s teamwork. And it really is. It’s our result. If you want to go even more fluffy at the Panky Institute, they call it a co production. This is a co production. This is a diagnostic co production. This is you having your input. This is the treatment result is a co production. If you go home with a numb lip and you chew your lip, well, it’s not a very good result, is it? Well, is that my fault? Is that your fault? Is it both of our fault? Probably both. What else do you want me to share? I think- Jaz Gulati: Well, you talk to us. I think you’ve summarized it beautifully in the way that, okay, actually if the ideal plan for that patient, let’s, let’s talk about that same patient who needs 25, 000 worth of work towards the ideal where we talk about Riyaz’s way of doing it, where we heard on the Tube it was LiveAid, so your way of presenting is that you, you know, the second appointment you will have your iPad, you will show them their plan on the iPad, give them a good in depth knowledge of what is their condition of their biology of every tooth, the mechanics of every tooth, how that fits into their goals, what the general overall aim is, and then when it comes to the final options, you’re gonna say, well actually we need to start with phase one. So you’re not gonna fire and trigger the sort of 25, 000 proposal, the letter with all the appointments, you’re going to say no, because yeah, because even if in a parallel universe, if you even if you did present that 25, 000 plan, the phase one is still coming first. Zak: Essentially, yeah, for sure. And the way that, for example, let’s say it could even be argued that you don’t actually even prep teeth in phase one. And I do to some for some situations, but let’s say, for example, if your isolation is meticulous, if your caries excavation is ideal, if you really know what you’re doing with proper bonding techniques, you can actually build what I would call a posh core. So that’s a giant size composite with all your fancy anatomy and contact points. And you can actually, what’s the purpose of a restoration. Biological seal, correct convexity and contours, so we minimize periodontal breakdown and we improve hygiene. And it creates, it just creates a seal, doesn’t it? It actually gives you some mechanical strength. Now, if you protect that tooth in such a way that you can actually come back to it in phase two or phase three, that’s the way I explain it to people. I explain this will buy us some time. And nobody knows how long some is because that kind of relies on how long it takes to get back to completing the rest of your phase one plan which might be driven by finances, it might be driven by time, it might be driven by your jet set lifestyle, where you’re abroad all the time, or whatever. You may relate it to the person, because that really matters. And then, when patients come to phase two or three, the way you’re explaining it is that we’re doing some further planning at this point. Jaz Gulati: Well, the patient actually, so the patient will be aware of the fee of the appointments in, that are encompassed within phase one. Sure. Phase two and phase three, they know that they exist, but, roughly do they know what phase two and phase three may involve in the future? Zak: Yeah, so, so, yeah, I do. I outline it at the very beginning, but I explain how would all of that seem to you. If you had a healthy mouth where we are confident or we’ve reduced as much as physically possible, the risk of pain, broken teeth, and improve things in terms of the way things look, particularly with front teeth, but I’m not providing elective treatment at that point. Would you be happy with that solution, do you think? And again, I’ve got a bank of photographs on my iPad from six previous cases and I’ll show them the full mouth stage one solution. And that might be even, I mentioned posh cause, but some teeth do have to have just provisional crowns on them. So I’m not scared if you probably know this already, I’m not scared of prepping a tooth and sticking a luxo temporal or bisacryl provisional crown on it and sticking it on with some polycarboxylate, some poly F, because that’s a long term way of treating a tooth. What does a provisional crown do? Still provides a bacterial seal, still provides good contact points, still improves hygiene, still protects the tooth mechanically, right? You’re buying time. But the patient’s opting in. Oh, I don’t need to have the definitive long term ceramic crown yet, no. But we know, and I know, you and I are on the same wavelength, aren’t we, buddy? Because we know that that wasn’t ever intended to last forever. The other thing, just briefly, that you can do there, Jaz, is a way I then pitch things when I get to phase two, which is kind of the jumping off point for further planning and stuff, is the patient’s got to know the fact that we really care about the way, you’ll love this because of the theme of your podcast, Protrusive, because patients will understand the way that occlusion works better. You can’t have a patient understand occlusion on day one, even if you’ve got the fancy diagrams, the fancy model. You remember that thing I showed you from DNR from years ago? All sorts of clever things you can use to explain it, but really you’re demonstrating your care for your attention to detail every single appointment. You place a restoration, you polish, you shape, you this, you that, whatever. And you know what happens at that point is I don’t actually give an itemized fee per item after phase two. If you go to BMW, you want to buy a car. Jaz Gulati: After phase one or after phase two? Sorry, I was trying to stop you there. So, just to clarify. I’m trying to understand that. Zak: Phase one, I do provide an itemized fee per item breakdown. For Perio, by the way, I don’t. I actually include Perio stabilization. So, anything of that sort of nature as a package. Because I’m not interested in patients who want to come and just have one thing done and then come back three months later but they’ve fallen off the face of the earth and they’ve not, they’ve not really, whilst I hate having to approach it this way, having to pay a fee for a service does sharpen people’s mind. It sharpens their mindset. And if your strategy is that’s a package of treatment, which includes X, Y, Z, you can even include the bells or the whistles. You can have the hygiene products included the electric toothbrush. You’re bundling it all in. Then I would do that as a package. But just to clarify what I was saying before, as I shoot off on a thousand tangents as ever, phase one is itemized, phase two is where we start doing some further planning. I don’t- Jaz Gulati: What I want to know, Zak, is when you’re presenting at that appointment and the patient now knows exactly what phase one’s going to involve and also know in the future what phase two and phase three will involve, but do they walk away with a number for phase two and phase three? So this patient who needs 25k worth of work to be in the comprehensive category. They don’t yet know what they don’t yet know. They don’t yet know. Zak: Well, I’m not evasive, but if somebody asked me point blank, so let’s say you’re the patient and you’ve gone, okay, well how much is a crown after that? I will tell them fee per item is this, the fee that we charge to do that. Long term and last for decades if it’s well maintained is between this and this is generally this kind of vocabulary. Jaz Gulati: Otherwise, you don’t offer that ballpark figure to- Zak: Not generally not generally but unless for example that a patient has been offered a provisional crown or recommended provisional crown in phase one, you do have to, as part of that item, I’ll say this will require a definitive crown because they can’t opt into the provisional crown and then you have them twist their arm later for a bit more cash. And actually that’s quite a, no, that’s not a way to make friends and compatriots yet. Jaz Gulati: So they know they’re, sorry to talk about numbers, but this is something that so many young dentists struggle with actually how to actually send patient a plan that makes sense to them. And this is the beauty of the way you explained to them, but also a one that phases pricing and money appropriately in practice. So they know about their, so they’ve had, they’ve gone through phase one. They’re at the end of phase one. How do you now signpost phase two? How do you know the patients are ready psychologically and financially for phase two? Zak: How do you know they’re ready psychologically because they’re still attending and they’re still fulfilling all of the green flags that we had identified at the beginning. And if there are any amber flags, which, occasionally I’ll look after patients who’ve got one or two amber flags. I’ll give an example. Somebody the other day prior to lockdown gave us their details. Clever little strategy I worked out, by the way, is that we actually, as part of their flow of getting to submit a request for an appointment or getting to know us better, we asked for their details twice. One point on the journey at the very beginning and the second point where they’re actually arranging a, I have an online scheduling software which is called acuity scheduling or Calendly is another one for example. So they’ll arrange a phone call with me at a certain time and they have to input their details again in there And if somebody inputs their email address differently from one to another or their phone numbers got one digit different, for example I receive those bits of information together and I’ll kind of have a little flag in my head that goes, why’s that person putting their details differently from one to another? And sometimes it’s because they’re just a bit kind of on guard about you, which is understandable. They put in a digit wrong because they were kind of like I don’t really want them to phone me, but sod it, I’ll have to put my number in because they’re forcing me to put my number in kind of thing. Do you follow? Jaz Gulati: Interesting. Zak: So that would be a little amber flag for me, just a subtle one, but I would skim over it. I’d have it in my head and I’d go, not sure, but okay. And coming to what you’re asking, at the end of phase one, you know a lot better which flags the person still has, or hopefully they’re all green flag patients. And if they’re ready and they trust you and they like you and you have good camaraderie and you like being around them, that’s the point at which I’ll offer them. What would you like to do next? How would you feel about spending some time with us so that we can look at things in more detail? Or, quite often what they’re doing at that point is they’re going, what can I do next? Can we move on to the, when can I have the crown on that tooth? Or when can I have the and that’s the point which you know you’ve got somebody who really gets what you’re doing. You can also at that point assess whether they’re suitable in terms of their hygiene and this and you know, then you can properly itemize a treatment plan that makes sense, but I don’t at that point for phase two onwards the point I was trying to make before is that I don’t at that point onwards give them an item itemized step by step per crown per this per that and the reason why is because if you go to BMW you want to buy a car BMW don’t tell you how much the wind mirrors cost. They don’t tell you much. The windscreen is, they didn’t tell you much. The alloys are, you might have choose optional extras for certain things, which is fair enough. You can do that. But I provide a flat fee, the fee to achieve complete stabilization of your health and achieve all your goals. A smile you’re proud of, or however, however you wanna pitch it is this. Jaz Gulati: Is that a panky thing? Zak: Yeah. Jaz Gulati: I knew it because that’s exactly how Hap does it as well. My, my principal Hap Gill, who for a long time he needs, he needs to get onto a podcast for sure. But yeah, it’s how Hap taught me to do it as well actually, so it’s Zak: interesting. Do you like it? Do you think that makes sense? Jaz Gulati: I do like it. Yeah, I do like it. Zak: And the reason why Jazzy, the reason why I like it at that point is because the fee, the total fee at that point doesn’t make any odds to that patient. That patient, remember, is a different entity to the patient that you were entertaining at the word go when they didn’t know anything about you, they weren’t sure about you, they didn’t care about how much you say you are nice and how you say your treatments are comfortable treatments and so on. Because they now know it, and they like you and they trust you. And then at that point really, the conversation isn’t about the total fee, it’s just about affordability. And that’s when you can go, okay, well, how about if how would it sound to you if we divide it up on a payment plan, blah, blah, blah, blah, blah. And that’s when you can offer different solutions. Because if they’ve got an objection at that point, it’s not the total, I promise you, it’s how it fits into my budget. Jaz Gulati: Brilliant, which leads really, really nicely to my final question is that many dentists struggle talking finances. Something I struggled for a long time, and I don’t think I’m, yeah, I don’t think I’m quite there yet. I think everyone’s got a certain number. Beyond that number, they start getting all actually what does Linc Harris say? Is it a discomfort number or something like that? And I think it’s the fear number, the discomfort number, something like that, yeah, where you start thinking, oh, actually, you doubt yourself or whatever. Zak: Hey, I used to be scared in VT or DF1 of when a patient used to ask me, so how much is the implant? And I used to start with, but we don’t, well, we don’t do them here, but it’s like, no problem, no problem, no problem, no problem. So it wasn’t me. And then you go, well, about 2000 plus. And in your head, you’re like two and a half, really. And people just go, oh, you know, the ball could have the price. Jaz Gulati: Have you ever had a patient laugh at you when you’ve given them a price? Zak: No, actually. Why, I’ve laughed at you? Jaz Gulati: That’s happened to me in the, during my DF1. Zak: I want to give you a hug. Jaz Gulati: This was, but during DF1, a patient took his tooth out and afterwards, he was a non English. He was a refugee. We sort of bonded because I’m also a refugee. I came to the country when I was six years old and he’s a refugee. Zak: Sock story all the time, Jaz. Jaz Gulati: Always a sock story. But anyway, so it was a cool guy, but then, look, he was NHS exempt and I took his tooth out. He says, okay, how much do I have an implant? And I said sort of like, you know, just over 2, 000 pounds or whatever. And he actually just started laughing. He was like He was like, wait, wait 2, 000 pounds? He just literally started laughing. And you know what I did? I started laughing as well! Zak: It is contagious, isn’t it? Jaz Gulati: That’s happened to me. That was a really awakening moment for me. You know what? I need to actually take ownership of what we charge as a profession. Not because I didn’t do implants at the time. I still don’t do implants. But I need to value the care that you provide. So when a patient, that kind of patient laughs at you, they don’t value what you have to offer. Zak: Exactly. Nail on head. They don’t value, because they probably don’t understand. And one of my favorite questions to ask back to them without being a politician is, well, what do you understand by a dental implant? Oh, it’s when they’re screwing things. It’s just Makano, blah, blah, blah. And then you kind of, you’re basically- Jaz Gulati: I get it in India. Zak: You’re so foreign right now, I love it. Brexit, tell ya. Jaz Gulati: Anyway, so overcoming, oh yeah, okay, so, how to help young dentists talk about money. Zak: Okay, well, It all comes down to the value that the patient, places on X result. And if you’re skillful at it, you don’t talk about the thing, because patients don’t buy quarter inch holes, they don’t buy quarter inch drill bits, they buy quarter inch holes. They want a solution. They don’t want the thing that makes the result happen. So they don’t care what you’re going to screw into their jawbone. Don’t say it like that. But they’re not interested in the acting and the act of doing it and how long it takes necessarily. Some people will, but really they’re interested in the end result. So that end result might be so that you can chew on this side of your mouth comfortably evenly so that all your teeth touch when you chew, which may reduce your chance of chipping and breaking and blah, blah, blah of other teeth in future. It will be important that we do da da da da da, and the procedure for that will be blah blah blah blah, benefit feature procedure statements, as we said on the other podcast. How do you start getting comfortable about money? Well, I was scared about and do you know what? There’s a certain gravitas that happens over your career, which is why you shouldn’t run before you can walk, which is that at the beginning of your career you look like you’ve got pound signs in your eyes because everything’s expensive to you and the reason why is because you were probably receiving a student loan of a thousand odd quid or something maybe 1500 or whatever it is these days per semester and that’s a lot of money to you. And the reason is because it’s within the context of your life. But if you start to explore what a patient believes, is going to achieve that result for them, what it involves, how many steps it might take and then you start to demonstrate it, which might be photos, videos, testimonials of people’s results, or a photograph of somebody being ecstatic about the result or whatever then you can kind of go, okay and to achieve this result, It will be important. We do this. Then you actually starting to get a bit more value, but I appreciate that in that straight off the bat. Give me the answer. That moment is actually quite a treacherous moment. Jaz Gulati: I think the more times that you have that moment in your career, the more you realize that it’s not about that number. Just like you said, it’s about giving them the care that they want and they deserve in and doing the dentistry that you love doing. And eventually. The money becomes a side thing. It’s all about how many people’s lives you can transform and making workful, being fulfilled. But you need to appreciate that we are in an industry where you are, right at the beginning we said we’re exchanging our time, our skills, for something at the end, which is money, and we need to be mindful of that. Zak: Sure, and it really is, without being too fluffy about it, it’s all about knowing what you’re worth. But you don’t know what you’re worth until you really understand your why and you believe it. Not believe it because you’re faking it, but you believe it because it’s really true. Jaz Gulati: Beautiful. Zak: I was losing my mind at the moment at the end there. You like that? Are we ending on that? Jaz Gulati: I think end on that, my friend. Any closing comments? I love that. You answered all the questions that I wanted to ask you. I think the listeners got a good grasp of what the presentation involves in your case. And we talked about a couple of examples. We talked about the Riyaz Yahweh, but we also talk about the way you do it and the differences and what the listener might take away is they might find their middle ground or something that they find most comfortable for them. Something that’s coherent with their existing environment. Absolutely. And it’s going to be a combination because we’re all the patchwork quilt, come full circle to what we said at the beginning. There’s nothing wrong or right about my method or Riyaz’s or whatever. It’s just what suits me from the demographic that I look after, where I pitch myself in comparison to other people out there. Zak: Because, they are a reference point. It has to be that way. But if you believe what you believe, because it’s true, because you’re being true to yourself and not just because your mate, that you graduated with, does it a certain way? Then, that’s what’s going to really come across with true gravitas and you’ll be valuable. Your hourly rate though, isn’t the reason why. Jaz Gulati: Beautiful. Love it. Thanks so much, Zak. We’ll always appreciate you having you on mate and until the next episode. Well, there we have it guys. Thank you so much for listening. All the way to the end. Do check out that ebook on the protrusives and the community on the website. And of course, I’ll put all the show notes up on the website as well. Of course, the full video will be on protrusive. co. uk and on Dental on Tubules if you want to get CPD or CE if you’re part of Tubules. Otherwise a few teaser episodes will be available on Instagram as usual. So thanks so much for staying all the way to the end and I’ll catch you in the next episode, which will be with Dr. George Cardoso. And they’ll be about crystal clear. Treatment plan that is and how to really make them stand out and how that can be such an important part But it’s actually the next episode will be very much a continuation of the themes that we discussed today So if you enjoyed today, you will love next week as well. So I’ll catch you next week guys. Thank you so much for listening.

Periodontology has some good studies and evidence base – but what is the current thinking in the role of occlusion/parafunction in the aetiology and progress of periodontal diseases? I am joined by Specialist Periodontist, London-based Dr Richard Horwitz to discuss exactly the correlation and link between occlusion and periodontitis. https://youtu.be/QhZfDxR4SoY Are those with Anterior Open Bites more likely get to get Perio? Full video episode out soon. Need to Read it? Check out the Full Episode Transcript below! This episode’s Protrusive Dental Pearl I picked up from Dr Dipesh Parmar on his fantastic Composite course Mini Smile Makeover – it is to use a sectional posterior matrix band (like the B100 from Garrison or Tor VM) in a vertical fashion to create perfect mesial and distal contours for your anterior composite restorations such as Class IVs. Maestro Dipesh Parmar teaching Composites I also revealed that the team at Doctify are offering all listeners to this podcast 50% off for the first 4 months – you just need to tell them you listen to Protrusive Dental Podcast. https://youtu.be/bpBSFyCFrN0 Full video episode with Richard’s cases – only on the website and on Dentinal Tubules I had a really fun chat with Richard which included so much: When and why would you consider occlusal adjustment/equilibration in a periodontally compromised patient, perhaps to reduce occlusal trauma? Can Periodontal splinting help in these parafunctional patients? How can you check for fremitus? What role can appliances have in the stabilised periodontal patient? Listen to how I ruined Richard’s canine guidance! If you enjoyed this episode, you will like my episode with Endodontist Kreena Patel on Cracked Teeth! Click below for full episode transcript: Opening Snippet: I'm checking the occlusion as part of your periodontal examination is a must, is something which is often left. And it is really important and valid. Just because I don't feel it's the primary cause of periodontitis doesn't mean to say I find it any less important in the progression of periodontitis and it has to be addressed, especially when I show you those cases where they were in part exacerbated by a trauma from occlusion. If you don't treat the trauma from occlusion, when it's exacerbated a periodontal problem, it's never going to be treated. So it's really important... Jaz’s Introduction: I am getting very nervous and very anxious. Why? Because it’s been so many episodes, since I talked about something occlusion related. So when this happens, I get very nervous. So let’s focus back in, let’s pull it back into occlusion. Can we? Today is all about perio and occlusion. I’m joined by my good friend, specialist, periodontist, Richard Horwitz, and we’re gonna sort of do some myth busting or perhaps some changing of perceptions, can occlusion cause perio? I’m about to say can perio cause occlusion? That would be stupid. Can occlusion? And what I mean by occlusion is Can someone with a dodgy bite, are they more susceptible to perio? Is that a thing like you know, occlusal trauma, we know that occlusal trauma exists. But what role does occlusion actually play in periodontal bone loss? So that’s the kind of stuff we’re covering today. So welcome, everyone to Episode 47 of the Protrusive Dental podcast. Now another massive thank you is due for everyone. around about a month ago now something pretty awesome happened. We crossed and I say we because you know, you guys are like family to me now. A lot of you on the Protrusive Dental community Facebook group. And I love seeing you guys there. We crossed 50,000 downloads, right. And this is pretty big, right? A lot of podcasts that get created. It’s like businesses like nine out of 10 new businesses will fail in the next five years or something like that, it’s a famous quote, right? So a lot of podcasts started and they never reach 50,000 downloads. And so I am so, so thankful to you all for giving up your time to listen in your commutes while you’re chopping onions while you’re gardening, that sort of stuff. And you know, it’s amazing. So thank you community, Which reminds me, I need to change your name and I need your help. If you can think of a better name for the people, the good people who listen to the podcast from something else other than family would really, what will be a good name for you guys, right? Help me out. I’m gonna post on the Protrusive Dental Podcast Community Facebook group as well. And hopefully we can get some good ideas you can Instagram me as well as @jazzygulati. But before we get to the episode, of course, I owe you a Protrusive Dental pearl. This episode’s Protrusive Dental pearl is when you’re doing anterior composites, and you want to get a very nice contact point, which we all do, obviously, the choice is often twofold, okay, and this could also be applying to resin veneers, you could either do the mylar pull technique, or you can do and I’ve talked about that once before, some episodes go in like a little mini episode. But I want to focus in on the other technique, which is actually using a matrix band. And the matrix band of choice. And I’m sure many of you know this already, is to use a posterior sectional matrix band. But use it vertically. Okay, anteriorly, I’ll see if I can get a photo of this here, of me doing this. Now, one of the places where I saw this being demonstrated in the best way and showing both of those techniques, ie using a matrix band on its side vertically, such as the Garrison B100, or the Tor VM soft one that can be used as well, compared to using the mylar pull technique and the nuances around that was the Mini Smile makeover course. By Dipesh Parmar, he really went over a lot of in so many cases and stunning case after case after case. And he really goes over several indications. So you know, hat tip to Dipesh Parmar, amazing, talented clinician that he is. And so the tip is to use a posterior sectional matrix band vertically and that could be you can use many but the B 100 seems to be quite popular for that and garrison, I tend to use, the Tor VM which is like a Russian brand, you can get that from Incidental Limited. So I hope you enjoyed that little tip next time when you’re doing a class four you can just put the matrix band in, a bit of a wedge and then this is once you build up your palatal walls. So you build up your palatal wall and then two handle the interproximal. To get the nice contour, these curved bands can be quite good to get the right contour mesially or distally, for example, so I hope that little tip helped. Before we dive into the episode, I want to discuss one more thing that we discussed in a previous episode with Shaz Memon, we talked about personal branding for Dentists. So if you haven’t heard this episode already, do check it out. And my pearl then was to check out this review collecting platform for dentists called doctify, which I quite like. I get quite a lot of reviews from patients and some of my patients come from there, it’s a great way to collect genuine reviews from your patients. And it looks really nice. When you type in a dentists’ name on Google that it comes up. Now the feedback I’ve had from a lot of people is that hey, you know, my I’m an associate. And when I told my principal, that I want to start collecting reviews for me myself, they’re a bit funny about it. Which is a real shame. I think, like putting myself in the shoes of a principal, I get it like you don’t want your associate to be taking their own review because one day, what if they go then all those reviews go with them. But that’s kind of the point that associates self employed, okay. But think of it as a good thing, like its associates getting good reviews, and getting patients coming through the door for the associate, then they’re doing their own marketing, right. It’s a great thing. So I think there is a win-win to be found in that. So for those people who are still reluctant, Alex from doctify very kindly, he came up to me and said, Hey, for anyone who listens to Protrusive Dental podcast, he can do you guys a favor, he’s willing to do 50% of her first four months. That way you can test if this is something that works for you, if you’re able to collect reviews at a decent enough pace, and you will be if you prompt your patients, there’ll be happy to review usually, so 50% off for four months. And so check it out. All you have to do is when you sort of are discussing with doctify about signing up, they’ll ask you, hey, how’d you hear about us, you say protrusive dental podcast I want the 50% off for four months. And just give it a go, you know, give it a go four months, see what you think. And then the more reviews you collect, the more you get out of it really. And then you’ll be able to see the response that you get from that. So I hope that helps you guys were sitting on the fence. And I’m hoping that even the principals who want to get doctify for their practice will be able to benefit from that. Anyway, let’s learn all about perio and occlusion. Main Interview: [Jaz]Richard Horwitz, it’s great to have you on the Protrusive Dental podcast. Thanks so much for coming on. [Richard]Thank you for having me. Really grateful for you inviting me. [Jaz]No, you’re a friend of mine. We went to uni a few years above me at the time. And I then went on to, after qualifying, I met you on a tube. And that’s when I found out I think you were commuting to Eastman at the time to do your perio training. And then next time, next thing you know we’re at an Indian restaurant, we’re at Regency we’re having lamb chops and whatnot. So again, over zoom. Who was locked down been for you. [Richard]It’s been good. It’s been tough, but I always like to, you know, find the silver lining and be positive. And for me, it’s been a bit of a paternity leave as I think it has been for you as well. So it’s been great spend time with my daughter who’s 11 months. And yeah, seeing her crawl for the first time, putting herself up on bits of furniture, gnawing bits of furniture while she’s teething. So it’s no it’s been really lovely. And I would never have had that. At the same time, I’m excited to go back to work so yeah [Jaz]I’m the same. Absolutely. So the same exact journey as you seeing the crawling development, standing or the mischief and stuff. So it’s been great. So yeah, my son’s 10 months, 10 in a bit months and Sophie’s obviously 11 months so it’s I think we’ve shared something special over the last few months but yes, we’re both a keen to go back to work. And for me, it’s going to be Friday, supposed to be tomorrow. For those listening by time this episodes published are hopefully going to be in the swing of things and not dressed as spacesuits anymore. I mean, I’ve got my hood now, so I will be dressed as a space alien. You’re gonna be going for a mask? [Richard]I think so. Yeah. It means I can’t do my [designer stubble], but yeah. [Jaz]But for those who don’t know who you are, Richard, please tell us about yourself and what you do day in day out, your speciality and what we’re gonna be talking about today. [Richard]Okay. I’ll start at the beginning. I’m born in London. So grew up in London, went up to Sheffield and had my fantastic years there. Met yourself in Sheffield. And yeah, it was a great experience people that are so warm and friendly. And I always have a soft spot for Sheffield and I do miss it. Friends and family’s in London. So I came back to London and did my foundation training. I found that what I liked and didn’t like in that year. That was a really important year for me. Every time I found a case which I wasn’t so sure about and I wanted to refer I wanted to see what the specialist was doing that was so special. I want to be able to see what could be done that I couldn’t do or didn’t understand how to do? So that was a great learning curve for me. I also found out what I really didn’t like as well. We’re chatting before I’m so happy to see your last podcast with Mark Bishop. He’s fantastic tutor, he taught me confidentially. He was a brilliant teacher. He’s a brilliant teacher. In that in those first years, when I was a general dentist, I found out what I wasn’t good at. And just to put this in perspective, I made a denture for a patient in practice working out in Dunstable outside Luton. It was a great practice I made this denture. It was one of these [Ivory] style because I was into perio I thought I knew I know I wanted to Perio and I want to make it cleansible. I made this [ivory] style denture for [Jaz]spoon denture [Richard]Spoon denture. It’s pretty much with two [inaudible] Okay? It was not something to be proud of, but I made it. I don’t know why I forgot about this denture, obviously, because I don’t keep a recollection of every denture I make. I go to do my training, at Eastman, my three year specialty training in perio. Enjoying it. It’s great. In our final year, they send us out on this outreach program to work in specialist clinics in the community. And I work in this place in Bedford. And I see this patient of mine in Bedford, he recognized me. I didn’t recognize the patient. I looked at this denture and I thought, God that is a bad denture. I didn’t say anything. Well, I just said When did you have your denture made? Because I think you need a new one. He said you made it for me. [Jaz]He said Really? Sorry. Really? Sorry. [Richard]I think I was thinking I’m really sorry. Moving on. Yeah, so it’s a bit of a long story, but it’s just an I’d say in finding perios my specialty. I found things I didn’t like in general dentistry. I was never, I didn’t want to. I felt like I really want to excel in things I loved and perio, surgery, implants were the subjects which I really wanted to master. And [Jaz]So that was a DF1 year where you decided in your journey? [Richard]I’d say the end of the DF1 and DF2. Yes. [Jaz]And did you do any shadowing of specialist and if you don’t mind me asking how many specialists did you shadow for how long? Because I something I advocate for young denstists, DF1s is just go out there and shadow to get the maximum exposure. How was your journey in relation to shadowing and mentorship? [Richard]So I shadowed an orthodontist, endodontist, prosthodontist, periodontist. I shadowed really every specialist, I could find. Anyone who I’d refer to, I’d ask if I could shadow. So I could see the journey of my patient. Patient was fantastic, which I am carrying and interested in them. But it’s a great thing to do to see your patient through the journey. And then you get to learn what the specialist does, which is great. And you find out I mean, actually in Sheffield, I loved endo, and I was I want to be an endodontist. Right? Okay, so and then I got into foundation year and I thought I really I find I’m stressing like every time I do an endo I get stressed, I get heart palpitations, I’m just go home. What a stressful day. Every time I was doing Perio, First of all, I was thinking God, there’s so much I don’t know. And even through my course I remember the first few weeks was hand scaling. We did like a hand scaling masterclass. I had no idea about these hand instruments. I just didn’t, there was so much to learn. [Jaz]There’s so many nuances, right? of every instrument that a manufacturer, which angle to hold it at, which part’s cutting, which part’s non cutting. The various little things which we know we just think we just picked this up and we just started scraping, but really, there’s a way to do it and there’s, you know, you can actually be doing a lot of damage or doing something completely ineffectively if you’re doing it wrong. [Richard]Absolutely. And what I felt was that within my journey, there were so many new things which I just didn’t know which I was thirsty to learn about. So that’s why I kind of fell on to perio. And yes, mentors are really important. I had, I mean I shadowed Jonathan [Lac] is a periodontist who I shadowed a lot and he encouraged me he was teaching at the time at Eastern encouraged me not to go forth with periodontal training. [Jaz]So in a moment, am I right that you work in, Wimpole street or Hollis England? [Richard]So I’m in Wimpole street and Hampstead between two and I do lots of lecturing for the CPD department at Eastman on aesthetic dentistry course and other courses. [Jaz]Excellent. We now know a little bit more about you Richard. Let’s get into the main topic for today, which is the main reason why I had this lovely pink background for you reflects Perio I’ve never gone for pink before so [Richard]I’m the loving the pink. First of all what I have a lecture title which I call thinking pink. So that’s all over it. But yeah, it’s like you’ve got the lighter stipple pink at the top of health and then the purple disease at the bottom. I love it. With contrast is I mean my computer is too old to be able to produce a background like [Jaz]Brillian. Thank you so much. Well, the thing I wanted to talk about is something that you know we were talking on Instagram and stuff something you know, you know, I’m already have an interest in it’s occlusion, it’s parafunction, it’s bruxism. So I know that in perio there are some very good long term studies now, you know, way more than I do about this entire subject, but I think of studies like is it [Axel or Axelsen?] like those sorts of studies where they’re in private practice over many decades, they follow up patients and they show that wow, we can really keep teeth with we know with good periodontal treatment and good oral hygiene regime. So I know that perio is quite rich in literature and some of it is actually very good. How much is there in relation to the role of bruxism and parafunction and Perio? [Richard]So short answer, not a lot. But I’ll go into in a little bit more detail. It was really the 70s where we had most of the studies which we now come to look to when we’re treatment planning, when we are looking at occlusion in perio and occlusion is a big part of my examination. Now, various periodontist will have different levels of importance put on occlusion, and people will go with different schools of thought. I think it’s incredibly important. And it’s a little bit of chicken the egg, which came first when it comes to perio or occlusion. But I think perio is all about removing causes, controlling the etiology. And whilst not to give the game away, whilst trauma from occlusion is not the cause of periodontal destruction. It’s an exacerbating factor. And like all modifying exacerbating factors, risk factors, they need to be controlled if there can be. So it’s important. And I’ll talk to you when we chat more really about why I’ve come to that conclusion as well. [Jaz]But Richard, if you want to study something on that it’s almost impossible to study, for example, if we’re going to design a randomized control trial, looking at parafunction bruxism, there’s so many variables, how long the teeth are in contact for? To what force? The size of the masseters? What kind of parafunction? Is it clenching? Is it excursive?, and also, all the myriad of inflammatory factors of blood tests, vitamin D, is just too many practice to be able to come up with such a study. So really, we might never know the truth. But we You sound like we have some good ideas. So tell me a little bit more where your, what your current thinking is. But I also want to know, as a periodontist, what is it that you look for in an occlusal exam, which may be different to I look for? Or maybe it might be the same? [Richard]I think it will be similar, but we’ll see. I mean, I would look for guidance, I’d look for anterior guidance, I look for lateral excursions, I’d see if there’s parameters in any teeth, I’d look to see incisor relationship and is there an anterior open bite, which may have further implications on the posterior dentition? I would look for wear facets, I’d look for non working side interferences and all these things that can influence bone loss. And because we do know, I mean, when you look at these studies, now the human bones aren’t many, because how can you design a study? And when they do have them, they read the original historical ones that cadavers, which had tooth wear, and then you can’t really it’s difficult. So they have these hypotheses, like you have our hypotheses and Glickman, which shows that there’s zones of CO destruction and but I think when further studies were done on on Beagle dogs, they managed to see histologically what’s going on when you apply a certain force on a tooth and if that, if there’s periodontitis, with the trauma from occlusion, or if it’s in a reduced periodontium, or if it’s in a healthy periodontium so all these things are measured. And all of these are important in forming an overall idea of the [role]. So and what we know from those studies is that we know that if you are a periodontally healthy dog, okay? Or human, you can infer that you’ll get no further periodontal destruction. You’re getting sorry, you’ll get no further pocket depth increase, if there is no inflammation, if there’s no periodontitis. What you will get is bone loss. Okay? You’ll get a widening of periodontal ligaments, you’ll get mobility increase, but you won’t get pocket increasing, you won’t get clinical attachment loss. Okay? [Jaz]But surely by bone loss that inverse clinical attachment loss. [Richard]No. So you because you would still have the connective tissue attachment and the junction epithelium so you won’t lose any attachment, but radiographically you’ll see changes. But the relation is bi-directional, because if you have that to then let’s say this is a Bruxist, who doesn’t have any periodontal disease, and lets you treat them with a splint, Splint therapy, and it works really well. Once that trauma from occlusion is address, you will find radiographic infill of the either bony defects or widen periodontal ligament. So that is reversible if there’s no inflammation. [Jaz]Let me just hone in on that. Let me just hone in on that point. What you just suggested is that if you have someone who through your therapy, you’ve managed to control that oral hygiene, you remove any sort of factors contributing to inflammation. And now the the other piece of the jigsaw puzzle is controlling the forces which you’ve suggested with a splint, for example, right? And that as a package, so one without the other, you know, you can’t let inflammation continue but as a package that has helped to see radiographic healing, am I right in what I’ve been further? [Richard]So you were talking about someone with periodontal disease, this can be in someone without periodontal disease, you’ll still see widening periodontal ligament and bony defects if they have torn from occlusion, but they won’t have increased pocket depths [Jaz]A new type of bone loss that I’ve classically described it radiographically is a funneling, [Richard]Yes, because you get that movement within the periodontal ligament. But what you’re doing, you stretch the periodontal ligament, you stretch the attachment, you’ll will get bone loss, but you won’t get pocket reduction unless of course there is inflammation. So inflammation is the key here. If there’s inflammation, you will exacerbate the amount of bone loss and the progression of the periodontal disease. So we know that from both the North American Studies and the Swedish and the European studies we have. [Jaz]So the next question I asked you is when and also we can talk about the how but or do you even consider the role of occlusal adjustment and equilibration when we’re, when you’re carrying out your periodontal therapy or post periodontal therapy to make sure that all the factors are controlled, so the forces being one factor, which may exacerbate the issue. So do you subscribe to school of thought whereby occlusal adjustments and a calibration are part of your practice? Is that make sense? [Richard]Absolutely. So as I’m not a prosthodontist, and I’m not a general dentist with occlusion as my subspecialty I very much leave it to the experts in a sense to adjust the occlusion as they see fit. Whether that be by taking occlusal records mounting and simply adjust articulator and finding out what the consequences of adjustment is, whether that’s creating a splint in Michigan or any other time is up to them in a sense. My view is it can’t be left. So if I was, if I had a patient with trauma from occlusion, I would definitely discuss it with the dentist and say, I would recommend either an occlusal adjustment or a splint therapy as you see fit. Because I can guarantee if you had 10 dentists in a room that all say different ways of treating trauma from occlusion and some will be splint therapy is the only way and some will be adjustment’s the only way and each of them would think the other one what they’re suggesting is complete the outrageous so I think really my view is both work adjusting and using splint. So whatever, at least you address it and you don’t ignore the problem. I think the issue is yes, without inflammation, it won’t progress. But if you have a patient with periodontitis, they’re prone to inflect inflammation. And when you keep them a three months, the recall you always see sometimes, okay, but all the pockets under four millimeters, you have some control but something will pop up every so often. And it’s important not to leave an exacerbating factor there which can cause further deterioration. So I think it’s always something that needs to be addressed might not be the primary cause, but it can certainly make things worse for the patient. [Jaz]Brilliant. Now, when we read these texts of like Dawson, and if you subscribe to some of the what Pankey teaches that actually in a patient who is parafunctional or exhibits bruxism that you may be more likely to see a recession, is there any, because sometimes I see a patient and I know they’re known bruxism, they’ve got their large masseters, they’ve got cracked teeth, and occasionally you see some teeth with recession now, recession is multifold, multifactorial, we know there’s the bio type that’s in play, we notice their brushing habit, which is very, very heavily implicated, how much bone they have all those sorts of things. But what do we know about recession defects? Stemming primarily, potentially from power function? Is there any causal link there? [Richard]Personally, I think there’s too many factors. For one to pinpoint occlusion as being the cause of recession. More often than not, it’s to do with over brushing, under brushing, aberrant frenum biotypes, things like that. It’s a difficult one. Because yes, if you have trauma from occlusion, you can get, what trauma from occlusion you won’t get attachment loss. So you will only get recession if there’s inflammation. So if someone is not brushing, because they’ve got an aberrant frenum on the lowered central incisor, it’s really hard to clean. Also, that lower incisor is in fremitus. Okay? And it’s just wobbling and it’s highly mobile, has a lot of guidance concentrated on that one tooth, probably going to exacerbate the recession. So it definitely has a role. I don’t think I’m going to factor. So it’s totally fine. [Jaz]Yeah, a lot of it is and you know, like we said that the right at the beginning, we will never be able to prove exactly, there’s too many variables. But what we do know so far is exactly what we said, these factors are contributory, they play a role, but they’re probably not the main big player here. There’s other things, you know, like inflammation might be, you know, brushing habits we need to consider. Now I’m very aware that some students have started to listen to my podcast and some young dentist. So just explain fremitus, What is it? How did I mean, we’re going back to basics here. what is it? How do you look for it? [Richard]You need to look at their static [equilibration] when they’re biting together what the relationship is, and when they’re moving in left and right lateral excursions and anterior guidance, what movement there is on the teeth. With fremitus, if unnatural excursions, the teeth are mobile, and there is a heavy contact on that tooth. And then that’s something which you need to be aware of and mark it down. You need to mark it down because it can have an adverse impact on the health of that tooth. [Jaz]I think you’re right about checking parameters in static, the simple way I like to explain to young dentists that when people bite together, you shouldn’t see that teeth move like piano keys, you know how they just flick out. And the other thing that you could do is if you put your fingers on their teeth, you know you’re indexing, so your actual fingers on their teeth. And when they bite together, there might be the odd tooth where you feel excessive movement in the PDL. And that’s a good way to check as well, because sometimes not always visual, it is by how you feel it as well. [Richard]Absolutely, that’s a really good I mean, using your finger is really the best way I use finger and ask them to bite together and that’s when you’ll feel the tooth move. So here I’ll just show you a couple of cases. [*shares the screen] Okay can you see? [Jaz]Yeah beautifully. [Richard]Okay great so this is a patient it’s difficult to tell here but complete wear facets on posterior dentition. This guy is 35 years old okay? Anterior open bite okay and here [Jaz]So that’s what i mean it’s good you mentioned that because there’s a lot of people who believe that by someone who has an AOB that their posteriors are “overloaded” and therefore you may see some more periodontal destruction so i think based on our chat so far, it may play a factor but we also need to be mindful of inflammation and all the other bits but we can take care of this so it’d be interesting to see how you manage this post in terms of the periodontal, the pink stuff but then also the forces. So please I’m keen. [Richard]So pink stuff, control of the inflammation you go through basics, you have your systemic phase you check the medical history, you check the roles of diabetes, you check the roles of any medical systemic influences, you go to the initial phase which is your non-surgical therapy this is also all things which we do in general practice which we’re all very good at. And then we have a residual pocket on this lower left five we have a residual pocket with bleeding it’s eight millimeters in depth it’s not going to respond to further non-surgical therapy because of this defect there’s a local factor stopping the closure of this pocket. So what is going on well it’s not just the inflammation that’s caused the bone loss, the bone loss has been exacerbated by a occlusal problem so yes i can treat the inflammation surgically okay but before i treat it surgically to try and regenerate this area the occlusion needs to be addressed. Now no amount of occlusal adjustment on a patient with an anterior open bite is going to reestablish the anterior open bite so splint therapy is i think personally if i’m wrong but vital in this kind of patient unless you want to send them to the maxillofacial surgeon. [Jaz]Yeah if someone’s got a you know skeletal AOB that’s quite gross like that then yeah splint is a reversible way to give them a more desirable distribution of forces which will then help the situation [Richard]So once you have that then we need to look at surgically what I do. I’ll just show you that so here this case was we use guided tissue regeneration. We preserve the papilla so this little bit of a papilla here we preserve and we suture back together over a graft material this is a bovine derived caldera bone graft and then we have a collagen membrane which is supported by the bone graft and we suture together and then we reduce it from an eight millimeter pocket to a four and we have radiographic infill. Now if we weren’t to adjust the occlusion or if we weren’t to address the occlusion I should say, it’s very likely that any inflammation in that site will lead to further bone loss and reestablishment of the injured bony defect so it’s really important now you’ve noticed that there is a rather bulky but there is a composite splint holding these teeth together ultimately i mean do you want me to talk about the splinting or when? [Jaz]Yes. So i’m going to ask about splinting but just worth mentioning for anyone watching this right now, some people listening obviously, but what we can see here is which has shown is guided tissue regeneration very nicely. It looks very neat surgery, we can see the wear facets, as you mentioned, quite flat on that molar and premolar and in this case, the bone, the bony healing looks fantastic. And we see a thick composite splint the front which we’re gonna talk about in a minute, but the reason it’s thick is because trust me, if it’s thin it will break, you’ll have a cohesive fracture. So it’s sort of happening. I’m sure we learn through trial and error. But these things have to be thicky. You made that mistake once and he learned you make is because you can get away with. [Richard]It’s more trial and error, believe me. [Jaz]Absolutely. So I mean, before we come on to the role of splinting generally for mobile teeth, where we suspect maybe occlusal, or not in a role, I want to touch on why, you know, I’m not expecting you know the answer to this, because I think no one knows the answer to this. But why do some people with OABs go throughout life without any issues at all? and others have these sorts of issues? Why are some of them having cracked teeth? And while others do not want? Why are some having periodontal breakdown? while others are not? It’s, you know, we just don’t know, it’s just one of those things. Now, I have theories, right? My theory is that those who are producing a lot of forces, I mean, yes, they have their AOB, but unless they actually at nighttime, if there’s 17 and a half minute chewer. And their teeth are touching, you know, 17 and a half mins a day, then they’re not much forced. And you know, the teeth aren’t taking that much force. But at nocturnally during parafunction, we can produce four times as many forces as we can, when we weren’t aware of it. So if you tally up the fact that we have a parafunctional patient with AOB versus a less parafunctional, patient or non parafunctional, which are rare nowadays, with an AOB, then that may have one role. The other theory that I subscribe to, is that there’s perhaps a weak point. So if we look at their teeth, if we look at their periodontium, and we look at their, you know, TMJ, for example, then one of these, they may, you know, naturally have potentially a weak point, whichever is the weakest link or suffer. So for example, if the bio type of their periodontium is hard, and you know what I mean, the type that I’ve got exostoses that are never going to get perio because they’ve got surplus of bone. If they smoked 50 a day, they don’t brush but you know, they don’t have any perio because they’re almost genetically immune in a way to Perio right? So they got really fantastic periodontium but then they’re getting cracked teeth because the parafunction is actually overloading the teeth, but not overloading the threshold of perio. That’s a theory. What do you think about that? [Richard]I think you hit the nail on the head when we said genetic, we know whatever Health Survey you look at, whether it be the adult dental health survey the [NHIS] in North America. If you look to the initial studies on periodontitis in populations in Sri Lanka, it’s all the same. 50% of people have periodontitis. 10% have severe periodontitis, their roundabout is pretty much the same wherever you go. Now. So even in untreated populations, treated populations, Western civilization, third world, it’s all the same, which means there’s a massive genetic part to play. Yes, there are risk factors. You’ve got the smoking risk factor. You’ve got diabetes as a risk factor, which have strong links to periodontitis. But it’s all to do with susceptibility. And this is what I tell patients all the time. I’ll say that if I’ve diagnosed them with periodontitis was for periodontitis, I say unfortunately, you are highly susceptible to something called periodontitis. Okay. Whilst I mean, whilst 90% of people, as you said, could have brux to their heart’s content or could not brush so their heart’s content and not have perio disease. Okay, the 10%. If they just look at pluck up for a second, they’ve got periodontal disease. And so I think shifting the blame away from you’re not brushing your teeth, to you’re susceptible to it. So you really need to, it’s a difference. And patients respond a lot better to it, because they are empowered by the fact that they know that they have something which is that which they are susceptible to. And that can be managed. And I think it’s really I think I’ve gone off on a massive tangent. [Jaz]No, no, I think what you said was great. [Richard]Back, yeah, current back to the tangent. Why do some people with AOB don’t have that bone loss? Because 90% of individuals aren’t susceptible to severe periodontal disease. If they are in that 10% they’re gonna get it. [Jaz]And do you find that your patients with AOB now this is an interesting question, because I just thought of it now wasn’t scripted or anything. So those patients with AOBs that are susceptible to perio, are they also having the same bone defects around their anterior teeth? [Richard]It depends. There are lots of Okay, if they are smokers, they’ll get defects anteriorly because by virtue of where they hold the cigarette, you get a local vasoconstriction as a general as well, but more localized to the front but or if their mouth breathers and it’s hard to brush up you get great inflammation and theory. So there’s lots of factors. But it’s often I’ll see posterior bony defects around patients without to recognize, [Jaz]So Richard, what I want to know you showed that Thick composites splint, obviously, and we discussed here why that may be necessary. So tell us about the role of using splints, for example, some dentists may believe, and I believe the work from what I was taught that actually splinting is more for patient comfort, it won’t necessarily prevent them from losing their teeth or whatever. But I feel like the evidence base is Harris. Am I right, Harris? Harris? Is that a name? Okay. These are just names. [overlapping conversation] In Harris, a legend. But anyway, so I believe the literature suggests that splinting has its role, but it won’t, you know, if you just splint everything, their Perio won’t magically stop. But what about those teeth were you, What about those cases where you believe there’s an occlusal role, where the splints come into that? And what I mean by splint is actually sticking teeth together, not the sort of appliance to wear, which we’ll surely touched on [Richard]Yes, which can get confusing, especially when talking to about it. Where’s the role? You’re right. The only benefits of splinting teeth is patient comfort. However, there are other roles when you do need to splint teeth together. One of them I showed you before, if you’re doing any regenerative surgery, what you rely on is wound stability. So if you need wound stability, you mustn’t have any mobility in the teeth. So for the six months healing, you need to splint to be to enable that bone to grow in the area in a undisturbed sight so it’s important splint. Then why are composite really whatever it is, is just has to be rigid. It has to be splinted. Now, you mentioned it needs to be a thick so a composite doesn’t break. That’s exactly true. But also, if you’re not making any occlusal adjustments, and you’re not removing the cause of the trauma from occlusion, that splint will break. Because if the patient’s a bruxist, they will just break through it. So the cause of the trauma from occlusion needs to be adjusted there with adjustment. So there is definitely a role for occlusal adjustment in that sense, in the isolated tooth sense. [Richard]I can actually show you a little example of that as well [Jaz]Yeah please let’s have a look [Richard]Okay let’s have. Okay so this case and another case which i use guided tissue regeneration on but this she was 30 years old and she had a really it was quite localizer periodontitis to this upper left 4 now there are local risk factors including a root groove and a furcation involvement. Now fortunately when i raised the flap and looked around the tooth there isn’t a vacation involvement yet but there often are roots, you often have two roots on a premolar you often have a root groove but also this patient did have a high contact on the upper left 4 that tooth was in fremitus and also on lateral excursions, it was in group function on left lateral. Left lateral excursions, it was in group function so if we’re going to treat this tooth regeneratively and we’re going to splint this tooth, if we splint it and don’t adjust the occlusion and in group function they’re going to break that splint every time they chew. So that needs to be addressed. Now whether it’s addressed by an adjustment of the premolar or adding composite to the upper left canine, we’re adding restoration to the upper left canine to [Jaz]canine riser [Richard]Yeah if it has a canine riser whatever it is, it’s really down to the dentist to decide what’s more appropriate and i think really in this case taking some cast seeing how much adjustment you’d have to do compared to using a canine riser will tell you a lot and so if it’s just a small adjustment then it might be just better off to make that small adjustment. If you’d have to really cut into your dentine to stop the lateral excursion contact then you’re better off looking at a canine riser. So i think that whichever approach you take it doesn’t matter but it needs to be done before Splinting. Now this was just a very simple adjustment which was done and it was splintered. [Jaz]I think we can see from the clinical photo, but would you say that the cuspal inclines of this patient were very steep, would you say? [Richard]Yeah, I mean, it’s hard to tell from that photo. Yes, it was. [Jaz]So it’s, you know, it’s interesting because when I think of his most patients, most people are actually in group function. You know, as much as we think canine guidance is important. Most people actually in group function, especially if you’re with any force, if you think if someone’s in canine guidance, you get them to press together really hard, as if the parafunction and then go incursions, they are quite usually in group function. So it’s good to mention here that some schools of thought suggest that actually, more than anything, having it to make sure there’s freedom from centric, so that when patients do have produced an excursion, that it’s smooth, and if you imagine a sort of steep cuspal incline, and if patients now moving their mandible as almost like knocking and hitting against that premolar it could be that rather than just pure group function, we will never know exactly, but this is just the sort of theory is why some people would group function and why certain teeth and when so it’s all a very interesting area, which will never really have the answers to but I just think it’s another thing to consider that maybe it could be that to it because of the fact it had a steep cuspal incline. And there was a lack of freedom from centric ie teeth are knocking [Richard]Yes, no, absolutely. What I’m going to be looking at is when I see this back, is whenever anyone talks about occlusion I don’t know if this is just me. It will be terribly embarrassing. I do notice it. Whenever you talk about inclines and guidance. I’m doing this [*Richard clenching] I’m checking my own, and I can’t help it. And I’m gonna look back at this video and I’m gonna see myself doing it and be like, oh, but I hope you guys out there watching this or doing the same thing as me and I’m not the only crazy person. Okay? [Jaz]I think many people are. Absolutely. [Richard]I can’t help it. With more [lateral] excursions that, am I my group function? Am I canine guidance? [Jaz]What do you think you are? What do you, before we had this chat, what did you think you were at? [Richard]I was canine guidance, but I’m very aware that I’ve got big canine facets. [Jaz]Okay, now if you actually press together really hard now we can do it live now, you’re going to press together really hard and you’re going to go to one side you feel your posterior teeth touching? [Richard]I don’t want to admit it, because I feel like I’m admitting defeat. But yes, I do. [Jaz]It’s food for thought. It’s just that this is why I love this area so much because it’s so fascinating. Sorry, the day the day I broke Richard’s canine guidance. I’m sorry. [Richard]It’s okay. It’s alright. Don’t worry, I’m over. [Jaz]You’re less superior human from when before we started this podcast. [Richard]Now the secret’s out. It’s out for everyone to see. [Jaz]We’ve discussed a few things, we discussed some controversial topics. Okay? And you know what, Richard? The truth is, some people will listen to this, right? And they will say, they will completely disagree with you. And it’s true, right? Because that’s a school of thought, that’s a background they have. But I think where we have as evidence based conditions, we have to follow the evidence, okay? And right now, it’s very much strongly in the favor that occlusion and parafunction, bruxism has a role, but it’s not the primary role. Now, some clinicians get very upset about this, because actually, they placed the role of occlusion as a way higher, in particularly in terms of and we can talk about this if you don’t mind is particularly in implant failure. Some clinicians suggests that actually, one reason why implants may be failing could be more to do with forces than any other factor. What was the evidence say? What do you think about that? On the same topic of forces and in a periodontal disruption, tell us about implants cuz obviously, they don’t have any PDL. They don’t have the sort of proprioception. [Richard]Some mechanical failures, definitely, no doubt about it, and they need to be managed really carefully. And implants are a they’re a treatment modalities for choice. It’s like a denture or like a bridge, whatever it is, you need to have the occlusion in mind. So any restoration, you need to consider the occlusion, if they are bruxists, you need to address it before you start with your implant restorations and planning. So that’s without saying biological failures. It’s very much an inflammatory process. And I feel the general consensus is that it’s inflammatory process. You have factors which can increase the risk. I mean, there are when I present on periodontitis, there are so many risk factors. I mean, you’ve got all the ones you’ve got with Perio. So all the systemic ones are Perio, pretty much with diabetes, and smoking, etc. You’ve got then local factors, like the implant design, okay, you’ve got things like the angle from the implant platform to the contact point. So recently, I was randomized control trials showing increased angle with more than 30%, higher incidence of bone loss. You’ve got implant surfaces, [polish collars, or a one stage implant versus with soft tissue component versus a bone level, so many different things. How many times you change your [button]? And that’s another debate, if you keep changing the route, does that. So I feel Yes, occlusion has a role, but there are so many others. And I think if you focus on occlusion as the bane of all problems, I don’t think it’s right. But yes, with mechanical screw loosening. And then if that screw loosening, will lead to an abutment loosening lead to micro gap with [ ? ], yes, it could cause bone loss. I don’t think it’s occlusion straight to failure of implant. Some kinda get sorry, I’m going to, sometimes get an initial failure through overloading it too early. That’s different scenario in itself. [Jaz]Yeah, I see a point that and I know that I think the, you know, the answer is somewhere where, you know, there are too many unknown unknowns. But you know, what it’s good practice at the moment is not to, yeah look for everything, your patient as a whole, all the factors involved. And like you said, it definitely has a huge, definite role in mechanical failure, screw loose things and whatnot, whereas the biological from what we understand at the moment is mostly inflammatory. And that’s, you know, it’s cool that you have that stance, and I respect it. And that is the main stance, you know, that is the body at the moment, that’s the evidence body at the moment, and any periodontist would back you up. But, you know, there are people who choose, who are not guided by the evidence and have these theories, and that’s all there is, but we have to sort of, you know, it’s everything is in balance, and you have to reflect on it. [Richard]I mean, evidence is based on testing theories. So it’s not a bad thing to have different theories and different opinions. I think that’s what drives us and makes us better dentists. So that’s fine. But we I mean, that’s why I say that checking the occlusion as part of your periodontal examination is a must, is something which is often left. And it is really important and valid. Just because I don’t feel it’s the primary cause of periodontitis doesn’t mean to say I find it any less important in progression of periodontitis. And it has to be addressed, especially when I show you those cases where they were in part exacerbated by a trauma from occlusion. If you don’t treat the trauma from occlusion, when it’s exacerbated a periodontal problem, it’s never going to be treated. So it’s really important. [Jaz]Thank you so much for coming on. If anyone wants to reach out to you, because I know you do a bit of teaching at Eastman. Maybe they work locally to you and they want to refer your patient, How can they reach out to you? [Jaz]That’s very kind Thank you. So reach out to me. Well, I have an Instagram account, london_periodontist, my email richardhorwitz.co.uk and any questions on trauma from occlusion or anything else, I’m happy to help. [Jaz]Richard’s a very helpful guy. If you ever messaged him, he’ll always be willing to help you out. So I would you know young dentists who want maybe some mentorship on Perio, implant that sort of stuff, you know, Richard’s a great guy to reach out to. So buddy, I’m wary the fact that Sophie will probably waking up soon and so as well as Ishaan. So thank you so much for coming on, mate. It was discussing something very controversial with you. Jaz’s Outro: So there we are, we covered lots of different points. And essentially, it is something that I hope most of us knew already that as far as we know, a bad bite or occlusion or even parafunction just by itself won’t cause Perio, but for that susceptible patient, it’s one more aggravating factor that can lead to trauma, that can exacerbate existing plop in periodontal disease. So hope you found that interesting. Thanks so much, Richard, for coming and sharing all that specialist information with us. I’m so sorry, Richard, for ruining your canine guidance. Okay? That one’s on me. I apologize. Okay? So, thank you so much for listening all the way to the end, guys, and I’ll catch you in the next episode.

We think we know what a tooth looks like….but most of the restorations that we see on a daily basis…how many of them have truly natural or morphologically correct tooth anatomy? I am joined by Dr Jurgita Sybaite who is the undisputed Queen of Tooth Anatomy! (Full video on main website) She works with Dr Basil Mizrahi and is passionate about Restorative Dentistry. https://www.youtube.com/watch?v=70KQXO9CGkY Full Episode only on Protrusive.co.uk Need to Read it? Check out the Full Episode Transcript below! The Protrusive Dental Pearl for this episode is to use a Thermacut bur (by Dentsply) to remove the interdental papilla when managing very deep, subgingival caries – an example case was posted on Instagram and Facebook for you to see how this works. https://youtu.be/thz07JOrDts What does Brad Pitt have to do with Tooth Morphology?! The three steps to learning and mastering anatomy: learn, draw, sculpt! What if you cannot draw? What tips would you give to anyone to improve their morphology (anterior and / or posterior) I play devil’s advocate – is knowing anatomy THAT important now with digital wax ups and tooth libraries? Should we really invest our valuable time with Tooth Morphology? Which is the best way to learn, additive or reductive? Wax? Soap bar? Do we need to master tooth anatomy if we are not a ‘cosmetic dentist’? Do check out Jurgita’s Instagram profile to see clips of her producing stunning anatomy! She also is a prominent teacher in this field – check out her website! https://youtu.be/9sTqKOznXpA Do we need to learn Tooth Morphology that well? Now we have Digital Tooth Libraries…? See what Jurgita has to say If you enjoyed this episode, check out Composite vs Ceramic with Dr Chris Orr. As always, hit subscribe on your podcast platform and leave a review on Apple Podcasts! Click below for full episode transcript: Opening Snippet: I think what we very often believe is that 'oh, we need to have a very light hand and be so artistic in order to be reproducing a really nice shapes of the teeth which is not true. Our hands they are not you know organs with the brain themselves. Our hands, they're merely following what our brains tell them to do. So the better you've trained your brain, the better you can recall it from your memory, the easier your hand will be able to follow with any material... Jaz’s Introduction: What makes your restorations look amazing? Well, the more natural they look, the better they will look. And I think to mimic nature, we need a really good understanding of anatomy. Now, this is something that we think we know when we qualify at dental school that we know our tooth looks like right? But actually, it comes with a lot of practice and determination and actually knowing in your mind’s eye what a tooth should look like. And that can be easier said than done that we all know what a central incisor looks like. But until you appreciate that the gingival zenith, that’s the highest point of the gum, for example, is usually around about a millimeter distal, or that the mesial line angle is straighter and the distal line angle is curved, these little subtle pieces of information that will be the difference between getting a flat and lifeless looking central incisor with something that looks really natural and reputable. And that’s exactly why we have Jurgita on the podcast today. She is anatomy queen. We’ll be talking about all things anatomy, how to make our restorations look better, starting from tomorrow, what is the work that you need to do now to get to a stage that you’re improving your anatomy. The Protrusive Dental podcast I have for you is something I’ve posted on my Instagram recently I posted a case of deep caries. Now it was a lower second molar and the patient had a wisdom tooth. So lower second molar distal very deep caries, the kind of thing that would ruin a Thursday afternoon, right? And it’s basically very subgingival caries. You may even need a root canal in the future but the tooth is still restorable the tooth, you can still save the tooth. So what is my way to manage these sorts of situations? Well, something I picked up from lots of Facebook groups [ ? ]. Tomorrow tooth, Maciek, who’s going to be a guest on a podcast sometime soon is that to get the best result. And to allow the rubber dam to actually be sealing the base of the cavity. And to allow your matrix to actually create the seal is you need to get rid of that inflamed excessive gum tissue, right? And the best way I found from learning from these people, is to use a thermal cut bur. Now, a thermal cut bur is a bur without any diamonds. And I believe that and don’t quote me on this is dentsply produced this. And they initially made it because they have this thermafill root canal system, obturation system, right? And the way that you would remove the plastic and the gutta percha will be to use this diamondless bur, right? It’s like this naked ball bur. But we found that actually, if you use it on full rev without any water, it just cauterizes and burns and just destroys the gum completely out of the way and just rid the papilla, you get rid of the papilla. And now you can actually get the rubber dam to seat and create a seal. And now you can get that all important seal with the matrix band. Because it’s not constantly battling the papilla, you can actually get better wedging as well. So that’s my Protrusive Dental pearl, consider using the set of the thermal cut burs. At now, if I was getting a set, I’d get the assorted set. So you get like a really small one, slightly bigger one, like the big one and a massive one, because interdental spaces all varied in different sizes. So the smaller one opens smaller gaps, the bigger one for the larger sort of molars that are sort of tilted away from each other. And with that, after you anethetize a patient, you can just remove the gingiva, you place the restoration. And don’t worry the gingiva in as long as a bone is there, it will grow back. Okay, the bone sets the tone, remember? So that’s my top pearl for you today. The other thing I would say before we just jump into the episode is really a thank you to guys. The last month or so, the podcast has really exploded, a lot of new people discovering I’m getting lots of messages saying ‘hey, I’m just found your podcast.’ People are bingeing it, which is like wow, the most flattering thing ever. And want to shout out Dr. Lincoln Hearst, whom I don’t think I’ve ever met before, but this guy has been so so kind, alight you name it. He went on this a couple of Facebook groups and just without me asking him shared my Michigan splints overrated episode and he just said so many little lovely things. So, Lincoln, thanks so much for sharing and getting so much exposure for this podcast. I really appreciate it. So thank you to everyone who’s continuing to support the podcast. I’ve got some great content lined up for you. Hope you enjoy this episode with Jurgita and I’ll catch you in the outro. Main Interview: [Jaz]How’s your day? [Jurgita]Been all right. I’ve been off been waxing the teeth so amazing. [Jaz]Okay, cuz you do I’m great thank you. You do your own wax ups? [Jurgita]Well no not often. I did the wax up from my own teeth so yeah, that I do myself but [Jaz]Why? Why are you waxing up your own teeth? I don’t get it. [Jurgita]Even dentist made some dentistry sometimes [Jaz]Are you get to make a stent for yourself and like you know put heated composite and do your own dentistry? [Jurgita]No. I won’t take it that far. I just waxed up. [Jaz]Okay, there we are someone who is truly dedicated to dental morphology doing your own wax ups and stuff and that’s exactly what we will be talking about today, Jurgita. Is it Jorgita or Jurgita? Like how do you say your name? [Jurgita]Jurgita with a silent j? [Jaz]So you are Hungarian? [Jurgita]No, I’m not. [Jurgita]Oh my god. [Jurgita]Try again. Try all the European countries that you know. [Jaz]guys might know it. Let’s not go. Long Night and very embarrassing to me and you. I just I don’t know why I thought you’re Hungarian. I’m sorry. [Jurgita]Yeah, no, I’m Lithuanian. [Jaz]Okay, fine. Fine. I know a very good Lithuanian dentist. [ name ] [Jurgita][Gudalif.] Yeah. [Jaz]He’s a really cool guy. [Jurgita]He’s my dentist as well, by the way. [Jaz]No way. He’s your dentist? [Jurgita]Yeah. [Jaz]Okay, that is pretty cool. So are you from Vilnius? [Jurgita]Yeah, I used to live there. Yes. And I worked there for quite a while. But funny enough I only met him after I left Lithuania. [Jaz]That’s cool. And he’s also someone who’s like you’re like you also someone who’s really good at the whole morphology. He obviously doesn’t teaching on posterior morphology nowadays. And I’ve seen a lot of your work as well, which is why I wanted to have you on the show today. And you know, let’s just kick right in. Tell the listeners a little bit about yourself, Jurgita. [Jurgita]Yes. So I am Jurgita with a silent J. I am Lithuanian as we found out already. I am a restorative dentist graduated from Eastman. I did my masters in restorative dentistry. I work in two lovely private practices in London. I’m very lucky to have amazing places to work. One of my places is with Basil Mizrahi. He in Harley Street in London. Another one is in Holborn with an amazing team. And yeah, so I do enjoy I truly am passionate about tooth morphology, not necessarily per se as tooth morphology I just find that it is very, very helpful for me. And it improves my dentistry. [Jaz]Well, anyone listening to that, and you know, Basil Mizrahi is an internationally renowned dentist. And the fact that you get to work with him and that you have access to his brain like so much so much. It makes me incredibly jealous and envious. So with that is an amazing feat and that you pretty much have him as a mentor, right? [Jurgita]I do. Yes. I think I’m very lucky to have him. I’m very lucky to have him as my mentor. He’s my friend and I think we make an amazing team. He teaches me the whole new world of Dentistry of traditional mechanical dentistry, like almost like a bit of an old school and I bring in a bit of a new well vog dentistry, a composite bonding, digital dentistry. So I think Yeah, I’m very lucky to have him. I’m very lucky that we are such a great match. Yeah. [Jaz]So I’m just trying to understand the dynamic and workflow with you and Basil Mizrahi like, in my head I this is what I’m imagining. Because I know the kind of Dentistry he does. He does like these massive rehabilitations that patients spend years in orthodontics and years in temporaries. I’m joking, obviously. And finally, [Jurgita]You are not that far off. [Jaz]I know but I have to say that I guess but yeah, he really you know that the step ladder of success that he’s known for, you know, one thing at a time, and the beautiful precision dentistry, but I’m just trying to think of like, do you see your own patients from beginning to end? Or is your relationship, working relationship in a way that he will send, refer the patients to you for some aspects, and then he will do some aspects like, Can you just tell me about your working dynamic? [Jurgita]Yeah, it’s really a bit of a mix and match. I have my own patients that come to see me through my Instagram from, I don’t know from Eastman, from the courses and I follow them through from the beginning to the end. There are certain things that I don’t do so inevitably I will be referring those patients either to Basil or other specialties, Endodontics, Periodontics So I really tried to focus on restorative dentistry and only do this field so yes, of course I will be referring my patients out for certain things. As it comes, when it comes for Basil and how we work, so yes, there will be certain things he doesn’t do. So obviously he would refer those patients to me. Patients that prefer for one or another reason to see me they would come to see me. But it really depends other cases, again, I would do myself from start to finish. Again, I asked him as a mentor, so I tried to, you know, to use him as much as I can like, I asked for his help. He asked for my help. So I think we thought of developing our and refining our relationship as we go. But it really is a mix of everything. [Jaz]Well, that’s amazing as one young dentist to another, I think it’s amazing where you’re at the moment and I’m excited to see your development, how you grow and grow and your work on Instagram. The sort of the documentation that you produce is phenomenal. And I just want to say like, women in dentistry, you know, we want more of a presence and to have role models like you for all women in dentistry is just absolutely amazing. And let’s just go back to the first time I got exposed to you, was I think it was 2018, it was the Dentinal Tubules Congress. I may have the year on but it was it 2018? [Jurgita]I believe so. Yeah. [Jaz]Time flies. Well, you You came on stage and you just blew us away with your lecture. I actually remember the opening part because I’m part of Toastmasters. And we practice public speaking and stuff. And the bold start you made was something so awesome that do you practice public speaking on the side? Do you do Toastmasters? [Jurgita]No, absolutely not. It’s a very strange thing that you’ve mentioned the Dentinal Tubule. So that was my first ever public speaking. [Jaz]No, get out of here. Get out of it. I know buy it, you’re lying. [Jurgita]I swear to God, it was our first ever public speaking exercise that I did. It was on that stage over there. I did ask around, you know, okay, I have no idea how to do that. Would you tell me now, you know, what do people say on the stage. So I did kind of look at, you know, Apple presentations and very famous talks, and I just tried to kind of take the best out of which, refine my own recipe, you know, you can’t really blindly follow the recipe that is given there for ToastMaster. So you have to adapt it to your own personality, which you’re comfortable with. And I think I just did what I thought I wanted to do and I talked about something that I’m passionate about, and I’m really glad that you liked it and that people loved it. [Jaz]You came across so well such that I remember when you made that initial you asked you started your lecture with a question. I’m sorry, I forgot what the question was. I remember the elegant way that you asked this question like, like you just asked a beautiful question. And then you captivates everyone’s attention. And then someone next to me was like, she’s obviously had some professional training and I’m not lying. That’s what’s he said [Jurgita]Really? [Jaz]Yeah, so his name is Dave. He actually won some of the Toastmasters in Ealing, I believe in the local area. So he’s a very high level Russian speaker and he sort of had said, Yeah, she’s obviously our training. So that’s amazing what you told me there. And you were talking about tooth morphology that day. And I guess it was you who changed my mind about it in a way that I used to think drawing teeth was a complete waste of time. And then you you showed me this amazing like how to make my crappy drawings amazing and how I can then translate that clinically and the importance of it, which is what we’re gonna talk about today. So tell me why are you so passionate about tooth morphology, dental morphology? [Jurgita]Well, Jaz, I must be a very boring person. And I have nothing better to do with my life just to be interested in tooth morphology. But jokes aside, I think that passion for it, it really comes from my personal experience with the tooth morphology, with the knowledge and what it did to my dentistry, how it elevated my dentistry and subsequently, how the satisfaction from my own job really grew exponentially as I started looking into that topic, because I think we dentist we all find ourselves at that point in our careers, no matter whether you’re a newly graduate, or we’re far away into the dentistry, we find ourselves at the point where no matter how many courses you go to, no matter how many articles you read, and you try and you try to gain that experience, you kind of hit the ceiling a little bit where you know what suppose what is the poster look like but it doesn’t really come out like that in your own work. And this is how I felt I think early in my beginning of my career, you know, I used to try really hard and it doesn’t look the way I want to do. So what I used to think that, okay, must be my materials that I’m using, I’m going to change all materials. So you’ve changed the materials, you change the instruments, you even change the technician and it still looks crap. So I think it’s the realization about tooth morphology, that it is actually important it came when I was doing my masters at Eastman and you know, we have a lot of modules, different topics, different fields of dentistry. So, I used to go to the occlusion topic module, right, it’s very extensive, and then it would briefly mention, ‘you need to know the morphology, if you want to achieve good occlusion,’ then I go to crown and bridge module and then they briefly mentioned that ‘Alright, you know, if you want to prep the tooth, really well, then you need to know tooth morphology.’ All right, then we start talking about treatment planning, and then they again emphasize how important is morphologies. And I was thinking, Wait a second, why do they really mean that tooth morphology? What does it even mean? You know, to know the tooth morphology? I know a tooth morphology I’m a dentist, I know the tooth morphology. And then I realized that do I really? What kind of training did I get about the tooth morphology in my undergrad? This is where we get it, right? And I was thinking yeah, okay, I remember when we were playing with a plasticine that was way early in dentistry training, the early days and as far as I was concerned, at the time, my priority was to be able to distinguish between the upper and lower premolar,right? And that’s, I think that’s how I came out. And then slowly, gradually started looking into that topic, reading different kinds of books, playing with plasticine, again, going to the courses and I was amazed myself, how it transformed everything, all my direct restorations, the treatment planning, the prep, the indirect restoration, everything it transformed, and I think, Oh my god, this is such a gap in dentistry. It’s not actually being taught that well, and we do underestimated and I think that’s how I grew it. And I wanted to spread the word and started to come up with the maybe courses and integrate that into our teaching with Basil into in our academy. So yeah, that’s the story. [Jaz]Well, Jurgita, you get you raise a great point, because I think you mentioned it like as dentist as we qualify, we feel like we know it, because we should know it, something we should fundamentally know and we feel we know it but it you know, all dentists listening to this right now, the next unless you work with Basil Mizrahi, the next five patients you see in their mouths that you look at, just look at the morphology of the restorations. And then think to yourself, can we as a profession and should we as a profession be upping our game? Right? And I think yes, and I’m sure you definitely say yes to that. Where do you think we need to start? Like, where can we start if you want to up our game with morphology, because I think you’re totally right. If we improve our apology, we improve so much more than just how good things look. So just tell us a bit about how to get started and what else can benefit from better morphology. [Jurgita]I probably will make a detour to answer that question is I think what you mentioned it’s exactly what it is we dentists we are a bit clueless if I be if I may be so daring about morphology and we are sort of are ashamed to admit that, you know, after having done dentistry for like 15, 20 years, how can you not know the tooth morphology? And everyone, I believe that everyone really can benefit from it. It doesn’t really matter what kind of dentistry you do, whether you’re a single tooth dentist guy or a full mouth rehabilitation guy. Here’s a couple of factors, Jaz. So we all like to do all this dentistry to the best ability, right? We try to improve every single time in everything what we do, okay? And here is another fact, we’re really crappy at morphology. And with dentists, we try to recreate a tooth form day in and day out. But we don’t know what we are trying to recreate. So I think this is the big gap. And you know, for the sake of the argument, you know, if you are that guy who says that, well, you know what, I do my single crown, I don’t really care about the aesthetics, about the pathology, how is going to come out? Why do I need to bother? And so I think, okay, if you’re a single, you know, tooth guy and you’re trying to do that crown you’re interested in I suppose the longevity, but how you’re going to achieve that if you’re not going to have the right anatomy, the right contact points? How are you going to be sure that is not going to fail? Or even more so than nowadays, cosmetic dentistry. Composite veneers are so big nowadays, right? [Jaz]Everywhere. Can we just say that it’s just a bit too much? I think I personally I see so many beautiful teeth that just need some whitening and that’s it. And I’m seeing composite being plastered all over. I guess if you’re that dentist placing all these composite veneers and of course, your anatomy needs to be good, but what about the, and I’m sure It comes is what about the non cosmetic dentist? What about the humble general dentist just working on posterior teeth? Is it as important for them to be really awesome with their morphology as long as things fit together? [Jurgita]I think what you are, what you mentioned now is and I’m really glad you brought this up, everyone thinks that morphology is only referred like concerns only cosmetic dentist or aesthetic dentist, which is very far from the truth. Now just think about that, teeth they look ver,y they have very specific shape this is how nature made it and they do have that shape for the very particular reason, for the very particular function which dentistry we call the occlusion, okay? And I think the morphology and occlusion it is not really possible one without the other. So you can’t have good function, good longevity without having good morphology and vice versa. But what happens interestingly, when you get that good morphology, cosmetic, and aesthetics is the natural byproduct. So if you will restore the form Yes, you will be concerned on a posterior teeth thrive here you’re one you know, you have good occlusion for the teeth, not too chip, not to break, quite stable, have enough room for your porcelain restorations, whatnot, you will restore it to the good shape and form. It will look aesthetic. It cannot not look aesthetic. It’s just the natural byproduct. I think it’s very important. [Jaz]Okay, so Jurgita, I get your point. But okay, nowadays, everything is going digital, right? Like you send something to your technician and he or she is like digitally waxing it up. And maybe your, the whole workflow is getting digital. And even to the extent that if you’re doing your composites nowadays, there’s so many different companies like smilefast, for example, where you get your stent, the anatomy is pretty much built into it. So should you therefore be investing, if you’ve got a finite amount of time, which we all do? And it’s like a budget, for example, in terms of what we how much time we invest in learning? Should we instead of learning about morphology, invest that time and learning how to work the different software’s how to do a digital wax up? I’m playing devil’s advocate, I appreciate that. [Jurgita]Yeah, that’s a really, really good point. And don’t get me wrong. I love digital dentistry. And I have to admit I’m quite early on. And I’m quite on a steep learning curve, I’m trying to really catch the wave and ride it. And I think it’s an absolutely amazing tool, especially when you plan your cases, especially when you have the patient in your chair and you try to visualize both for the patient, for him or her to be able to see and for yourself, when you’re doing the treatment planning, right? You need to start with the end result at the end of the day. And you know that you know, the basics of the treatment planning is that you start with the end result. And then slowly you try to work your way backwards, to see what you need to do in order to get to that result. And I think they’re the digital dentistry is absolutely amazing. It’s very, very quick. But also there are a couple of issues with digital dentistry. I think people take it that as it digital dentistry is artificial intelligence, as if you upload everything to the software, and it will do everything for you. Well, at the moment, at this point in time, it’s not artificial intelligence, it’s still being used by human intelligence, which means that there is an actual person, whether it’s going to be you or dentist or the technician is an actual person who’s going to sit behind that software and pull out this tooth libraries, tooth morphology libraries, he’s going to upload that and select the form that fits to that patient will adjust that form in order for the occlusion to be well and functional, etc. So you still need the human power, and you still need to have that knowledge. So let’s say you can solve that just by exporting everything to the lab and the digital technician will send you back the models you can do your mock ups, etc. Now imagine what happens if you know technologies don’t get everything right there is an actual human being in your chair. Now the tooth morphology on its own without other smile components such as the face, the lips, the gingival components, the skeletal pattern means nothing right? So you’re going to try everything that digital software produced for you. And you’ll see that you know what? It doesn’t look right. So if you don’t know the morphology, how are you going to tell the software change this or change that? It’s not the artificial intelligence, you need to have the power for you know, in order to use the digital technology. And I love how [Paolo Khanna] once said and [Paolo Khanna] if you know he’s a brilliant dentist from Brazil, who wrote a beautiful book about tooth morphology and he is now very big on digital workflows from start to finish using everything and he does those cases absolutely beautifully. So I really loved how he once said that digital dentistry and all those softwares and tooth libraries, they are not going to let you to jump and skip the morphology completely. But they will allow you, those software’s will allow you to achieve that end result quicker. And me personally, what I have, what issue I have with digital dentistry at the moment is it’s bloody expensive. You know, if you want to have, if you want to have a full access to all the libraries to use all the tools that they have, it’s enormous money at the moment, obviously, that is going to change at some point. But at the moment as it is now. It’s quite expensive. So I probably use it at the beginning for the treatment planning. But then I ended up using quite a lot the analog stages, and I am in control still. It’s not the software that’s in control. I am in control. And I know what fits, what whether it was selected, right. So yeah, digital dentistry is great. It’s got the huge potential, you’ll still have the human being in your chair. And you’ll need to know how to apply that knowledge and digital dentistry also, is everything to do with the indirect restorations. What about the direct one? Who’s going to tell you you know how to sculpt the tooth when when you do everything directly? So yeah, it’s useful. It has its place, definitely, but it can’t replace human brain. [Jaz]So two things I want to add to that. One is, for example, if you’re using some of these, like stent systems, like smilefast, for example, what if they come in with a chipped tooth one day, you don’t have a stent, you need to know the line angles, need to know all that sort of stuff, you need to have those skills with you. So that’s the whole direct thing. And the other one I guess and a comparison to what you said about if a technician is selecting from like a skin or a template of an occlusal morphology, he still needs to know his morphology to choose, which is the best one for that scenario and I guess the best comparison would be for those of us who do Invisalign, the outcome simulator is an outcome simulator. It’s not the human. And how many errors do we see from the outcome simulator doing these ridiculous movements, which are just not possible in biology? So we have to respect that AI, like, just like you said, it’s AI and you still need that human expertise. So this leads nicely to the next question, which is if I want to improve my morphology, what’s the first thing I should do? What are some practical, tangible tips you can give to listeners about improving their morphology today? [Jurgita]Right. So there’s no easy way to do that I can show you that I can take this disclaimer. Now, there is no easy way to learn the morphology, it requires a lot of effort, it’s quite time consuming. And I know I’m a dentist and I know how we love you know, you go to the course on a Saturday, you come back on a Monday and you want to apply all everything that you’ve learned you want to charge for this. So here’s the thing with a morphology, it’s not going to happen. Instead, it’s the knowledge that you’re going to be able to apply to every field of the dentistry that will massively improve the quality of your dentistry. Obviously, better quality of the dentistry the happier patients are, the happier you are yourself. The happier the patient, the more patients you get, the more patients we get, then you start earning a little bit more. So it’s quite a slow process. However, I’m a firm believer that everyone is capable to learn that if you give them a recipe, so I the way I teach the morphology is it’s not that I you know, I’ll explain you how the upper left teeth is. And then you’re going to go back to the practice and repeat it. I think there is a protocol that needs to be followed. But it’s better to follow in order to be more efficient. So the way I teach it, it consists of three steps. First, stupid simple actually, First, you need to have the knowledge meaning that you need to visualize the morphology. When you look at the particular tooth, you need to understand what is it exactly that you’re looking at? How to understand one thing that our eyes are only going to recognize those features of the morphology that our brain taught us to see. As if you know, well imagine very simply, if I know Brad Pitt, and I bump into him on the street, I’m going to oh my god I bumped into. Yeah. And then if I don’t know, but I’ve never heard of him before I can bump into him three times a day, it will not make difference for me. Right? So it’s the same with the morphology, you look at the tooth, you have to understand what is it about the tooth that makes it right? or wrong? What are these features that you’re looking at? What are these cusps? Why are they there? What are they? Where the tips are etc. So I think the knowledge and that visualization is a very important step. And this is what you do first, you get the books, you look at the pictures, you look at any courses that you know, you may find online. You can read about it. But then you need to take an action from that. Now imagine, Jaz, what would happen if I show you the same Very beautiful, cute upper left six, I can explain everything in detail about that six for you. And I tell you now go and do that in the mouth. Would you be able to do replicate that straightaway? [Jaz]No, of course not. I mean, surely one needs to practice, practice and you know, close your eyes, visualize it and keep practicing. Now, that’s my guess. [Jurgita]Exactly. So I think, you know, practicing that on our patients, we do that inevitably, we practice that on our patients, but it’s very difficult to be predictable and quick. So therefore, I think the step number two, that is very useful and is very controversial, and is very hated by a dentist is when you start drawing the tooth. And I don’t necessarily mean a very fancy drawing with shadings and colorings, it might be a very simplistic, very, very simple drawing, where you repeat the same tooth over and over again, it allows you to make mistakes, correct them quickly produce numerous amounts of the same drawing or different drawings on the same tooth, and learn how the human form is supposed to look like. So if you make a mistake, you can correct it. And what I mean by that is that you know, when you draw again, and again, you teach your brain to recall everything that you what you call that, because knowledge when you were reading about it, it just trains your brain to recall, to reproduce all these features that is somewhere there in the brain. And finally, the third, [Jaz]What if you can’t draw? What if, like me, you can’t draw? And that’s a common objection you might get. Yes, number one, you said, you know, what the tooth looks like, and the case so i can completely learn the anatomy of an upper first molar, the transverse ridge, visualize it, but then like, when I’m drawing it, I look like I drew like a banana or something, you know, like, [overlapping conversation] [Jurgita]You know, I mean it’s a very common question that I get, or the remark that I get from the courses. And oh, trust me, the eye rolling that I’ve seen on the corner, like, what are you trying to become Picassos here or what? Well, if you don’t want to be an artist, well, don’t be, you’re a dentist, you don’t need to draw the tooth, you know, for it to look very three dimensional. Drawing, there’s a difference between the artistic drawing when you try to produce the piece of art and there is a drawing as an exercise to learn the tooth morphology. And that is two completely different things. So me, for example, I can draw you a very realistic tooth, very three dimensional tooth, does that mean that I’m an artist? Jaz, you should look at my drawings. I mean, they are complete rubbish. I mean, you asked me to draw a horse, it will be a disaster. But I can draw a tooth because, to me drawing is very methodological, it’s very logical, I follow a very precise sequence, thinking about the features of the morphology, and training my brain. So you know, if you don’t want to do very complicated drawing, draw me like or try to draw me the shapes and the symmetry of six interior teeth, for example, right? If you can do that, I know that somebody who can draw six anterior teeth to the symmetry to correct proportions to correct alignment, will, is likely to be able to reproduce that on maybe composite veneers the next day. Whereas the other way around, it’s not very common. Don’t be an artist. [Jaz]So, visualize, draw, but it doesn’t have to be fancy 3d, it could just be getting the sort of the basics right, so you can take them step one even further and basically be able to train your hands. What about number three? [Jurgita]So the number three is the three dimensional sculpting of the tooth. So this is when you literally, whatever you’ve learned, whatever you visualized, whatever you’ve drawn, you’ll surprisingly, how quickly you’re going to be able to reproduce that three dimensionally with any material on any tooth. I think what we very often believe is that oh, we need to have a very light hand and be so artistic in order to be reproducing a really nice shapes of the teeth which is not true. Our hands, they are not you know, organs with the brain themselves, our hands, they’re merely following what our brains tell them to do. So the better you’ve trained your brain, the better you can recall it from your memory, the easier your hand will be able to follow with any material. [Jaz]So what’s the best material so if someone’s listening to something, okay, I’m going to do number one, I’m going to learn my anatomy. Number two, I’m going to start drawing I’m gonna start following on Instagram, I’m gonna start copying what you do. And then number three, I’m going to start sculpting. When it comes to actually sculpting and getting that practice. I see some technicians and they’d like carved soap for example, is that the best way that you recommend dentists who want to get to number three or stage three In practice, is that a good way to do it? Or is there a different product or material way to practice number three? [Jurgita]So I’ll tell you this, a soap was really good during the lockdown. Because we didn’t have an access to our dental materials. And the soap was probably the cheapest or the easiest one, and accessible to everyone. Any material is really good. Whether it is the bar of soap or amalgam, or the composite, or the plasticine, or the wax, any material that you can achieve the three dimensional form. Now, me personally, I do quite like wax. And I did that a lot, actually, when I was learning morphology myself, but I know that dentists hate two things, drawing and wax up. Because the argument is that, you know, I don’t do my own wax, my technician does that for me. And so why would I waste my time? And I get the point, but I always have like a question at the back of my mind, why wouldn’t you learn the wax up? Okay, yes, you would rely on the technicians and Jaz you probably know, you know, you probably have your, the technicians that you love. And they are damn good. I love my technicians, I learn a lot from them. But are they always getting the result 100%? They don’t. Of course they don’t they’re not gods, they don’t have the patient in the chair. They don’t see the patient’s face, they don’t see the mimics and the dynamics of the face. They can’t get it right. So imagine you’ve got the full mouth wax up, you see the patient for the mock up, the trial, and you realize that doesn’t really look right. So what you’re going to do? You can bring the technician and say, Well, I’m sending it back, can you give it another go with it, and then send the wax up again, you try again, you can take photos, or in my opinion, what I typically do is I take the wax I adjust what needs to be adjusted, be the shape, be the length, or the proportion, or embrasures, what not. And I adjusted myself, I send it back to the lab and I say okay, I’ve done the adjustments, just make it a bit neater, clean it up and we can proceed. So it’s a really good material to actually, it’s very useful material to know how to use. But I think what people really do love is to use the composite to try sculpting, because that’s a material that we’re very familiar with. We use it a lot every day. And it you can use it in small increments, you can trim it, you can add, you can subtract. It’s a really versatile material. I think this is the reason why I came up with this kind of idea to organize a course where I teach morphology and composites on the same course. And I teach the composite, everything you need to know about composition, like layering, etc. But I also teach the morphology and morphology through composites and I think it marries so well everyone is so used to that. Results are great and you learn a lot about composites, you can apply that straightaway in the practice. And it’s easy. Honestly, in my personal opinion, I think that our composites, especially when it comes to the anteriors, anterior teeth, they look as good as your morphology. It’s you can be layering left and right. But if you’re not going to finish it right, so the morphology, it’s not going to be right. [Jaz]I’m just visualizing, practicing that stage three. And I agree with you, I think composite makes somewhat sense. And I’m glad that’s how you teach it. It’s just hands on something we’re very familiar with compared to the wax, but I’m just thinking, as a dentist, we’re always usually doing additive stuff, right? We’re adding increments of composite. So for me, I mean, if I’m going to be practicing my composites, the bar of soap doesn’t appeal to me as much because the soap is reductive. Do you think if you completely miss the reductive techniques, and you only focus on additive, is that okay? Or do you think to train the mind you need to be able to practice the third element with both additive and reductive to be as good as you? [Jurgita]You’re quite right additive and subtractive techniques, they are quite different. And I think when it comes to the bar of soap, it doesn’t really matter. The purpose of the bar of soap is to train the morphology meaning is that you are going to try to sculpt the shape, the cusps, the fissures depth, marginal ridges in the right place, is going to take time it’s going to be time consuming. Now subtractive in the mouth, it’s way more difficult. And what is the next material that is subtractive in the mouth that we use clinically? It’s the amalgam. Now have you tried to sculpt the morphology from the amalgam? It’s really, really difficult because what you do you overbuild the tooth first and then you use very flat instruments to sculpt at Very delicate rounded morphology. So, it’s extremely difficult to produce naturally looking convex surfaces with an amalgam. So, therefore, the additive techniques, such as composites, there are way more probably easier for us dentist. Now, having said that, when I say additive techniques is the composite always purely additive material, most of the time it is yes, but then you need to do the occlusal adjustment, then you need to do the finishing where you really try to flow through you know, the primary morphology, the secondary morphology, the tertiary morphology, you still end up subtracting. So, in my view, if you are training and learning, it doesn’t really make much difference which technique you are going to be using when it comes using that in the mouth, additive is easier, but you will use the subtractive methods as well. [Jaz]I’m just so I was just reflecting how it’s been four years since I’ve placed an amalgam stick to additive as well. Jurgita, thank you so much for a really insightful three steps that you shared with us there. I think people can go away and be able to retrain their minds and try and pay attention a bit more about learning this sort of what makes a tooth, that tooth you know, what are the key occlusal features or morphological features of anteriors and then do the whole drawing it and then eventually sculpting it and obviously they can reach out to you for help with that. Your Instagram handle if you want to share your Instagram handle? [Jurgita]Yes, it’s drjurgitasybaite, you probably need to put that out I think just because it’s unpronounceable also unsellable. [Jaz]No worries. [Jurgita]I am on Instagram, I have the website which is called toothmorphology.com. So have a look around in there. I am also on Facebook with my own name and as toothmorphology.com. So if you have any questions, need any advice of what books to read, or even if you want to take a shot of what you’ve been doing, you know, at your free time with the morphology, I’m always open to having a look and maybe giving you an advise to it. [Jaz]That’s amazing. And I just remembered a really cool video you posted recently, whereby you had, I think you had some models, and then you were doing some anterior equilibration adjustments. And then you had all the red dots and then maybe one tooth is missing. And you go step by step about how to adjust the palatals of the upper incisors to get even contacts. I mean, if you guys are on Instagram, you definitely need to check out the profile, just to watch that video alone, as well as all that beautiful content that you have in clinical and non clinical. It’s really great. And as well as you one last question, Jurgita is you’ve done the Masters at Eastman. And Eastman is like known as this hardcore Institute, right? Tell us about one tip you can give us about work life balance. [Jurgita]Oh my god, I am a really bad person to give that tip because I have no work-life balance. And I think when I did it, my personal life was a bit on hold. And I’m very grateful for all the family and all the friends and the ones who still remember that I exist. But yeah, I think always remember the people that try to support you in everything you do. Our lives would be absolutely meaningless without them. And try to enjoy everything you do yourself, both in career and in your personal life. [Jaz]Amazing. Jurgita, thank you so much for coming on Protrusive Dental podcast and sharing your insights. It’s been great having you on today. [Jurgita]Thank you very much for inviting and I look forward to upcoming Protrusive Dental podcasts. Thank you, Jaz. [Jaz]Thanks so much. Jaz’s Outro: So there we have it. Thank you so much for listening all the way to the end, it’s probably time we started to draw some more teeth, starting to carve some more soap, wax up your own teeth like she’s you know, Jurgita’s so dedicated with all our wax ups and whatnot. So that’s amazing, and I really appreciate the chat that we had with her. If you found value from that please let someone know who may be struggling with their anatomy. Or if you’d like to leave a review if you listen on Apple. So anyone who listens on Apple, please subscribe, and please consider leaving a review. That’s how the podcast grows. So I’ll catch you in the next one. Thanks so much for listening all the way to the end.

Interproximal reduction (IPR) is a useful way to create space in Orthodontics, but it has to be performed carefully to make sure it looks good and is effective. If you are new to Orthodontics or have never performed IPR before – this episode is for you. I am joined by Dr Devaki Patel, specialist Orthodontist, to discuss IPR techniques and the nitty-gritty details and answer the questions you always wanted to ask about IPR…but never did! https://www.youtube.com/watch?v=v9dAcHtPiCU&ab Need to Read it? Check out the Full Episode Transcript below! GDP Orthodontics has boomed in the last 10 years. More and more of us are treating orthodontic cases and often this may be referred to as Short Term Orthodontics (STO), or Anterior Alignment Orthodontics (AAO). Protrusive Dental Pearl: If you view a ClinCheck or a similar 3D simulation, make sure that the initial bite/occlusion is set yup correctly. You will be surprised in how many cases this may be wrong and it has not been picked up! If you are starting out with Ortho cases, IPR may be something that worries you. You may have questions like: Which are the best strips? Are strips better than a bur? How should you hold/orientate your bur? How do you perform IPR when there is crowding? What are the secondary benefits of IPR? Should you place fluoride after, or is that overkill? A really great and helpful guide to IPR ipr-orthodontics-guide-dentistsDownload If you enjoyed this orthodontic episode, you may also enjoy my episode with Dr Almuzian on whether Class I molars are really that important? I appreciate you all listening – do subscribe on your preferred podcast platform so that you do not miss the latest episodes. Click below for full episode transcript: Opening Snippet: You know, 9 out of 10 patients, they'll come in saying, I don't like this. And like you said, as the teeth straightening, they spend so long looking at their teeth, they'll find other things that are like. So it's just always worth gathering this information at the beginning, you know, as much as you can. And so you can exceed the expectations rather than under deliver... Jaz’s Introduction: Do you remember when you had to learn a new skill? Maybe in dentistry, you are learning a new technique, a new procedure? Maybe you were learning orthodontics? What were the things that you’re most worried about back when you were starting out? Or maybe you’re thinking about going into orthodontics? What is it that worries you? You know, for me at the beginning, I have to say IPR was a tricky subject, because it’s not really the theory, because the theory makes sense. You know, you create some space, you move some teeth, the theories are fine. And we know evidence base suggests is pretty safe, if done well. And we’ll talk about that in this episode. But it’s more about the How to and How not to do it wrong. Because once you’ve seen the photos of when it has been done badly, then that’s all haunts you. So when you’re there doing your IPR, you’re under doing it at the beginning, you’re not doing, you’re not creating enough space, and therefore you’re not meeting your treatment objectives as fast enough. Or if your God forbid, removing it overzealously or your technique is such that it’s leaving your teeth in a slightly suboptimal morphology. So these are all the considerations I was having when I was starting out IPR. So then I consulted some mentors and a principal who was very helpful in helping me to do the right techniques using the Bur. My principle taught me how to use it. And I’m very thankful for that. It can be a topic that can be of concern to some people, because we all want to do a fantastic job for our patients. And we all want to do it safely and effectively. So this episode will hopefully cover a lot of the nuances of interproximal reduction for orthodontics. And I hope it helps, I’m joined by Dr Devaki Patel, who is a specialist orthodontist. And she’s gonna be showing us a few diagrams, a few of the strips that she uses, and how to use all these sorts of tools, when to use them, when not to use them. Because you know, it’s very much case dependent. Every case will come at you with this unique challenges. And therefore you have to adapt your techniques to be specific to that patient you’re treating. The Protrusive Dental Pearl I have for you is an orthodontic one, because chances are if you’re watching or listening to this, then maybe you’ve already started dabbled in orthodontics, maybe you do a fair bit of orthodontics already. So it’s only right that I make the pearl an orthodontic one. And chances are but nowadays, you may be using a clear aligner system of some description. Now, some of these clear aligner systems have got their softwares which they can emulate a virtual teeth if you’d like. So, some companies may call it clincheck. When you’re looking at your clincheck, the first thing that you need to do and the pearl is basically the first thing you do is check that the bite setup is correct. Because every now and then you get a clincheck back and you like to look at it, it’s looking good and you approve it. But you don’t realize actually right at the beginning, the technician who was setting up your case, either because they didn’t have the correct information or the best quality information, ie the setup wasn’t perfect for them, it wasn’t easy for them, they’ve set the case up wrong, which means that the occlusion that you sent them is not quite what is actually happening in the patient’s mouth. So my pearl for you is if you’re doing clear aligner system with a clincheck type of software. The first thing to do when you get your case back from the technician is check the setup. Make sure the teeth are touching correctly as they are in your patient’s mouth. Because sometimes they do get wrong and spotted this before and they get it wrong, then your whole treatment plan from there will not be accurate, it will be completely arbitrary, because it may align the teeth to some degrees, but it will not match the arches up. So that’s my Protrusive Pearl for you today. So let’s join Dr. Devaki and learn all about IPR. Main Interview: [Jaz]Devaki, Thank you so much for coming on the Protrusive Dental podcast. How are you? [Devaki]Yeah, I’m brilliant. Thank you so much, Jaz, for having me. I’m so happy and excited to do this. [Jaz]No, it’s gonna be a great topic. It’s IPR. So this is all about IPR. And the reason I wanted to discuss about IPR is because as I was saying earlier, sometimes when you’ve done something I’ve been doing orthodontic so for a few years now, got a diploma in orthodontics, and obviously you’re a specialist, we’re gonna come on to a little bit about your journey and stuff. But sometimes we’ve been doing something a while you almost forget where you disengage yourself with the struggles that you have the beginning and for me, one of the struggles I had is like IPR, like how to orientate your bur? Which strips to use? How to use them safely? And we know with being a minimally invasive dentist, you almost really worried about cocking it up. [Devaki]Yeah, I completely agree. I mean, especially now we want to be conservative, you know, especially with IPR and something like enamel. You can never get it back once you’ve taken it away. So it’s something really important you want to plan it properly. You know, if you fail to plan you. Plan to fail, so. [Jaz]Absolutely once you see photos or once you actually see clinically, some IPR that hasn’t quite gone to plan. That’s a really horrifying scene. So that’s why I’m really happy to be covering IPR. So we’re going to make this the most impactful content, hopefully audio and video on interproximal reduction. I do think with some of my episodes, the video version may have better value. But obviously, if you’re driving or you’re chopping onions or listen to something, then this is going to be hopefully useful to you still, because we’ll discuss a little bit about the history and the evidence base and the sort of risk and stuff but we’ll cover A to Z, and we’ll make it like you said earlier, Devaki, we’ll make it very clinically applicable. [Devaki]Yeah, exactly. So it helps everyone. [Jaz]Absolutely. So tell us a little bit about yourself, Devaki. [Devaki]Okay, so. And I’m a specialist orthodontist. And I actually graduated my ortho training last year, so quite newly qualified in that. I did dentistry at Barts and The London and qualified in 2013. Then I did my foundation year, and I pretty much knew at undergrad that I wanted to do ortho, so everything after that was just ortho, ortho. Want to get in. And as you probably know, it’s just jumping after one who after another. So, after that I did a year in maxfacts. And then I did a year in pediatric community dentistry. [Jaz]You did the very standard classic route. Unknown SpeakerStandard, classic route exactly, you know, doing posters, publications, presenting that sort of thing. And because I knew what I wanted to do, and there is a specification of how to do your application, I just followed that really closely. And then I applied for training, I got in and went back to the Royal London again. And so yeah, really enjoyable. And I really love ortho. It’s amazing. [Jaz]That definitely shows through in your social media channels and that’s why it’s great to have you on, someone passionate about what they do, which is what this show is all about, basically. I want to bring passionate people on with their respective topics. So yeah, it’ll be great speaking to you about this, but one thing I do want to know Devaki is I used to joke and please let this slide, I used to joke before I did myself did a diploma in orthodontics that and take this lightly I said I used to say that if you don’t like dentistry do ortho [Devaki]Oh my gosh. That’s my joke. [Jaz]Basically I’ve since changed that view, obviously since I’ve started getting more involved in orthodontics, but it was just a thing because I find that you know if you don’t want to fiddle around with a bit of gum and the matrix band that you want to work more with your mind. [Devaki]Exactly. You know what, it’s not even a joke, if you ask most orthodontist, not many of them really liked dentistry. And like you said orthodontics is pretty much 90% just in your mind, is planning and then 10% actually doing. So, it’s very clean. And it is like that. It’s just basically like a puzzle. Yeah. [Jaz]Yeah, absolutely. Well, one thing I have appreciated more for you, you know, especially as in anyone doing orthodontics is that, you know, in restorative dentistry, and even let’s say occlusion and prosthodontics there’s so many conflicting views and opinions. Okay? But they’ve got nothing on the world of ortho. You guys, the ortho world. Honestly, you guys have like some polar camps, who you know, you got the Damon, you got the Damon law, you got the MBT law. Yeah, got the or, you know, the ortho tropics, orthopedic-orthodontics, the people who tell you that if you remove premolar, you’re gonna die, because you won’t get the [opposite] anymore. So you’ve got real polar views in orthodontics [Devaki]You’ve got extraction is, non extraction is, you know, Invisalign lingual. Yeah, you’ve got so many different teams. [Jaz]So, it’s sometimes confusing, but it also makes it very interesting. [Devaki]It does. And you can choose the type of clinician you want to be and and the way you want to practice, so it’s great. [Jaz]Awesome. Well, let’s talk. Let’s just dive right in, as I say to the first question about IPR. So the mission here is to help those starting out with IPR to do it safely, and even those who’ve done a fair bit of IPR, just to revise are we doing it the best way? Could there be a more effective way? Because there are sometimes more challenging scenarios to approach? So let’s start off with by talking about the methods of IPR, or maybe we should talk about IPR from the beginning as an IPR as an alternative to extraction and what the evidence base is perhaps for IPR? [Devaki]Yeah, of course. So IPR stands for interproximal reduction. It’s known under many different names. It’s also known as Stripping, Slenderization, Polishing. There’s so many different names for it. They all mean the same thing. [Jaz]What do you say to your patient? [Devaki]I actually call it interproximal stripping. I guess it’s the way I was taught. But the way I said to the patients is just like filing in between the teeth or polishing between the teeth. Yeah. And it’s just much easier for them to understand. And actually the way I would describe it to a patient is very different to a clinician. And it’s a method of space creation, right? So if I see a case, and it is case dependent, that has mild crowding, or early moderate, but mainly mild and mild is anything up to four millimeters, I would want to go down the stripping route as method to create space. It’s not just a method to create space, you can use it for various other ways, for example, retracting your lower incisors if you’ve got a particular class three tendency, so a bit of a reduced overjet. And if you’ve got a Bolton’s tooth size discrepancy, so you want to correct that. Got a discrepancy. [Jaz]Yes. Yeah. Let’s touch on that. Those listening right now who don’t know what a TSD is a Bolton’s tooth size discrepancy, if you just briefly describe what that is because actually, from my orthodontic teaching that I’ve had is that sometimes if you use IPR in appropriately, you actually create a TSD. [Devaki]Yeah, you’re completely correct. Yeah. And that’s why it’s really worth mentioning it. And so Bolton’s tooth size discrepancies, basically, you add up the mesial and distal width of your anterior six teeth, or you can extend it to the posterior teeth. So the two different types. And if there is a discrepancy of the some of the mandibular widths to the maxillary widths, and there is a figure, it’s I think it’s 91.3% for what you’re what it should be. And if it’s outside two standard deviations of that, then you’ve got a Bolton’s tooth size discrepancy, right? Yes? [Jaz]My professor who taught me taught me how to really good analogy in a way to describe a TSD. So tell me if you’ve heard of this one, it’s like the foot and the shoe. So your shoe has to be just a little bit bigger than your foot, okay? For it to fit, snugly and perfectly. But if either your foot is too small, or your shoe is too big, or your shoes too small, and you know your foot is too big, or vice versa. And that is a discrepancy. And so either if you’ve got your maxillary teeth too big, or your mandible what and it could be various combinations, but it’s not going to fit together, you’re not going to get the right overjet. [Devaki]Yeah, exactly. And that can present. So if you’ve got too much tooth tissue in the top, you’re going to have an increased overjet, for example, too much tooth tissue in the bottom, you’ve got reverse overjet, you’re going into a class three kind of bites. And that’s so important. I mean, one of the things you need to consider when you’re aligning teeth, if you don’t want your lower teeth to procline, you don’t want them to come forward, you want to maintain that position. It’s so important for stability too, so that’s why a bit of IPR helps maintain your lower incisors, as well. And so yeah, there are three different ways you can do IPR. You can do it with a dental strip, abrasive strip, or a diamond and crusted strip. And you can also use a rotating disc And you can also use the bur. So there are the three kind of main ways and there have been a lot of more developments on those, for example, oscillating hand pieces and that sort of thing, but they’re predominantly the three different areas in which they’re used. [Jaz]Orthodontists have a lot of breadth of evidence on various things like I know there are some studies looking at the fact that but if you were to pre stretch some elastic before you apply it, does it make a difference or not? And like you don’t even like look at the minute details. So is there any evidence to suggest that one way or one method of IPR is superior to another? [Devaki]Most of the evidence is about the effect and stability of IPR. There isn’t really I’m haven’t come across any studies showing the different types of IPR. And I think that is basically case dependent and also the you how comfortable the user feels with using these methods as well. And, but there is plenty of evidence to suggest how much IPR is appropriate. For example, Sheridan in 2007 said 2.5 millimeters for that anterior five contacts and I think it’s 8.4 millimeters for the buccal eight posterior contacts is an acceptable amount. And there have been studies to show that anything more than 50% of the enamel thickness can be detrimental to the tooth in terms of developing decay and periodontal problems. So that’s why anything less than 0.5 millimeters is deemed acceptable. [Jaz]Is there any point, so that’s great. So take home message is if you’re in and around 0.5 or less, you should be okay as a whole. Obviously, there are other tooth morphology issues we’ll come on to later. But as a general rule of thumb 0.5 and below is fine. Now I once had a case where I had a lady who her upper, her main complaint was that she didn’t like her upper central incisors, they were too big. And the width of her upper central incisors per tooth was around about 10.3-10.5 millimeters each. So that’s like a megadontia category. So in that case, I actually want to for my clincheck, for aligner case, I requested a bit more IPR than what I would normally do to help me overcome this issue. Is that an acceptable thing to do? In certain cases? [Devaki]Yeah, I think if you’ve got a tooth, which has megadont, then that is acceptable. And obviously, it can be used to recontour teeth, if they’ve got unusual morphology, and it’s also optimizing aesthetics, right? So your central is an aesthetic zone, you want to give the patient the best result possible. But then you also have to consider the shape of the tooth. So McLaughlin Bennett described three different shapes of teeth. So you’ve got triangular teeth, and rectangular teeth, or barrel shaped teeth. And if you’ve got a parallel tooth, it’s not really advised that you what I mean by parallel is a rectangular shaped tooth. It’s not really a [Jaz]maximal area of contact between the teeth Unknown SpeakerExactly. Yeah. And IPR in those sort of teeth is not really advice. Whereas if your central is kind of triangular shaped, then you can afford to take away tooth tissue near the incisal contacts. So it would lend itself better. [Jaz]You had a diagram, I believe, to show this. [Devaki]Yeah, exactly. So excuse poor drawing. [Jaz]Fantastic, it’s way better than I do it, honestly. [Devaki]So here’s an example of some lower incisors. And these teeth are fan shaped, so triangular shaped. And here, this red area is where you would carry out IPR. And you can see that we’ve taken away a lot more tooth tissue, and incisally relative to the gingival area. [Jaz]So the tooth on your right was the triangular one, whereas the one on your left is the rectangular one. Yeah? [Devaki]Exactly. So you can see how it affects the amount of enamel you take away. [Jaz]Big time. [Devaki]But then imagine that tooth tissue removed, then you’ve got parallel edges, you would then use that to relieve your crowding and then move the teeth together. But then I think it’s also mentioned, good to mention something to your patients and also for us to know as well is black triangles. Because obviously, the as we get older, and we suffer bone loss and migration of the gingival tissue, we are going to have black triangles, and patients often notice it as the teeth align. Because if you’ve got overlap teeth, and they’re aligned, you’re going to start noticing these things. So and that’s another case where IPR can help if you have the fan shaped teeth. [Jaz]I’m a huge fan of using IPR to detriangularized teeth, and to get rid of black triangles. And it’s a great thing to do. And a term that I actually learned from Tif Qureshi years ago is PPR. So it’s Predictive Proximal Reduction where, you know, you’re doing it in advance so that as the teeth move in the correct position, aligned position that you’ve already accounted for that. So it’s a great thing to plan in advance, so that you can actually remove the amount of enamel that you need to do to get a more rectangular appearance and therefore get rid of the black triangle. [Devaki]Yeah, exactly. And, I mean, I never tell a patient that I’m completely going to get rid of the sphere. Because you never really know. And you don’t want to take, you don’t really want to take away. If you have that fun shape, you can’t take away the tooth tissue which is [further] gingival. Right? So I said I always say I can [Jaz]If you’ve got the parallel mean, you’ve got the barrel shape to that. Yeah, [Devaki]Yeah, that’s when it’s difficult. That’s when I say I can’t, because if they’re parallel, you’re just going to end up removing quite a bit of tooth tissue. And even to the extent we could traumatize the gingiva, so. [Jaz]And you’re completely right, communication with these patients. So don’t over promise because it’s not 100% predictable. If you can get rid of them or not. You can say I’m going to try. And this is what you may be end up with, but I’ll try my best and let’s see how your body responds. But the other thing is that, you know, you learn this early on is that if you don’t want the patient about black triangles, then you’re really fighting a battle. And the best way I find is that when I show them a photo of their crossed over tooth, I say that can you see that your teeth are squashing your gum? Your gum is squashed. So when your teeth become straight, your squash gum unfortunately doesn’t grow back, you’re going to have a area where Spinach will get stuck. Can you imagine what I’m saying? And all they all Yeah, I see. [Devaki]Yeah, exactly. And it’s nothing you’re doing wrong. It’s basically their anatomy. So if you explain, you know, this is where your bone sits, and this is where your teeth sit, and there’s a void, and that presents itself as a triangle and they pretty much understand. [Jaz]And as a restorative dentist, I’m happy. And I really like using the bioclear matrices to close these back triangles. So sometimes where it’s where you see that it’s going to be difficult to close fully, then you could tell the patient that look, there may be some additional procedures you may require afterwards with composite or whatever, to make sure we can get the full closure that we want. So it’s often unrealistic say that orthodontics alone will sort it but obviously is case dependent. [Devaki]Yes, it’s case depend. But I completely agree. You’re right. And it’s good to have that alternative option. [Jaz]Brilliant. So now we just we touched on the three methods of IPR. Which do you prefer? [Devaki]I personally prefer the abrasive, the diamond strips. Because [Jaz]Can you show us which ones? Can you show the listeners? [Devaki]Yeah. So and I normally buy an assortment. So this is single sided diamond, and the color is yellow. Okay? This is the finest, it’s extra fine. It’s then followed by red, which is fine, and then blue, which is medium. So normally, I would always suggest if you’re trying to carry out IPR, you go in first with the serrated metal strips, because that helps break the contact point, then I would use a yellow diamond strip like this. And to go in and kind of see it bit like floss when you see it around the tooth, and go up and down. And then the other way, and then I would move on to the red and the blue. And then you measure it’s always worth measuring how much you’re taking away with a IPR gauge. So I think I got this from Henry Schein or [Jaz]I mean, I know a lot of orthodontists who have just been doing it for so long and complains that they just eyeball it. I personally find that I’m much happier to use a gauge. It just is very scientific. It’s very proper. I like doing it. But have you got any tips? Because look, that gauge is you can’t always use it. Now. It’s a great opportunity for me to show you that case that we can discuss some difficulties you may have with IPR, we can actually discuss this case. How would you plan that IPR? So let’s let’s do that. Okay, great. So this patient came in with crowded lower anteriors main complaint. And there we are, I’ve been a good boy, I haven’t done any more than 0.5. Anyway. So in that scenario, let’s just pause at that, in that scenario, once you’ve removed some enamel on here, I might use something like a Sof-Lex™ discs, a coarse Sof-Lex™ discs to just remove some material. And above the strips, I certainly wouldn’t be using burs in this case, because I think you’re just contacting the the gingival area not actually doing anything higher up where you need to do it. Is there anything? In this case, Is there anything different you do and also in this instance, you may not be able to use your gauge, right? [Devaki]You can still use the gauge, I find you can still use the gauge. Because the way I do I don’t do it all in one go. So I spread out my IPR and especially when you’re planning your clincheck, you have to think of each stage as a different stage in its own right? So you plan, for example, we know that your lower left two and your low right one needs space. Right? So you’re gonna have to do IPR adjacent. So that’s where I would start off doing my IPR adjacent to those teeth that I could then bring them in. And I think you’re completely right. I mean, you could even use something like a separator to be able to facilitate access for IPR, and then use the strips and then I know a lot of my colleagues, they start with the strips and then they will use something like a mechanical IPR system or the [ ? ] disks. [Jaz]I think what I found useful in cases like these is to use a measuring device. I’m trying to think of it is a very normal measuring device. You know, the tools the, in this case, I use like a digital caliper to measure beforehand. And then when I use my Sof-Lex™ discs, or maybe even a bur very carefully under high magnification, just remove that sort of the incisal pathway is a bit more triangular, and then measure it again. I find that sometimes in my hands can work better than using the IPR gauge, because I just find in between that lower left two and lower left one, I might find it quite difficult. It might be like an angle it might not be like, especially after the first visit completely sort of adjacent to the tooth. [Devaki]Yeah, no, yeah, they are. They can be tricky. You have to put them in them the certain angle to get down, because especially in between their laterals and their canines, okay, canines are so bulbous. So you can have a really sometimes quite a tight contact width there. [Jaz]And what are you hoping to feel with the IPR gauge? I mean, should there be should because sometimes you try and put it in gently and you won’t go through. But if you just put a little bit of force, it will go all the way down. So my understanding is that how they floss should feel so like, you know, you have to be a little bit tight, that IPR gauge, it’s okay to just force it a little bit, ehereas some people have said that actually, there should be no resistance, you should have to go all the way down. So which is the right way? [Devaki]I could liken it to how floss feels when you’re taking it through a contact point. [Jaz]A little bit of a nudge. [Devaki]Yeah, but not to the point where you’re, you know, ramming it down, then you haven’t done enough. So normally, I normally spread out my IPR. So do about point two, for example, at a time. So if we look at these, I’ll always start by getting the 0.1 in. And once I know I’ve got my 0.1 in, and the 0.1 is so thin, you know, some people have the space between their teeth already. And then after that, I’ll go 0.2, and you can even get other ones where they have 0.15, 0.2, 0.25. That’s how I would normally do it. I actually really like these. I think it works really nicely. [Jaz]So I think it’s a really handy tool to you as well. Completely agree with you, something official test. Yep, go for it. [Devaki]Okay, there’s no space in there. But either you go through this way, or you’ll go through downwards. [Jaz]Is it the same thing. Yep. By the way, should be the same. [Devaki]Yeah. [Jaz]Thank you for that. It’s really handy to see. So just to go this case. So yeah, that’s how the clincheck, obviously, clincheck is cartoonodontics is not real ortho. So always don’t compare to real life. It’s just a guide. Anyway, we got this through one round of aligners. Okay, alignment. So far, we’re just going to do some additional aligners to get the torque correct. And you’ll see here the asymmetry of those incisors as well. But it’s not a bad way. So it’s pretty good result, patient was chuffed. The patient actually wants to stop now and I’m like, “No, no, no, it’s not perfect yet. Let’s just get that perfect, and I will be happy.” So if this was your starting position, Devakin, if this was your starting position, and let’s say there was a space requirement to remove 0.5 millimeters, here, I might then be happy to use a bur and in my hands, I’m happy to do 0.3, 0.4 per se at the first day, and then just do a little bit as we go along. I know my Principal at Richmond, he’s very happy to do as much IPR as possible, where the contacts are already straight. What are your thoughts on that? [Devaki]I always think it’s better to be conservative with your IPR. You know, after you’ve taken away that enamel, you’re not getting it back. And you also have to think about the aesthetics, what’s it going to look like. If they’re going to look like tombstones. It’s not going to be nice for the patient. So and I prefer not to do my IPR at one go. I like to stage it because teeth are continually moving. And you need to forward think and think, where are my teeth wanting to go and then do the IPR to facilitate and create space for them to move, if that makes sense. If you do it all at the beginning, you could lose space and space is at a premium. So especially with IPR. So you want to be really, really careful. [Jaz]I’m happy and I respect that because that’s the beauty of dentistry, you know, everyone’s got different opinions and different ways to do it. So you’re in the camp that you’d like to do it sequentially. I am quite case selective. Some cases, I’ll do it sequentially. Other cases where I have to admit, if I’ve got a beautiful straight contact, then I’m maybe happy to do a bit more, but I see your point about them like tombstones, I think in clear aligners to get away with it more than it fixed. [Devaki]Well, to be honest, in fixed Normally, we wait until the teeth are aligned and then carry our IPR. So it’s a little bit different and there should really be a difference, because whether you’re doing fixed or Invisalign, you should plan and treat the same. But I also like to mention that it’s really worth when you’re planning that you consider your rotations because I always correct my rotations first before any IPR because you always will gain space from derotating teeth. Otherwise, you might be left with too much space at the end then you then have to close [Jaz]I’m just trying to visualize that. So a central, an upper central incisor if an upper central incisor is rotating, it will, usually require space. Right? [Devaki]Yeah, Sorry, what I mean by that is your premolars and your posterior teeth. So yeah, sorry, that’s confusing. posterior rotate teeth will give you space. Anterior rotated teeth are crowding. They need space. [Jaz]So and just leading on from that. In those scenarios where And you’ve got those barrel shaped or parallel contacts and you want to avoid IPR, then maybe in those cases, if it’s still a mild case, you should be looking towards expansion. Arch development. Is that is that how you’re looking to achieve your space? [Devaki]Yeah. So if you’re going the non extraction route, you want to be thinking about things like expansion. Now, we know that expansion is a great way to achieve space creation. But it’s also can be quite inherently unstable, especially in the lower arch. You don’t really want to be expanding the lower canine to canine and so there’s lots of studies on that from [Little] and others about how you’ve got a higher risk of relapse if you expand the lower tooth canine width. So you want to keep that the same. But then you can expand more on the premolar [Jaz]I think there was one about how IPR can actually improve your stability. Do you want just touch on that? [Devaki]Yeah. And so there has been research to show that IPR can even help stability post treatment, [ ? ] suggested that if you have parallel edges, then there’s less chance of contact slippage. So in theory, your teeth should remain stable after treatment. And, and I can even in if you’re using common sense, that makes sense, right? I mean, if you’ve got parallel, [Jaz]if you’ve got more contact surface area, it just, there’s less on to them come away. [Devaki]Yeah. So IPR is even being used as a reason to achieve stability in cases like that as well. Okay, so here is a patient who had quite significant crowding, you can see that she probably has about five millimeters of crowding. And it’s displayed in the anterior region. But because it is quite significant, it’s also extended up to where the pre molars are. So I actually did two plans for her, I did a plan where we did a lot of IPR and an extraction of a lower central incisor. She didn’t want an extraction at all. So hence, we’re going with this plan. But we can see if I’m just taking it through, there’s a lot of IPR at the beginning. That just because it says 0.3, I might not do the whole 0.3 right at the beginning. But I will always make a note of how much I’ve done. And I think Medical legally that’s really important, as well [Jaz]Yes, it’s gold standard. [Devaki]Yeah. So I use my gauge, I even up the contacts, the teeth will then start to move. And you can see that it’s been planned so that as the teeth need it, that IPR is taking place when it’s highly highlighted in yellow. [Jaz]So and you’re using your the Devaki approach of sequential stripping as you go along? [Devaki]Yeah, exactly. [Jaz]Any deviation in this case, for example, that lower left premolar and molar if you just go back to when it was a bit crowded. So yeah, it tells us it always between the two promoters. So that’s a tricky one. Because if you start, if I also start stripping the mesial surface of that lower left second premolar than actually, that would be the buccal, that would eventually be the buccal surface, right? If I started if I just put a strip there, and imagine I put a double sided strip there, for a while, you’re actually removing it from the buccal. That’s not where the contact is. So in that case, I’d be more inclined to get my Sof-Lex™ discs out and actually disc, the mesial surface, is there a better way to do it than that? There’s a different way? [Devaki]Yeah. So Alternatively, you could use a really fine non cutting bur. And the bur I would like to use, and I will only use those posteriorly. So anteriorly, I’ll just use the strip’s only, because I’m more control, I can protect my soft tissues with proximal [inaudible]. And you can also use suction to protect your soft tissues. But posteriorly I’ll use if I need to take a significant amount away, I’ll use the bur and the bur I use is then strips. This is the bur. So this is from top dental. But you can get these from various other suppliers. It’s non cutting at the bottom. And the diameter of this is 0.3 to 0.4. So it’s giving you the amount that you want posteriorly, some other flame shape burs are more than that. That’s why I don’t like to use them. And I have less control with here. I mean, he’s using this anteriorly but I would use it possibly really. [Jaz]Yep. Let’s just put your hover your mouse over that photo again, the way that the this clinician is using it now. There’s no right or wrong because that is what works in your hands and your experience. So let’s start with that there’s no right or wrong. Now some people and I’ve seen some videos back when I was had my first IPR case coming up some years ago and I was looking at Okay, how am I do IPR, I was watching all these videos and stuff and asking different clinicians. And some would say hold the bur like this and go up and down. Okay, whereas others were saying, if you do that and you slightly deviate you make a nasty shape, a nasty little tooth [Devaki]A ledge. [Jaz]A ledge. A negative ledge in that way. So then the other way to do it would be hold it like so basically and then just do like little brushstrokes, which is what I do most 99% of time that’s what I’m doing. Do you have a preference? Because obviously, you’re doing posteriorly. So, I mean, going near the gingiva and going up for me, it’s it that angle, it doesn’t make sense to me as much. [Devaki]Yeah, I mean, I’d have to agree with you that I prefer to go parallel to the tooth rather than perpendicular with a bur. [Jaz]Yeah, but if you can get the right access, I’m not saying it’s the wrong thing to do. But if you can get the right so if you have any experience doing it, just be very careful use high magnification, it would be my opinion. [Devaki]Yeah, I completely agree. I mean, I’m going incisally then downwards parallel to the tooth just enables me to remove more tooth tissue where I need it, where there’s more incisally. I don’t really want to remove as much gingivally. And although it’s a non cutting bur, I’m just trying to think about where I want to remove, [Jaz]What do you mean by a non cutting? [Devaki]So and these burs, the non cutting at the tip [Jaz]At the tip? [Jaz]Yeah. [Jaz]Brilliant. So is there any technique to hold it? For example, I’ve seen some clinicians go really, really fast. And that’s the way to do it. Others put a lot of sustained pressure, any tips you can give us? Is there a wrong way to do it in certain holding it whatnot? [Devaki]I think, I don’t know if there is particularly a wrong way. And the way I do it is I do it pretty much like in this image, I’ll bring it down, and I will see it around the tooth bit like floss. And then I will do this. Like that up and down. And just to make sure that I’ve removed an equal amount. Now some people criticize trips because they say they’re time consuming etc. But I feel like with the strips you have the most control. And it happens really slowly. So chances of any soft tissue trauma or anything like that are reduced. I feel. [Jaz]I agree with you, I think these strips have been a constant source of repetitive strain injury for me. It is a controlled way of doing it. But yeah, sometimes when you’re doing like 0.3, or with the scripts, and you’re really there and the patient’s like, when’s this gonna end? So yeah, [Devaki]but that’s when I think you want to then go in with your disc or your file with [Jaz]Yes as na adjunct one, you can mix and match. It’s good. [Devaki]Yeah, exactly. This is a good entry, and then you can follow on with those other ways. [Jaz]Do you apply fluoride as a rule, or every time you do IPR? [Devaki]So there are mixed views on this, there’s some evidence to say it’s good to reduce plaque formation and things like that. But other evidence to say it’s unnecessary. I personally don’t use fluoride, unless someone is reporting that they get quite sensitive teeth to me beforehand. I don’t use fluoride, I just recommend them as sensitive fluoride toothpaste. And [Jaz]I’m in the same camp as you. So I used to apply fluoride all the time, until I looked at the evidence and suggested actually, the slider is going to do a good job of remineralizing it, and you don’t need it, and the other thing is that, what message are you sending to the patient, if every time they come in and you’re like, we have to apply the flouride, I don’t eat for half an hour or whatever. They will be “Oh, my enamel is was getting weakened?” They’re having to do all this adjunctive stuff. So it sends a wrong message I think so I do it for sensitive patients just like you. [Devaki]Yeah, and even in the evidence, that person did a 10 year follow up study and people had very minimal risks associated with it, you know, since there wasn’t much sensitivity, though, periodontal or caries risks associated with it. So I just think, you know, it’s case dependent. Has the patient got good oral hygiene? Have they got healthy gums? If so, then [Jaz]that’s the most important thing. [Devaki]Yeah. [Jaz]Right. Cool. I’m gonna check for any more questions. I think we’ve done really well. You’ve definitely pretty much answered all the questions I had. Is there anything that you think we want to cover to make it a really, you know, cutting edge resource excuse upon, for IPR? For Beginners? [Devaki]I think the most important thing is planning. So it’s really important to take the time at the beginning to assess how much crowding you have? Where is the crowding? Look at all your factors, what is my tooth shape, like? What are the aesthetics like when the patient is smiling? How much teeth have showed, the display? I mean, a lot of this information you will get from your assessment, and then when you’re planning don’t just follow what the contracts telling you. Although Invisalign cloud billions of pounds into their system. And it’s a really great system. I love Invisalign. But it is about the clinician planning the case. And that’s one thing I think is really important. So think it through, you can tell Invisalign, I want IPR at this stage. And that will make you an even better clinician. And if you put your take on it, because you are the person planning the treatment, Invisalign is just a tool. [Jaz]Brilliant, I love that. And one thing you just reminded me of is you mentioned earlier about whether you’re doing fixed appliance or Invisalign, the movements and the stages of the movements are very similar, if not identical. So, in fixed appliance, you’re waiting for the contacts to become parallel, uncrowded. And then you’re doing the IPR whereas when I’ve been on the the Invisalign courses before they’re very scared about round tripping. Can you explain why? Why Invisalign folks, scared of round tripping, where actually in fixed appliance where we are around tripping a lot. [Devaki]Okay, yeah. Well, I mean, my professors would kill me for this. But I mean, in theory, you should never round trip ever. [Jaz]Minimize round tripping? Of course, yeah. [Devaki]Yeah. Basically, in fix, in theory, you shouldn’t be [married to ping] either, because you should be switching back your wires controlling your AP arch links and things like that. And so, round tripping isn’t a good idea. Whatever you do, because you’re proclining teeth, you’re putting strain on the gingival tissues, you should all show also be considering if that patient’s got to then gingival biotype. And, again, this is where people just accept the clincheck. But they don’t realize or may not take consideration into one of my patients’ gingival tissues like. Can I just leave them changing their aligners every week without monitoring that? So that’s really, really important. But I completely understand what you’re saying, with fixed treatment, your NiTi wires, the teeth are tipping everywhere. And I’m sure if we actually then put that on a clincheck, we would see a bit of forward back movement. But with Invisalign, the beautiful thing about it is you can digitally see where the teeth are going to go. So because of that foresight, you can plan for it not to happen. And that’s why I love the super imposition tool. Because I say, and I specifically say to Invisalign, unless my teeth are retrocline and I can afford for them to come forward as best I can say to Invisalign do not procline the lower incisors. And then, if there’s too much, IPR, lower three to three, I’ll take it back to the premolars. Premolars a bulbous, you can afford to do that. [Jaz]Perfect. So I think the answer well, so we want to ideally minimize, round tripping where we can and with the the beauty of clincheck virtual plans, we can stage IPR in a way that will have to mean less IPR, even though they’re not fully aligned just yet, but you can split the strips, I think it gives you that ability to take away a little bit per time. And I’ve just realized something that we didn’t do is that we talked about round tripping, but there may be some young dentists out there who don’t do any ortho you’re just listening in, and they’re maybe thinking about starting over. And they have no idea what round tripping is. I didn’t know what round tripping when I was an undergraduate. And maybe you did because ortho was your passion area. Can you just explain round tripping? [Devaki]Yeah, so round tripping is basically as the teeth align, there’s a tendency for the lower incisors or even the upper incisors to procline, and that is called tipping. And in ortho, you want to torque the teeth to enable the roots to be in a stable position. So then what ends up happening is after your NiTi wires for example, you go into more rigid wires, and the teeth end up coming back. Because you’re then torquing them because you’re moving the roots in the right position. I don’t know if that’s a good explanation. [Jaz]It’s fine. So it’s coming forward. And then coming back again, you’re going around again, [overlapping conversation] Constraining exactly was in common. So why is it round tripping bad, it’s gingival. The supporting structures, maybe taking a bit of a beating. [Devaki]Exactly. And you always want to move teeth in bones, if you’re just, if they’re just proclining. And there’s a risk of you know, God forbid this would ever happen. But perforating the cortical plate, etc, [Jaz]getting gingival recession areas and whatnot [Devaki]Dehiscence and that sort of thing. And this is another really important tip is if you do notice any recession, and in your assessment, it’s really worth noting it and measuring it and documenting it because sometimes the recession can get worse as the teeth align. So [Jaz]That’s a really good point. I think our photos help us but it’s medical legally really good to measure it with a Perio probe or something because every orthodontic patient I’ve ever had, who had significant or moderate to significant recession to start with, but they were periodontally healthy and we’ve chosen to do orthodontics. You know what they all say? They all email me especially not every I’m emailing, I’m checking in on patients. And they all say, “you know what, I feel like my recessions got worse.” In fact, some of my whitening patients, okay, I just give them whitening trays, which are nowhere near the recession, because I want to keep it away from the root surface. And they come back. So yeah, my teeth are whiter. But I think the whitening cause my recession. But what they do is just, they’re more aware of the recession now and some sort of teeth are aligning there, you can see the areas where you couldn’t see before. So a lot of the times patients are thinking, Oh, my God, my recession is getting worse or whatever. But really, it’s probably not happened. But if it has, you need to make sure you’re on top of it. And that’s where your documentation comes in. [Devaki]Yeah, I completely agree. And, you know, 9 out of 10 patients, they’ll come and say, I don’t like this. And like you said, as the teeth of straightening, they spend so long looking at their teeth, they’ll find other things that don’t like, so it’s just always worth gathering this information at the beginning, you know, as much as you can. And so you can exceed the expectations rather than under deliver. [Jaz]That’s a really good communication point. That’s one thing. The way I like to do, Devaki is when they say their main complaint, and then I say to them, okay, and what else? anything else? and then they might say something else. If you didn’t ask them that they would have never said that second thing, and then you keep going, you keep asking until he has nothing more to say. And then I sometimes tell my patient that okay, the reason I’m pestering you is that, although you’re unhappy about this main thing here, I often find that when we sought that one main thing out, then you know, just all the other myriad of things. So it’s really important that you know, you take a good objective look, obviously subjective as well, because beauty is in the eye of the beholder, and orthodontics oftenly say that. But it’s a great communication point, you raise that to have a chat with the patient in that way. So Devaki, thank you so much for coming on and helping us about IPR and getting the nuances and how to hold the bur and the different methods and a brief overview of the evidence, really appreciate it. [Devaki]It’s been an absolute pleasure. Thank you for having me on here. I’ve really, really enjoyed it. And I hope people find it useful. [Jaz]I’m sure they will. Thanks so much. [Devaki]Thank you. Jaz’s Outro: So hope you enjoyed that chat with Devaki all about IPR. Thanks so much for listening all the way to the end, as always, really appreciate it. If you’d like to suggest a topic, please get in touch. Follow the Facebook page or the Instagram page and let me know how I’m doing. I want to put on some good topics. I’m enjoying myself. Look, I love podcasting. I love learning from my guests. So it’s a hobby of mine and you find it’s bringing value to you. And please share it with your friends and suggest some topics that I could cover. Thanks so much once again.

I am joined by a young Dentist, James Martin, who started a really cool Facebook group called Dentists Who Invest. Well, if there is a group dedicated to Dentists who own Air fryers, then James’ group definitely has a need! The advice we share on this podcast is aimed at Dentists who have no clue about Investing. Forget dental school, but even in our general education we are not taught personal finance and investments. https://www.youtube.com/watch?v=UHpkM-9Vg94 Protrusive Dental Pearl: have you been a victim to ‘lifestyle creep’? This is when your income increases, your lifestyle and expenditure also increases. This is all good and well, but it is so important to watch your savings rate (how much money you save). Here are the 5 topics we cover in this episode aiming to improve your financial literacy: 1) How to get started with Investing?We share our individual journeys. His involves cryptocurrency, and mine involves accidentally stumbling upon Tony Robbins’ book about financial freedom! 2) DIY vs Financial Advisor/Investment Broker. The Pros and Cons of doing it yourself vs picking a portfolio with an investments company 3) What is the best investment? Stocks? Real Estate? Cryptocurrency? Bank accounts? 4) WHEN should you start investing? 5) What other piece of advice do you give for Dentists looking to invest? If you enjoyed this episode, do check out Personal Branding for Dentists with Shaz Memon!

I want to talk about maximising your learning potential from all the courses that you attend, but particularly the online ones. I was inspired from listening to a book called Limitless by Jim Kwik (check it out if you’re in to maximising your potential and the human mind). It had so many gems in there which I thought would be so useful for Dentists to learn when we’re attending courses so they have more impact on us. https://www.youtube.com/watch?v=F6Qc0BwTGRU Need to Read it? Check out the Full Episode Transcript below! More importantly, now that with COVID-19, a lot of the education is going online. You now commonly hear the phrase “I’m webinared out” – we are attending too many webinars and are itching for in-person courses again. Over lockdown it was definitely the case, you could fill your whole day with webinars during lockdown. That just gave us digital fatigue. I want to refresh and recap on what are the ways that you can maximise your learning while you’re on dental courses, but particularly on the online courses, so you don’t feel “webinared out” or “digital fatigue”. We can apply this to any online education – in fact, as a Dentist you probably already subscribe to membership only platforms for dental education. However, like many of us in our busy lives, you may be guilty of not giving these platforms enough time to gain from them. It is so important to make time to actually watch that content and actually immerse yourself in that content. I like to call this ‘protected time’. Time is scarce. This is why when you do find time to watch these videos on the online platforms or actually attend these webinars, your time is so valuable. You really have to maximise what you gain for every single course that you do, and every single video that you watch, and every minute that you invest in them. This is why I want to share the FAST protocol to maximise your learning, inspired by Jim Kwik and Limitless. F = Forget A = Action S = State T = Teach F stands for forget, which sounds crazy. Let’s imagine you’re doing a course on veneers – maybe a webinar or an online course on veneers. The way to maximise how much you learn from that particular course is to forget everything you know about veneers. One of my favourite quotes is from someone called Malcolm Forbes, and it’s “the role of education is to replace an empty mind with an open one”. The A stands for action, and it can also be interpreted as active learning. For me, it’s definitely the case that I learn better when I’m taking notes. One thing that Jim Kwik teaches is that we do not learn from consuming. We learn from creating. When I’m creating notes, or when I’m creating mind maps, and some people like typing manually on their iPads or on their laptops, basically almost transcribing what the lecturer is saying… you gain so much more from that process! So note taking or whatever you need to do (whatever creative way that you learn), it’s so important to have that rather than just consuming blindly or consuming blankly, you need to be able to create and that way you will learn more. The other thing that comes with active learning is that multitasking is an absolute myth. We can’t multitask effectively. For example, have you ever been on a course and maybe you’re sat in the front row with all good intentions…but what happens is that you get a text message from your practice manager or patient emails you and now your attention is completely somewhere else. And now you’re dealing with a staffing issue or a patient issue. Of course then you leave the the course to make a phone call. You’re now dealing with the patient or the staffing issue. You’re absent from the course. It’s basically that you’re trying to juggle a few things at the same time, and it’s just not going to work. You’re not going to maximise your learning potential. You have to focus intensely on that course in front of you and forget everything else. Forget the distractions. As humans, we can’t process a negative. Because we can’t process a negative, if something pops up in your mind or you get an email. You can’t just be like “okay, I’m not gonna think about this..”. The best way to handle that situation is make a note of it somewhere or make a to do list, focusing on that task at hand, and then move on from it. The S is super important for all realms, but particularly online. And the S stands for state. That means your environment, your emotional state, and also physical state (what is your posture like as you read this?). Are you doing an online course or webinar, in your PJs, lying down in bed, sideways? It’s not going to make sense compared to working in a home-office, far away from the kids (as far as you can be!). Your posture is important. If you’re slouching on the laptop, your physiology has an effect on your mind. How about your emotional state? The courses where I have learned the most from have been the ones where I’ve been really excited. So I remember when I saw Jason Smithson’s 2-day course about onlays and veneers – I was so excited about that. I was also really excited for Michael Melker’s course in Stockholm. It is therefore no surprise that those two courses had a massive impact on me in terms of how much I took away. Jim Kwik says that your ability to retain information long term is governed by a formula: Longterm Information Retention = Knowledge x Emotion. The knowledge that you gain that day is multiplied by your emotional state. If you’re actually excited to be somewhere and genuinely excited to learn that content, then you will learn so much more. You must tap into your mind and create a sense of excitement and eagerness and be keen and you will learn so much more, you will retain that information, because of your emotional state is being multiplied by that knowledge for better retention. The last part of the FAST protocol is T, which stands for teach. Now, what I don’t mean is you do one online course or webinar and suddenly you start running your own bespoke courses! That’s not what I mean at all. What I mean is that if you attend a course, or an online course, with the intention of passing on that knowledge that you learned to a colleague, then you will learn so much more because “when you teach, you get to learn it twice”. I’m a firm believer that the best students make the best teachers and vice versa. I think when you when you’re able to teach something and pass on information that you’ve gained from a lecturer on to someone else, or apply it to a clinical case, that will really amplify your learning. So there we have it, some things to consider about how to maximise your learning from attending courses using the FAST protocol. Forget what you know already. Be active, be in the correct state. That’s your environment, that’s your emotional state. Consider teaching someone something you learn because that way you get to learn it twice. If you found this useful, please do share it with a colleague! If you enjoyed this episode, you will also like How to Win at Life and Succeed in Dentistry. Click below for full episode transcript: Opening Snippet: This podcast episode is all about maximizing your learning potential from all the courses that you attend, but particularly the online ones... Jaz’s Introduction: Hi guys, it’s Jaz Gulati here with another episode of the Protrusive Dental podcast, it’s the interference cast version where I just sort of I got a little tangent. And this is all about how to make the most of learning from the courses that we attend. And the reason I came up with this is, I’ve been reading a book called Limitless by someone called Jim Kwik. Check it out if you want to, if you’re into sort of maximizing your potential and the human mind, and really so many gems in there, which I thought would be so useful for dentists to learn when we’re actually attending courses. More importantly, now that with COVID, a lot of the things are going online. And you commonly hear this term, I’m Webinared out, you know, people go into too many webinars nowadays, and over lockdown, it was definitely the case, you know, there was like, easily, you could fill your whole day with webinars during lockdown. And it gives you sort of like a digital fatigue of some sorts. So I want to just refresh and recap on what are the ways that you can maximize your learning while you’re on in person courses, but particularly on the online courses, so you don’t feel webinared out. We can also apply this to some websites like dentinal tubules, or ripe global, these are two websites, I subscribe to which you’ve got loads and loads of clinical videos and sort of courses online that you can watch on demand. But I think all of us are guilty of this, right? Like we have subscriptions to dental magazines or journals, subscriptions to online websites, but it’s about making time to actually watch that content and actually immerse yourself in that content. Like it’s almost like having the requirement of protected time. And that’s so difficult to make nowadays. And when you do find time to watch these videos on these online platforms to actually attend these webinars, your time is so valuable. So you really have to maximize what you gain for every single course that you do in every single video that you watch. So this is what it’s about. And I’m gonna introduce you the fast protocol, the F-A-S-T protocol on how to maximize your learning. Inspired by Jim Kwik, Limitless. Here we go. Main Podcast: So the FAST protocol starts with F. And the F stands for FORGET, right? I know that sounds crazy. But to actually learn and really gain as much as possible. Like let’s imagine you’re doing a course on veneers, right like an a webinar or an online course on veneers. The way to maximize how much you learn from that particular course is to forget everything you know about veneers. One of my favorite quotes is from someone called Malcolm Forbes, and it’s “The role of education is to replace an empty mind with an open one.” And it’s the same concept that if you actually attend a course or an online webinar or online course, with an open mind, the new art so much more likely to absorb and learn more. So the F in the FAST protocol is Forgetting what you know already about that topic. The A stands for ACTION, and it can also be interpreted as Active learning. And for me, it’s definitely the case that I learn better when I’m taking notes. And one thing that Jim Kwik teaches his book is that we do not learn from consuming. We learn from creating. And for me when I’m creating notes, or when I’m creating mind maps, and some people like typing manically on their iPads or on their laptops, basically almost transcribing what the lecturer is saying. But you gain so much more from that process. So note taking or whatever you need to do, whatever creative way that you learn, is so important to have rather than just consuming blindly or consuming blankly, you need to be able to create and in that way you will learn more. And the other thing that comes with active learning is that the whole thing about multitasking is an absolute myth, right? We can’t multitask effectively. So have you ever been on a course. And maybe you’re sat in the front row with all good intentions. But what happens is that you get text messages from your practice manager or patient emails you and you sort of open up the email. And now you’re dealing with a staffing issue or a patient issue. And you nip out the course to make a phone call. And then you’re sort of thinking about the patient or the staffing issue. You’re absent from the course. And it’s basically trying to juggle a few things at the same time. It’s just not going to work, you’re not going to maximize your learning potential. So really, you have to focus intensely on that course in front of you and forget everything else. Forget these distractions. And one of the tip is that as humans, we can’t process a negative. So if I tell you don’t think of a pink tree, you just thought of a pink tree. So because we can’t process a negative, if something pops up in your mind or you get an email. You can’t just be like okay, I’m not gonna think about this. I’m not gonna think about this. The best way to handle that situation is Make a note of it somewhere or make a to do list, focusing on that task at hand, and then move on from it. Because you can’t process the negatives. Now you’ve actually written it down or typed it up somewhere, and then you refocus back on the course. And that’s the best way to manage your distraction in the middle of a course. So far, we have Forget and Action. to action being actually taking notes and being creating and not being distracted. The S is super important for all realms, but particularly online. And the S stands for STATE, like, what is your state, and that means your environment, your emotional state, and also physical state, you know, your posture was that like, so if you cover a one by one, like, what’s your environment? Are you doing an online course or a webinar, in your PJs, lying down in bed, you’re sort of sideways, it’s not going to make sense compared to working in a home office, far away from the kids as far as you can be. And you know, being actually looking the part and dressing up as if you actually go into a physical course, like that environment is so much more conducive to learning. And also, your posture is important. So if you’re laying down, if you’re slouching on the laptop, compared to the physiology, and the effect that has on your mind, if you’re actually on your desk, sat up straight, there has a huge bearing on how much you learn. So your actual physiology and your state in terms of environment is really important, but also your emotional state. Now, the courses where I have learned the most from have been the ones where I’ve been really excited. So I remember when I saw Jason Smithson talk about onlays and veneers over two days, I was so excited about that. And also Michael Melkers, in Stockholm, I was mega excited. I was on this flight. And I was like, Okay, fine. I’m exploring a new country because that was in Stockholm. But also, I’m exploring, I’m actually going to Michael Melkers course. I was super, super excited to learn from these two amazing clinicians. So those two times is probably why those two courses had a massive impact on me, because I was mega excited to learn from these two masters. So you’re, the way Jim Kwik said it is that your ability to retain information long term is governed by a formula. And that formula is basically knowledge x emotion. So the knowledge that you gain that day, but it’s multiplied by your emotional state. So if you’re actually excited to be somewhere, if you’re actually excited to learn that content, like you know, if you’re excited, or like me, and you have, you know, real palpitations, excitement about going to these courses and learning from these great people, then you will learn so much more. So really have to tap into your mind and create a sense of excitement and eagerness and being keen and you will learn so much more, you will retain that information, because of your emotional state being multiplied by that knowledge for so much longer. So the last part of the FAST protocol is T and it stands for TEACH. Now, what I don’t mean is you do one online course or webinar, and suddenly you start running your own bespoke courses. That’s not what I mean at all. What I mean is that if you attend a course, or an online course, with the intention of passing on that knowledge that you learned to a colleague, then you will learn so much more, because when you teach, you get to learn it twice. So when you teach, you get to learn it twice. And in such a great way, I’m a firm believer that the best students make the best teachers and vice versa, the best teachers also make the best students. So it goes hand in hand. And I think when you’re able to teach something, impart some information that you’ve gained from a lecturer on to someone else or apply it to a clinical case, that will really amplify your learning. So there we have it, some things to consider about how to maximize your learning from attending online courses, but also physical courses as the FAST protocol. So once again, it’s FORGET what you know already. Be ACTIVE, learn actively be in the correct STATE, that’s your environment, that’s your emotional state. And consider TEACHing someone something you learn because that way you get to learn it twice. Jaz’s Outro: So hope you find that little interference cast useful. And I’m hoping that over the next six months looks like a lot of the content is going to be online, you’ll be able to take away a few gems from that and really take it forward and learn and gain so much more from these courses. So thanks again for listening all the way to the end. I really appreciate it as always.

Get ready for the best summary of bridges you ever heard, including diving deep in to this mystical design of bridgework called ‘fixed-movable’ bridge. You cannot search about Bridge Design on Google without landing on the great content that Prof Paul Tipton has released. https://youtu.be/h9mmRiFtHmU Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: where to place your grooves for crowns and bridges?Crowns: place grooves mesial or distal, or mesial AND distal. Ideally in tooth and not in core material (we elaborate in the episode). Why mesial and distal for crowns and bridges? The forces will be transmitted bucco-lingually on a crown – therefore grooves perpendicular to this force vector to resist it would be mesial/distal. How about for bridges then? For conventional bridges the grooves are placed buccal or lingual, or buccal AND lingual. This is because the forces are now acting antero-posteriorly on the bridge via forces on the pontic(s). The buccal/lingual grooves will resist antero-posterior forces. Prof Tipton and I discuss: The benefits of fixed-movable bridges (such as negating the need for parallel preps of abutments) The contraindications of Fixed-Moveable bridges (such mobility of abutments) Why fixed-moveable bridges should be the default design Myth-busting Ante’s law What is the maximum span of fixed-moveable bridgework? What are the rules that govern cantilever bridges? what about mesial cantilever vs distal cantilever? Why is Distal cantilever worse, and is there any evidence to back this up? The steps in planning for Bridges: 1. Design anterior bridgework first 2. Choose your abutment teeth 3. What Design? (F-F, F-M, Cantilever?) and 4. Type of retainers for the abutments (Adhesive retainer, conventional crown, onlay etc) We discuss an actual case and live planning for a Fixed-Movable bridge Where is the fixed-movable attachment housed? Anterior or posterior? Inside the abutment or outside of it? The one thing you must do when placing Fixed-moveable bridges or you would have wasted the time and effort:Remove a small portion of the male component – about 0.25mm on average If you enjoyed this episode, you will like the complete denture tips given by Dr Mark Bishop – check it out! To learn more about Tipton Training, check out their website for courses. Click below for full episode transcript: Opening Snippet: For me, this is 100%. Okay? I know we should never say 100% in dentistry for 99% that the fixed movable attachment is always on the distal aspects of the anterior retainer... Jaz’s Introduction: Hello everyone and welcome to another episode this time with Professor Paul Tipton. Listen, if you’ve ever been a student, or in your foundation year, and you want to find out more about fixed prosthodontics, you turned to Google and you start searching about bridges. You can’t get very far on Google without coming across Paul Tipton’s papers. In this episode by the way is absolutely full of bridge work gems, which I think are so helpful. So we’re going to talk about all things fixed movable bridges, the common mistake areas that dentists make when it comes to bridge work and bridge design. We also talk about grooves, so my Protrusive Dental pearl for you is when you’re placing grooves for crowns, placed them mesial and distal. When you’re placing grooves for bridges, placed them buccal and lingual or buccal or lingual. Same with the mesial distal is mesial or distal or mesial and distal. And so does that make sense? We go into in more depth. So to find out exactly why those rules exist, then you have to listen all the way to the end of the episode. Because towards the end of the episode, we discuss all that. But there’s so many gems in them. The meat and potatoes of the episode is basically about fixed movable bridge work, the nuances of it, when to choose it, what are the contraindications to fixed movable bridge work? It’s actually interesting actually that fixed movable bridge work is their default design. Prof. Paul Tipton says actually you shouldn’t be finding reasons not to do it and and therefore settle for fixed fix. Whereas in dental school we don’t really get taught or certainly in my experiences that we didn’t really get taught that much. And I never placed a fixed movable at Dental School. So I hope you find this episode useful. And I’ll join you in the outro. Main Interview: [Jaz]Professor Paul Tipton, thanks so much for coming on the Protrusive Dental podcast. How are you today? [Prof Paul]Yeah, good. Thank you. Yeah, looking forward to sunny day. Hopefully, we’ll have some good weather today. [Jaz]Good weather and a good chat ahead. So for those listening in the future years, we’re coming to the end of lockdown. We’re starting to get back into work. You’ve been doing great things in the education, part of your teaching, educating dentists all over the world, which is usually what you do. This time, using the power of the internet. I saw your video right at the beginning of lockdown that got thousands of views, you know, saying that, you know, let’s make a difference. Let’s provide some education. So how has that journey been for you providing education, you know, pretty much on almost a daily basis. [Prof Paul]It’s been pretty tiring. We had four people who are working for me. So at the moment, we’ve got sort of, obviously no income because we’re not doing courses. But rather than furlough all the stuff we put our four main guys with this to work doing something else for the profession. So what we’ve been doing is trying to give free webinars, free education to the profession during this time. And in some days, I think it was today we’ve got three webinars on one at 9 o’clock, one at 1 o’clock and one at 3 o’clock. [Jaz]All bases covered. And I have to say the caliber of the speakers you’ve had on have been great, and I think is wonderful, what you put on for everyone. So you know on behalf of the profession. Thank you. But today, we want to touch on something that I know very dear to you. And I can only assume that because the reason I want to speak about this topic is as a student, I remember googling about bridges. And you can’t get very far on Google, by Googling about fixed prosthodontics and bridges without seeing your name plastered everywhere, and seeing your papers that you’ve posted on your website and stuff. So you are definitely someone who would be a great person speak about this. You know, we could have picked up many of topics that we could have, but let’s just hone in on one. And that’s bridges. So the first question I’m gonna ask you Prof is, I think and tell me if I’m wrong, it’s my perception, I see that, from what I understand people who used to do the masters courses at Eastman, for example, in the 60s and 70s. It used to be lots of fancy bridge work and whatnot. And then implants came along, and then we went more as a profession more towards implants. But do you think now that perhaps dentists are becoming a bit more cases selective about the implant cases, and that the role of bridges has become, has resurfaced again? Is that a fair comment? [Prof Paul]Yeah, I think that’s a very fair comment. I think it’s happened. Everything in your life, Jaz, if you live long enough, everything in your life comes full circle. I mean, everything, flat houses come back into fashion. We can talk about something that you were talking to Jason about verti preps, suddenly they’re back you’ve yet in the 60s and 70s. There have been done so everything comes back around. And I think the major stumbling block for implants has been in the last 10 years, the rise of peri-implantitis. And if we look maybe 10 to 20 years ago, we would have taken the brand of art studies. And we’d say to our patients, yes, you’ve got 90% success rate over 15 years, there’s no reason why that should not last 20, 30, 40 years. That’s all changed. Talk to any implantologists, who are worth their salt now, and ask them the question, how long is my implant going to last? And most of them will be saying, well, maybe 15 years. I’m not gonna say anything more than that, because we don’t know. And that’s our problem. So that brings it then into the realms of bridge design as well, because I wouldn’t be doing a bridge for somebody unless they really pushed me without saying this should last 15 years plus, it’s fixed prosthodontics. I do my fixed prosthodontics from a science base, we know what works in the science, and therefore there’s no reason why my fixed prosthodontist should not last a minimum of 15 years. So I think we’ve got this now lovely situation where bridge work and implants will probably be lasting the same amount of time. So we can be very selective with which cases are the right ones to do. And you say, you’ve got a missing six and a low sinus. Do you put the patient through sinus grafting and an implant when the seven behinds got a large MOD and the five imprints got a large MOD, for instance? Or is it better long term to do a fixed bridge there or fixed movable bridge and take the patients away from having the surgery? So I think your questions are fabulous one, and I think yes, implants are going down a little bit, bridges are coming up. And now we can be very case selective. Or one major problem, however, is that people don’t understand bridge design. It’s not taught. And therefore you know that there’s myself obviously that lecture about it, and probably one or two more, but not that many, until you go through university. And most of the time, the University guys are still saying Antes law, and Ante’s law got [debunk] several years ago. So it’s not taught. [Jaz]So true. And then that’s why when I was googling about to find out more knowledge about bridges, and that’s when I learned about you Prof. And that’s where you came into my radar. And I’ve been to a couple of your educational events, which is very, very good. And that’s what we can explore further in bridge design. So, you know, you’re someone who’s been educating dentists for several years. What is the most common area of lack of knowledge, let’s say or the common myth that you want to bust? Or the weakness area? I mean, yes, in general, you’ve touched on very nicely there that Yeah, bridges are not taught as well as they perhaps should be ante’s law. So ante law could be one of them. Are there any other misconceptions that young dentist may have? Because of the lack of training about bridges that really might annoy you? [Prof Paul]Yeah, I think, if we just go back a little bit, the bridge will involve doing usually not always usually a full crown preparation, or a fairly largest preparation. The first myth is that all young dentists are taught from a very early age, it appears that if you do a crown prep, then you’re going to have 20 to 30% of those going on by, Okay? And I want to just throw that away, not even [Jaz]touching on the Saunders and Saunders, sort of paper and whatnot. [Prof Paul]Yeah, that’s not the science. The science shows, as those studies are done without teeth being vitality tested before they were crowned. Now, if your vitality test before crowning, and you’re quite stringent with those vitality tests, and if you get a non vital response, you do a root filling, that drops down to about 5 to 6%. And that’s some French studies that the French are quite big on root filling before they do crown work. But they’ve got some good studies there. So that’s the first myth. And that drags itself then into fixed bridge work, whereby dentists don’t want to do a bridge because they’re worried about the tooth losing its vitality. [Jaz]Well, you know that saying Prof.? Crowns, kill teeth. Bridges kill them faster. Is there any truth to that? [Prof Paul]There can be if it’s not done properly again. So we then come a little bit more into the nuances. And I suppose one of the myths is that all bridges should be fixed, fixed. And I teach an awful lot about fixed movable bridges. And one of the great aspects about fixed movable is that you don’t have to get both abutments parallel. So you’ve got your typical missing a lower six, you five’s looking like that, you’re seven’s looking like that. To put a fixed bridge in you have to now really over prepare that seven. Okay? But what we’re talking about more and more, and this has been around for a long time, fixed movable isn’t something new, but again, [Jaz]but it’s not taught. I was never taught about it. [Prof Paul]Prepare it down to it’s long access. So we know how one path of insertion for one tooth one path of insertion for the other. The joint together with the stress breaker called the fix movable part. And that means that you don’t have to over prepare is now just like doing two crowns. Now you can’t do that for every single case. But when I lecture to my, my students, I go and say to them, you’ve probably been taught that you’re going to do a posterior bridge today for the patients. You’ve been taught that some posterior bridges should be fixed movable, but you can’t think why, therefore, you’re doing as a fixed, fixed bridge. Okay, I think that the, the thought process goes to a lot of dentists mind, I would like them to choose the opposite scenario. Okay, to get a complete shift, and say it’s a posterior bridge, it is there for fixed movable, and there are one or two reasons why it should be fixed, fixed. And if they do that, you’ll have far better success rates long term than just doing everything fixed fixed. [Jaz]Well, let’s just emphasize what you said that I think what you said there was really great. So by default, when we’re thinking about bridgework, that what you’re saying is that the default option actually should be the fixed movable, and you should have to justify the few reasons where perhaps thoses that’s not suitable and should be going for fixed fixed. So which are those couple of reasons, but actually, we should be doing fixed, fixed and not the default. And I’m gonna we’ll get into a bit more about the nuances of fixed mobile, but what are the contraindications to fixed movable? [Prof Paul]The major contraindication is mobility. So if one tooth is mobile, then it should be fixed, fixed. Otherwise, by having two abutments together, on one of them’s mobile, you’ll get an increase in mobility. So that’s the major one, there are some smaller ones such as the fixed movable usually means there’s going to be metal showing in the joint, which to some patient, especially in the lower jaw, maybe a contraindication. If the opposing tooth to the Pontic, or distal abutment, isn’t there, then the fix moveable can actually over erupt as a contraindication. And the other one is length of span. So very, very long bridges are not ideal to be fixed, movable, because that puts too much stress on the distal abutment. [Jaz]Is that like a ratio? For example, can you do let’s say we got a lower right four and you’re missing the lower right five and six. 4:7? Is that the limit? Or would you say? [Prof Paul]Generally, we would say that, again, very generalization of all three unit, posterior bridges, fixed movable, all five and six unit posterior bridges fixed fixed. The four unit is the transition area, where we have to look at other things such as mobility, such as the quality of the abutments, et cetera. [Jaz]Brilliant, well, then before we go into a bit more on fixed mobile, what you haven’t mentioned yet is a cantilever. So what are your thoughts on conventional cantilever bridges? Let’s say we have a missing six and you’ve got a heavily restored seven and the five is unrestored? Yes. You could do a fixed movable I’m sure. But what about the you know risk? Canterlevering after seven to replace the six? Are you concerned about the talking? We’ll talk about mesial versus distal cantilever as well. Tell us about your thoughts on cantilever bridges. [Prof Paul]Okay, so, generally cantilevers work very well. So cantilever bridge work is the only bridge work where we now design it going back to Ante’s law. Okay, so Ante’s law is going out of the window. Apart from cantilever bridge, it’s quite a nice resume of Ante’s law. We know that periodontal ligament space of the abutment to should be equal to or greater than the teeth that were being replaced. Interestingly, in Ante’s law, Ante also talks about fixed movable bridges. And that is the 1926 paper. And it’s movables being advocated by Ante, nobody picks up on that. But if you read the paper, he talks, every single posterior bridge, ideally should be fixed, movable, so that’s the sign. So we know that cantilever has worked very well. But we now have to go by Ante’s law. So at the front of the mouth, fine, we’ll have done central upper central lateral upper canine no problem. As we go to the back of the mouth, the only realistic time where a cantilever would be okay, from Ante’s law point of view, would be a premolar of a lower. So I’m very comfortable doing a five upper six, or if the fives missing and the six has come forward of four upper six. So we’ll move on to your question, which is the six upper seven. So what’s been found with those is that and these are Swedish studies longer and people like that. They found that It depends what’s in the opposing jaw. Because if you have a six coming off a seven, and you have a lower six, which is there, it’s not splinted to anything it can over erupt, what will tend to happen over a period of time is the lower six will over up by a few microns, that’s all. And the Pontic will then be in hyper occlusion as the context in hyper occlusion, then that will put a torquing force on the distal abutment. And there’s a possibility that we can start to get orthodontic movement of that seven due to the over eruption of the six. So one of the ways in which you could do i’m not saying don’t do these, one of the ways in which you can do this is to continually go back every six months, and adjust either the lower six tooth, or the upper six Pontic. Keep it in that hypo, not hyper occlusion. Another way would be, let’s just say for instance, the lower tooth is a bridge pontic or bridge abutment, it can’t over erupt, and therefore Yes, you can do a six off a seven, keep the six gently out of occlusion or again, occlusion and you don’t get the overeruption. So you can do these, it very much depends on what’s happening in the opposing jaw. [Jaz]Just to clarify on that, if you have a lower six, and we’re worried about it over erupting into an upper six pontic, then if we design it so that it’s very light contact in MIP and no excursions. Why is it that they still over erupt? [Prof Paul]If we look at vertical dimension, generally, teeth are always over erupting. So we have these compensating mechanisms that are going on all the time. We have this we love a little bit of tooth wear, and we have an over eruption. So that’s alveolar bone growth. As you mentioned, deposition, happens all the time throughout life, slows down in the older patient much more quick in the younger patient. So everything I’m doing, if I’ve got an older patient, I’ve got a much greater chance of being able to work with that patient to stop the over eruption because it’s not happening quickly. So what happens is we bite on the upper Pontic. Okay? and straightaway the upper Pontic will move slightly, because we’re biting on it with a bolus of food. Okay? t will stay there, it will spring back at some stage, but we will also have then a micron or two of over eruption. So this over a period of time has a cumulative effect on those compensation mechanisms just going on all the time. [Jaz]I love your fantastic direct good answers. I’m really enjoying this chapter. Okay, so one thing I spent a long time researching once one time was to find the evidence base for mesial cantilevers versus distal cantilevers. Because in a mechanical and physics viewpoint, it makes sense that distal cantilevers are not great, especially posteriorly, or those torquing forces. It just it doesn’t make sense. And I think it might be I’m guessing it might be one of the things that will never really get evidence for. And it’s a bit like you we know that we don’t need evidence that if you jump out an airplane without a parachute, that sort of thing. Am I right in thinking that actually that we don’t need evidence for that? Or we’ll never be able to get evidence for such a study like that, and that distal cantilevers by the nature of the forces are, tend to be avoided? [Prof Paul]Yeah, I think that there’s certain things in dentistry, we’re never going to be able to prove, as you say, just that we can’t prove them also means we can’t disprove them. So it doesn’t mean because we can’t prove something that it’s not right. And sometimes you might look at it completely differently, say, Okay, you go ahead and disprove me, you can’t disprove me, therefore what I’m doing is Okay, so we’ve got that sort of status quo in science generally. So we’ve got two things happening with the Mesial Cantilever vs Distal Cantilever. The first and obvious thing is, the further back in the mouth, we go forces increase, we get closer to our joint, we get closer to the fulcrum we get increase in stress, and we have the potential for the Nutcracker effect, class two leverage which will increase forces on the tooth. If the tooth happens to be a Pontic, there’s going to be more force on there and therefore more bending force on the abutment tooth, that’s number one. And number two, we have something called Mesial drift, and all our teeth are mesially drifting throughout life. That’s why as we get older, we tend to get a little bit more imbrication of our lower teeth. That’s why when we lose a lower six the seven tilts forwards it doesn’t tilt backwards. So with the mesial drift, mesial cantilever sort of fits in without mesial force that the tooth is used to having. They’re not used, the teeth are not used to having a distal cantilever force. So those two things together leads me out I think other people to suggest that we do distal cantilevers, but we have to increase the abutment numbers and the root surface area of our abutment teeth when we’re doing a distal cantilever. But all we have to say to our patient, this is not a brilliant idea. Maybe in these instances, implants are far better if the patient can’t have an implant, okay, for whatever reason, we have to go with what the science tells us. And what’s important again there is to try to stop any over eruption from recurring. [Jaz]Brilliant, thank you so much. I think that’s a common question we find, you know, Mesial Cantilever, Distal Cantilever base, I think you’ve answered that very succinctly. So then the last part of the podcast, so we’re gonna focus in on something that you’re very passionate about educating because honestly, the if you actually type in on Facebook, fixed movable bridges, it’s just, you just educating dentists on the various threads for dentist by dentist, dentist UK, Australian threads, American you name it, Indian threads, you’re just there. And you’re always you know, helping people out, actually design it that way, design it this way. So it’s great to see. So I know there’s limitations. Obviously, we’re doing this video component, a lot of people listen to the podcast, there are some limitations. And I urge everyone to check out the content that you put out there is really great on fixed movable bridges, some cases that you’ve posted before as well, but we can maybe tackle some of the nuances. For example, let’s talk about, let’s make it tangible, let’s talk about scenario and how you would design it. Let’s say we have a missing upper right four and five, we have the six which is got a large MO composite. And the canine is got a small, conveniently at small distal composite. Missing premolar we’ve got canine and first molar both restored to some degree. How would you design it in the sense that where would the male part of the connective be? Where would the female part be? Any advantages of doing it a different ways? If we’ve talking about in that scenario, if that’s okay? [Prof Paul]Sure. The first thing that we would decide so when we do bridge work, and when we do bridge design, we have to go through a scenario whereby we go through treatment planning, we come up with what we think is the ideal. So [Jaz]actually, you know what I’m gonna do something, I’m going to show you a photo I’m actually ever scenario that can show you that is this scenario that I’ve just remembered. So that will be really cool for people watching. Sory to stop you there prof. I think add more value. Okay, so can you see that? [Prof Paul]Yes I can. [Jaz]So there’s the canine and it has got a small distal composite. There’s the first molar, it’s got an actually a DO not an MO composite. So it’s fairly close. Is that the sort of thing that you had in mind when i described the case? Brilliant. So that’s a little visual for people to get that people are visually minded. So yeah, please do carry on about how you were saying how he would actually plan and think about bridgework. [Prof Paul]Yeah, so so we plan a case. First of all, we have four stages in planning the case. Okay, number one is, if we’ve got bridgework, potentially in other areas of the mouth, we design the anterior bridge first, and then the posterior bridge later. Okay? So that’s number one, always designed from the front going backwards. Number two, is to choose your abutment teeth. Certain abutment teeth are not great teeth, such as mobile teeth, such as post crowns where there’s no ferrule, and it may well be that you decide that you’re going to take a tooth out and make a longer bridge that will have a better success rate than keeping a poor abutment. The next one is to go and design the actual design itself of the bridge. So is it going to be fixed, moveable? Fixed, fixed? Cantilever? Multiple abutments? Coping design, that sort of thing. And the final one, then is to go and design or choose the actual retainer type. And is that going to be a crown, three quarter crown, inlay, onlay, Maryland wing, etc, etc. So that’s the way in which we’ll take every single case. So in this case, it is no other bridge work. So we’re just going to design that bridge work. We look at the abutments the three is healthy, the six is healthy. So we have no problems there. We now go and look at the design. So the design is going to be dependent upon mobility. So is the six mobile? No. /-no mobility/ Three mobile? No. So that gives us the opportunity to go fixed fixed or fixed movable. The next thing we’ll do then is, again, look at root support. Are they short roots? Are they long roots? I presume the six and the three have got reasonably good roots. In which case then you have the scenario, do we go fixed, fixed or fixed movable? There’s no contract indications to fix movable and therefore we go back to some of our studies which show that fixed movables because they have a stress breaker, there’ll be less stress on the abutment teeth, less chance of fracturing off, less stress on the cement lut, less chance of cementation failure, less stress on the porcelain, therefore less chance porcelain fracturing. And we go back to some of the studies that say those potential for failures can add up to about 50% of all the failures that occur in bridges, versus what’s the percentage of failure occurs in bridges due to occlusal overload. And that’s about 6%. So your way up the two things here, and you come to the conclusion. What I would do, the fixed moveable would be the better long term solution. Now, if any of those teeth were mobile, straight into fixed, fixed, okay? So we’re into fixed movable the final stage then is to go and decide what our retainers are going to be. And we know from our retainers, that the best long term retainer for success is a full crown. However, as we know, full crowns can be very detrimental to tooth destruction, etc. So can we get away with other types of retainer? And we look at the science that says in fixed movables, there’s not as much stress on the cement lut, therefore, we can go with retainers, which are not as retentive as a full crown, and therefore not as destructive. So for me during this, I’d look at the six and say, that six looks as though it’s got a pretty hefty composite. Looking at that six looks as though those buccal walls are not that thick, therefore I’m probably going to go and do a full crown on that six, that would be my thought process. Distal composite, we know that inlays, for instance, or a Maryland wing would be a reduction in the amount of tooth destruction. So it’s going to be a little bit easier for the patient, easier for the enamel of the tooth itself, if you don’t go and traumatize it as much. So for me, I’ve now got the situation, shall I use a distal gold inlay? Or should I use a Maryland wing? The Maryland wing is going to obviously change somewhat my guidance. And it may well be I look at that and say, you know what the patient doesn’t have canine guidance, the canines aren’t contacted. And therefore I’d like to put something onto the palatal aspect to give contact and give guidance. Another part would look at it and say, the canines, fantastic, it’s a gorgeous looking tooth, we’ve got great guidance, the patient’s not bruxing, why change that palatal inclination at all. And therefore I’ll go with a distal gold inlay. So that’s my thought process. At the end of the day, no one bridge is right or wrong. All we’re doing when we design bridge work, is we try to get three things into every fixed restoration, we do. We want maximum longevity, we usually want minimum preparation for that. And we want to get as good or aesthetics as we can. So that can be a single crown, it can be all the way up to a 8-10 unit bridge or whatever. Well, those are the three factors. And we’re always looking to try to get those three factors in our favor. Now, what we do find over the years, however, is that no one restoration will satisfy all three. So we have to make a choice. And we have to usually say to our patient, choose to which two out of those three are the most important for you. And then we can design a restoration. So for instance, if I was going to do that bridge, and the patient said, maximum aesthetics, absolutely maximum aesthetics, I’d be probably thinking I’m going to go to zirconia. But that’s going to have to be a fixed fixed bridge. And so I’m going to have to take more tooth tissue away. If the patient said maximum longevity, I’m probably going to go and put a gold crown on the six as an abutment. So we have to work within those three parameters, but also discuss with the patient what they want. [Jaz]Well, what was the third parameter? Sorry you say longevity, conservation [Prof Paul]Longevity, minimal prep and aesthetics. We can’t do any restoration we do. We cannot get all three. We don’t have that gorgeous scenario. [Jaz]Perfect Well, since we’re doing amazing time, and you’ve literally covered a blitz through the bridgework in such a I mean, the nuggets people are going to take home from this bit alone is fantastic. So it’s just a homerun on that final part of the design design process of the nuances of that fixed movable. If the inlay, if the gold inlay is on the canine and that’s facing distally and you have the full coverage retainer on that first molar. How do you then instruct the laboratory to design the male and female components? Because I believe there are a couple of ways to do this. And there are a couple of camps. Can you just talk a little bit about that and where you can find out more information? [Prof Paul]So for me, this is 100%. Okay, I know we should never say 100% in dentistry, the 99% that the fixed movable attachment is always on the distal aspects of the anterior retainer. Okay? So the anterior retainer, in this case, it’s going to be the canine, it’s going to be gold inlay will house the female, which is the slot. Okay, the male portion, which is the rod that fits into the slot is always connected to the Pontic. And the Pontic is always connected rigidly to the distal abutment. So for me, it’s always in that distal aspect. Now, it depends in that distal aspect whereabouts you put it, you could with this gold inlay idea, you go and drill a box, in your scenario, you’ve got a distal composite. So you’re going to drill that distal composite out, tighten the wall, so there’s a little bit more retentive print inlay, you’ve not lost an awful lot of tooth tissue there. But you’ve got now a box into which the female can be housed. Now the advantage of this is that when the male bites up and down, the road goes into the tube, and the tube, the force is now put down the long axis of that canine so we get really good forces down the long axis. Now the second scenario, not particularly in this case, but if we’re doing say, a crown, a full crown with a female attachment. The second scenario is now that the rod tube, we do not cut a box. So to get the female down the long axis, we have to cut a box. And that box is usually about two millimeters wide, two millimeters deep. Now if that’s a perfectly healthy tube, let’s say the we’re doing using an upper four, and the upper four has an MO but nothing distally. You then say to yourself, should I cut a distal box, a four millimeter square distal box just to house that female so forces can go down the long axis versus if I just do a normal crown preparation, my attachment will now be slightly off axis. So when I bite up and down, there’ll be some off Axis forces. What’s the root like on the four. Does the four have a good root and good bone support? In which case potentially it can take that stress. So again, always on the distal of the anterior abutment, but it can be housed internally, on the edge or externally. The other aspect that we should know about the fixed movable is the technician initially, he buys this from a company such as [Sondra Materia], or something like that. It’s a plastic burnout. And he waxes it into his reconstruction, so that the male actually bottoms out and hits the bottom of the female. So that’s how it’s returned to the dentist. Now as a dentist, as a clinician, we need to therefore take a little bit off the base of the male to allow this movement to occur. So if you just cemented in place without having adjusted the base of the male is now acting on the loan like a fixed fixed. [Jaz]This is a really key point here. So those listening and watching right now, you have to really hone in on that because that could be a complete waste of you doing the fixed movable. So what Prof is saying you have to remove the base of the male, so that it has that sort of give and that space to actually act as a stress breaker, which is the whole point. That’s a really, really key point. [Prof Paul]Yep. And we usually take about a quarter of a millimeter off it. And the lovely thing also about fixed movables is that we can selectively put more stress on to one of the abutments. With a fixed fixed bridge, you bite on it both abutments take the stress and therefore if you have one weak abutments there’s no way you can protect it. Now with a fixed movable, if I have a weak abutment, especially if my anterior abutment is weaker, if I take a little bit more than my quarter of a millimeter off, that’s throwing more stress onto my distal abutment protecting my anterior abutment so we can play around with the nuances there and protect teeth to get that extra little bit of longevity even more. [Jaz]That is absolutely fantastic, honestly, Prof you’ve given such concise learning points for bridges. I’m absolutely really pleased with all the knowledge I know I’m going to get loads of messages saying “Wow, Prof just gave out all the answers and it’s a great way.” So I’m really happy with all that choice. If you’ve answered every single question I had about bridges. This is a. look this is a complex rule, every scenario, every mouth every every patient is unique so that anytime I give you a scenario And you have his methodological system to go through and design. But at the end of day, every case will be different. And there’ll be some nuance in each case. For those wanting to learn more and go on any hands on training that you might have about this. Can you tell us a bit more about how we can come on to those? [Prof Paul]Yes. So Tipton Training, as you’re aware, we’ve been doing courses, [PG materials, Diplomas] for many, many years. And we’ve been doing this for, I hate to think it’s about 25 years now. And the courses have obviously evolved as dental science evolves. But we do a full day on bridge design, which is, it is a full date to understand it fully. It’s going through the papers, and I’m a big one for self discovery. I’m not when we do our courses, I don’t like to just lecture to people, I think lecturing is a really poor way of getting knowledge across. So when I went down to the Eastman all those years ago, to do my master’s degree, it was the first time that I’d ever experienced sitting in a group around a table and discussing things and having a mentor lead the discussion. The mentor knew where he wanted to lead it, what everybody else in that room was discovering things for the first time. And that really stays in your mind. So what we do to teach bridge design is we go through about 20 papers, and I leave the discussion, and I let the guys in the room go, ‘Ah, that’s why we’re doing that.’ And that just stayed with people. So it’s a far better education method. So I down bridge design, we have about 10, till two in the afternoon, where we do four hours, it’s a tough day of pure science, the lectures, we then have a lunch break, and then I follow that up with two hours of slides, going through my lecture showing obviously photos, case scenarios, etc. And then we also have a full day on the Phantom head, the operative course that we do at Tipton Training, where they go into the lab, they have webinars before that, so they can get all their information, again, via webinars. And then they spend from 10 o’clock till 5 o’clock, prepping various bridge designs, which we put in front of them. So that’s how we do that. That’s part of our restorative courses. I don’t go and do any other one day courses on bridge design, because I think for bridge design, you have to understand dentistry, as you’re trying to get through there. And you made the point really well, the nuances are key. And the nuances come from and [Jaz]This is why, Prof I had you on but I realized that you know, a lot of people this might be the first time to learning about fixed movable. I have a very, very young audience. And they may be learning about fixed movables for the first time. So I don’t want anyone to go away thinking that they listened to this podcast episode. And now they can confidently do maybe with some mentorship. Yeah, fair enough. There are some great dentists out there. But I think for those who want to really get to the meat and potatoes to consider, and I like what you said about the ‘aha moments’. I think last year, I went to your Watford one day at the Hilton, amongst other things I’ve been to as well, and that I definitely member having some aha moments there. So I like your teaching style. So I think definitely that’s a takeaway point to make sure that Yeah, you’ve got this introductory knowledge about fixed movables. But you may need to find out more about the nuances because really is about the nuances. I mean, we haven’t even covered about the cementation, and how to do that. So there’s so much practical stuff to learn still. [Prof Paul]Yep. And with every bridge, we can’t get around. It’s the elephant in the room, the Beagle, occlusion. So occlusion matters hugely, how long that bridge will last, whether you get the guidance, right, whether you get the five principles, the occlusion, whether you managed to get no class two leverage it converted to class three leverage, whether your pontics are discluding or not. So we’ve got that. We’ve got another huge topic, which is tooth preparation. To make sure that you understand resistance, retention form and how with a bridge you need to increase, especially fixed bridge resistance retention form. We’ve got lab techniques, and most dentists, unfortunately, don’t understand lab techniques. And throughout the course, we’re always going on about visit your lab, talk to your lab about lab techniques. As an aside, if you don’t mind me for just a minute, one of the major influences on my life my dental life was going down to the basement and doing my master’s degree. And I was we did my master’s degree it was a two year degree. I went down there three days a week for two years from Manchester. And during the daytime usually from 9 till 1 it was a seminar from 2 till 5-5:30. We did our practical on patients. But then from 5:30 to 9 o’clock we’re in the lab doing our own lab work and this is a huge key. If you look at any successful restorative dentist, prosthodontist around the world, okay named the top 10, they’ve either been trained as a technician first [Christian Coachman], something like that, or they’ve got really good technical ability, and they’ve learned how to do the technical side of things. So again, a take home message to all the young dentists out there is understand what your technician does, you’re in a partnership, you cannot get away from that partnership, he needs to understand what you do, you need to understand what he does. And so the mechanical principles of casting of dealing with fixed movable twigs, how the made die spacer, things like that are so essential, and technicians every single day when they’re doing your lab work, face about 10 or 15 decisions, how they’re going to do your lab work. And they might go down the wrong route or the right route. Okay, I’m very often that’s due to financial constraints, you need to be there saying right route, please, right route, please keep on going on the straight and narrow. And that way you get better long term results [Jaz]The more you can understand about the technical side, the more you can communicate with your technician in a language that you both understand, because there are different ways of thinking about it. So I completely echo what you’re saying, to have that sort of communication with the laboratory and relationship with the lab, which will really help you because they can make great mentors. But also I say that even though your technician, even the twice your age, will always benefit from your ideas as a dentist as well, because they might come to some of your courses, and then come to your way of thinking and they may have been missing a key point in the technical aspect. So I think they can learn something from us and we can learn a lot from them as well. So I think that’s a great point you raise that. So Prof, before I say goodbye. There’s a one more thing I just remember, I forgot to ask you is when you’re in this is going to be my Protrusive Dental pearl and be like okay, so Prof gave me this pearl for today. And this is when you’re placing grooves for crowns and bridges. Is there a rule in terms of, for example, do the grooves for crowns need to be mesial and distal and for bridges, they need to be buccal and lingual, is there a sort of guideline that we how to, where to place your grooves in certain restorations? Can you please share that with me. [Prof Paul]So grooves are placed for single crowns and for bridges differently. So first of all, we have to go reason for a groove through retention because of surface area, but it’s mostly for resistance form. So the groove was not stopped the crown being pulled off this way. Okay? The groove will give you resistance form, which means the crown being pushed off from a non axial direction of force. So if we look for more crowns, and you still together, grind from side to side, it’s usually a buccal lingual force that will, that’s the direction buccal lingually. Then we put our grooves at 90 degrees to the direction of force. So for a single crown, we’ll put our groove either mesial or distal, or mesial and distal, that will give us more resistance form. So the question then comes is it mesial? Is it distal? The rule state that you’re better off putting the groove in tooth tissue than you are putting it in restoration, if you put it in restoration, then the resistance form is directly due to the actual resistance form of the restoration, which might not be very good. We’ve all had times where we’ve prepped to tooth taken the impression and the cores come out. So sometimes that’s not brilliant. Next thing is, is your groove parallel sided or tapered? Parallel side will give you more resistance form. Tapered a little bit less. If you’re putting multiple grooves in you got to make sure that those multiple grooves are parallel and not like this. Then we come onto bridges and we look at bridges and we say Okay, first thing grooves for resistance form. What direction of force will bring a bridge off? Now it’s not tense does not to be buccal lingual, it’s now anteroposterior. So the usual thing is we bite on the anterior abutment and the posterior wants to rotate off, so it’s anteroposterior and chanted a good paper [TJAN] looking at the anterior and the posterior abutments the posterior is always under more stress, the cement lut and therefore with a bridge which is going to be a posterior one. I seldom put a groove in the anterior abutment, always put a groove in the posterior abutment. Okay, and now because it’s going to be an anterior posterior direction of force, which brings the bridge off. Okay? Where do we put our grooves? Our grooves are now placed buccal or lingual or buccal and lingual and don’t forget also and important part here. We can also get resistance form, increased retention as well occlusally. So very often we will be doing a bridge prep, a crown prep on a tooth that’s got an occlusal amalgam for goodness sake, take the occlusal amalgam out, make it into an inlay. If it’s an MOD amalgam puts a slot down it. And again, you’re going to get several things, you’re going to get increased rigidity, rigidity is really important with bridgework, you’ll get increased rigidity, you’ll get increased resistance and retention form and the other thing that we find with most crowns and bridges posteriorly. If you look at 100, crown bridges, okay, units, aesthetically, the area where most technicians and dentist struggle is when they’re doing occlusal reduction. They never reduce enough in the central fossa. So if my cusp bang goes like this, the prep cusp bangles are like that. Okay? By putting a groove mesial distally, you’re now allowing the technician to get a really nice deep central fossa, which will also increase aesthetics. So don’t forget the occlusal surface occlusal stuff is really important. [Jaz]What a fantastic comprehensive reply. Thank you so much. Prof that’s been a really, really educational session. I really appreciate you coming on the show. I know how busy you are. And it’s been a great chat. I’ll let you know when the episode’s out and then for everyone to listen to it as well. I hope you have a lovely summer and I hope you get back into the swing of things with the courses and clinics and whatnot. [Prof Paul]Thank you very much, Jaz. It’s been a pleasure talking. Any other time happy to do another one. [Jaz]Thanks so much. [Prof Paul]Appreciate it. Jaz’s Outro: So there we have it loads and loads of bridgework gems as I promised. I hope you found that useful. I’ve had so many superstars on recently honestly, I’ve been quite blessed. So yeah, as always, thanks for listening all the way to the end. I really appreciate it and I’ll join you in the next episode.

One night when Dr Rajiv Ruwala was up all night as his daughter would not sleep…he came up with a very inspired list… He was interviewing Dentists for associate positions and asked himself, ‘What are the habits of the most successful and valued Dentists?’ He came up with this awesome list which we discuss point-by-point in this episode of the podcast: https://www.youtube.com/watch?v=NJeMUF05T18 Here are the 10 habits below: They can listen to the patients story and find a treatment to become a solution for the patient. I asked Rajiv if he has any tips in encouraging patients to tell their story or their goal? They often do not offer this info up front. They are proactive in recommending treatment, not reactive. I asked Rajiv to give a tangible example of being proactive. I also asked how to handle the situation when a proactive Dentist inherits the list of a reactive Dentist. They don’t get validation from how much patients pay them, but from how much the patient values what they have to say. If the patients value what the dentist has to say, they naturally accept the treatment. How do we serve patients who do not value Dentistry? They work with their nurses to make sure everything is ready and set up before the patient enters the room. The value of a great nurse is monumental – are you a checklist kinda guy? You may be surprised by the answer he gives… They do not moan about their working environment, the “system” or their staff, they help find solutions to problems and improve the situation. I like this because I always like to approach people or managers with solutions not problems. Rajiv has lots of solutions to work effectively in the NHS. They are happy to refer out and develop a skill/niche that allows people to refer to them. I have my views on this but how do you think one should find their niche? Rajiv gives his ideas. They don’t ask for something for nothing. Instead they build value before investing/ asking for investment. This is massive. How can you build value in to the care you provide? They look to improve in three key areas; clinically, financially, and personal growth, and aren’t afraid to ask for help to do this. Tell us how you, Rajiv, have looked to improve in those 3 domains for inspiration? They are not adversaries, they want to associate/collaborate. I find most successful dentists are so willing to share and help! They take adequate time off to be fully charged/energised. How much time off do you recommend, or is it personal?How about 10,000 rule when you are newly qualified? Rajiv talked about courses for communication which also features making the NHS system work, rather than moaning about it! You can find out more about that here: Course for Associates – PYP course Course for Principals – KYN course If you would like to pre-register for the Splint Course (limited delegates to allow mentoring and support), please subscribe for updates and surprises if you are looking for a comprehensive, step-by-step, clinical splint course.

As Dentists we do not treat headaches – however, we can manage the parafunctional forces and you will be amazed at how many patients will reduce their use of analgesics after these appliances. This is the big one….we finally delve deeper in to Anterior appliances as part of Splintember! https://www.youtube.com/watch?v=0jX7mB_jDKc Need to Read it? Check out the Full Episode Transcript below! Lets talk about these really evil devices [/sarcasm] – the anterior only or segmental appliances, the ones dental school told me to stay away from… There are lots of names/derivatives/ and brands for these such as: B splint or Dawson B splint NTI /SCi/Mci Bitesoft FOS E-splint named after Jimmy Eubank DAASA or the umbrella term for this splint family which is called AMPSA I have decided the only way to make this work for those that listen to the podcast on your commutes and while you garden is that I will urge you to go on to the Protrusive Dental Community where I will post example photos and videos of the various appliances. If you have not listened to Episode 8 with one of my mentors Barry Glassman – I really urge you to, we talk about these appliances and whether or not they cause an anterior open bites. In a nutshell – many dentists condemn this appliance. They believe that by having a splint only on the front teeth, that the back teeth will over-erupt or dentoalveolar compensation will take place. Does that happen? – NO, they do not tend to cause a Dahl effect for the following reasons: AMPSAs are only worn during sleep Dahl effect you need bone deposition – its not going to happen from 8 hours a night! I was careful with my words, I specifically said they do not cause an AOBs due to the Dahl effect. Technically, ANY appliance can cause an AOB due to muscle deprogramming and condylar repositioning +/- postural changes depending on which camp you believe in. You can actually predict which are the patients this might happen to – once again, from any appliance, but because the anterior ones are more efficient at relaxing the lateral pterygoids, this is why they are implicated for it. How does it work and which records do you need? The way it works is similar to the concepts or rationale of anterior guidance which I discussed in the previous episode. By not involving the back teeth – you are furthest away from that powerful nutcracker AKA the TMJ, and also due to the proprioception from anteriors, you are able to switch off the anterior temporalis muscles. What does this mean? What records do you need? Why do I like leaf gauges? Find out all in this episode of the podcast – I will go even deeper with Part 2 – watch this space! If you would like to join us for Occlusion2020 Virtual 2 day intensive program on 27th and 28th November, there are a few tickets left! Join me in Part 2 where we will talk about: Deciding upper arch or lower arch, or sometimes both arches What is the difference between these various anterior appliances and is one better than the other? Why even an AMPSA can be an overkill and which patients may actually benefit from simpler devices How many of my patients have developed AOBs, which splints caused them, and how to manage such a scenario Click here for Full Episode Transcription: Opening Snippet:As dentists we don't primarily treat headaches but we can manage the power function now you'd be amazed about how many patients have stopped taking analgesics after i prescribed these sorts of appliances... Jaz’s Introduction: Hello everyone and welcome to episode 41 of the Protrusive Dental Podcast. This is the fourth one i think for Splintember. We’ve already covered which is the best dental appliance so that was like the g splint theory, we also covered some basic TMD anatomy and the weakest link theory. I talked the last episode about why michigan splints are totally overrated and now this episode we’re going to focus on anterior only appliances Now, if i didn’t piss enough dentists off already from my last episode about a michigan appliances being overrated, this is bound to lose me some more fans i guess but hey the truth must come out because anterior appliances are ones that dental school taught me, never to go near like these are evil evil appliances. Don’t make anterior only appliances because catastrophic things will happen and you will get sued and you will lose your license and you will be begging on the streets forever and ever. So this episode i hope will restore your faith in anterior appliances when correctly prescribed and this part one just really is the basic overview, what the functions are? What the mechanics are? And what records you need to make an anterior only appliance? There are lots of different types of these appliances on the market some by type of design, some are branded for example most common ones are something like a b-splint, NTI or SCI or MCI, same thing different branding there’s also called the FOS, the flexiorthotic splints which is pretty cool. The bite soft An e-splint and which is called a Eubank splint. A Dawson b-splint which is pretty much a b-splints.  A dual arch version of these and yeah the list goes on and on and on there’s many different types but the umbrella term that all these appliances is anterior only segmental appliances come under is called an anterior midpoint stop appliance, so how about if it’s okay with you i’m going to call these appliances AMPSAs. So if i say AMPSAs you now know what I mean. So we’re going to talk about AMPSAs Now this is actually the appliance that i wear every night and it’s for me, it’s a protective and palliative appliance like i feel better i feel more relaxed and it also protects my teeth against the force of parafunction. So for that’s the role it has for me i guess what i want to say before we dive right in is this episode i want to talk about each individual appliance but i’m going to save that for the next episode because it will just flow better but if you’re looking for photos like a lot of you are listening to me right now while you’re driving or why you’re gardening and you won’t you don’t get the visuals that i’ll eventually show so what i’m gonna do is all the different splints i discuss i’m going to show you what they look like and how they work and hopefully i’ll six a few videos on as well on the Protrusive dental community facebook group which is a private group it’s my way of making sure that no members of the public and patients come in just dentists only and especially those who listen to podcasts and once you join that if you’re not already part of it you’ll see all the different splits i talk about. So that’s where i’ll be posting all the videos and images of different splints. If you haven’t already listened to episode 8 please listen to episode 8 it is called Do AMPSAs cause AOBs? So do these anterior midpoint stop appliances, do they cause anterior open bites and that was with one of my mentors Dr Barry Glassman, it’s a really insightful episode all about this basically we did some myth busting i guess i will have to because if you haven’t listened to it i’ll have to summarize it very briefly in in this episode but it’s well worth a listen especially if you want to get deeper and deeper into these appliances.  The Protrusive Dental Pearl today will make more sense if you listen to the last episode where i talked a little bit about the lateral pterygoid muscle. So the pearl i want to give you is any patient who has a history of joint issues let’s call it so something that’s perhaps intra-articular clicking joints and you’re going to be doing some restorative care or even extractions anything that will involve them opening their mouth for a long time it is really really important that you give them a mouth prop on the adjacent side or the contralateral side because the function of the lateral pterygoid is to keep your mouth open. Now a lot of these patients you’ll realize who are parafunctional when you’re doing work on them you realize that they start closing and you’re like can you can you please open up again and they keep closing and you keep nudging them, can you please open up again these very annoying patients and because it’s basically because their muscles are already in a state of being tired you know they’re already overworked at night, they’re parafunctional and they struggle to keep open and their jaw gets tired and start getting pain and it’s basically a lateral pterygoid it’s hurting because it’s already so knackered right?  So what can you do if you give them a mouth prop, it allows them to relax they no longer have to stretch open the whole time. They can relax into it. It gives an opportunity to for the lateral pterygoid to have a break and it also prevents the muscle going into spasm because what happens if it goes into spasm it will pull the disc even more forward and then they might have a lock jaw as in a closed lock and that’s not a nice situation to be in straight after dental procedure maybe this has happened to you before after root canal or long procedure that your patients are unable to sort of once they’re close together they’re unable to open again because they’re feeling a lot of tenderness on pain on one side.  So it’s a great thing to do for anyone with a history of internal derangement to give them a mouth prop because it will help the lateral pterygoid. So that’s a the very relevant Protrusive Dental Pearl I have for you today. Main Interview: So back to AMPSAs this appliance is actually condemned by some dentists because they believe and this is very principally, fundamentally what they believe is basically because it’s an anterior only appliance they believe that it will act as a Dahl appliance whereby it will cause the posterior teeth to over erupt or perhaps a degree of dental alveolar compensation and therefore your patient will get an anterior open bite. So that’s the main sort of those people who are against anterior appliances, that’s their main argument that yes it causes AOBs and we want none of it so that’s their main argument but really i’m going to do a bit of myth busting following on from episode 8 that actually that’s not quite accurate. Two reasons, one is that your patients who you give an anterior midpoint to appliance to they only wear it in their sleep. Now if our patients are only supposed to touch their teeth for 17 minutes a day and maybe about three and a bit minutes at night time only on average based some studies then really they’re only really missing out on three minutes of teeth concept per day for the non-para functional patient, the para functional patient is it’s a god send, this appliance because their teeth are no longer rubbing together but because they’re only wearing it for maximum you know 8-9 hours of night time then really that’s not enough time for a dahl effect to take place and number two is that this sort of Dahl effect it actually requires bony deposition i.e you the the body needs to lay down some alveolar bone to allow the posterior teeth to sort of overrupt or compensate and really this needs more time you can’t achieve this in 8 hours per night, ask any orthodontist.  So this is a fundamentally flawed concept that you get a Dahl type effect and it’s really false and if you’re if you’ve been afraid of this appliance for that reason then don’t be but you can still get an AOB not from the dalh effect that’s why i was very careful to say you don’t get an AOB from the Dahl effect but you can get an AOB in any appliance, you can get an AOB from a michigan appliance one of my patients believe it or not she came to me with a posterior only appliance which should in theory cause posterior intrusion and a posterior open bite but she came to me with an anterior open bite. You can definitely get AOBs in any sort of appliance and the mechanism for that is nothing to do with a Dahl effect, it’s called condylar repositioning and that’s the most common theory. I’m just gonna go into that a little bit now. So remember back to the last episode where i talked about the lateral pterygoid muscle deprogramming. Imagine we deprogrammed your lateral pterygoid muscles those poor little stressed out positioner muscles, these super muscles are tired the whole time keeping your condyle in the correct place so you don’t keep crashing into your centric relation contact point and also doing parafunctions working really hard and now we managed to de-program it.  Let’s say we give you an appliance any appliance and this deprograms your lateral pterygoid.  Now what happens is that when you remove the appliance the lateral pterygoid forgets how you used to bite together and because it forgot how you used to bite together and it really likes this new situation it doesn’t miss the tension and the stress of the old position, it’s now relaxed and you know what it’s happy that it forgot the the old position and now the muscles are suddenly relaxed and the consequence is that actually you’ve forgotten how to bite together and because you forgot how to bite together you just bite together on your back teeth and maybe now you have an anterior open bite this is a real gross simplification of the process but essentially the best way to remember it is that your muscles forget how you bite together and this is called deprogramming or an anterior open bite due to condylar repositioning. There are a few more theories about how this actually works and a few other accessory theories about the other causes of AOBs with respect to splints but let’s just go with this one because it’s the most simple one and it’s the most common one actually.  So you essentially forget how you bite together you can actually predict which patients are likely or a higher risk of getting an AOB whenever i’m prescribing these anterior only appliances in my notes i’m writing whether my patient in front of me is low risk or high risk of an aob and there’s certain traits for example if you’ve got someone with a ridiculously deep overbite they’re not the ones who are going to come in with an aob just accept it because if you can suddenly miraculously treat all these very deep patients non-surgically and suddenly take them from here to an AOB you’re a miracle worker, it’s not going to happen right? So there’s certain occlusals traits, there’s certain features of their dental anatomy which will mean that they’re more likely to have an aob and you can predict it and then you can write in your in your notes low risk or high risk and i’ll go into that in the next episode.  The best way to figure out how anterior only appliances work is you know in the last episode where i talked about anterior guidance and the benefits of anterior guidance i.e being furthest away from tmj hinge and switching off the muscles, that’s essentially how anterior only appliances work that’s how AMPSAs work. They switch off the anterior temporalis muscles from proprioception and also they’re far away from the tmj hinge What does that actually mean? Well let’s do a little test, a little experiment, if you’re hopefully not driving and you’re able to do this if you can get yourself a clean covid free pencil or something like that or if you’re in the clinic get some cotton rolls, get a couple to disclude your back teeth basically so you put your pencil in your front teeth or around about your incisors or the cotton roll at your incisors and i want you to put your fingers by your anterior temporalis i want you to squeeze together with the pencil or the cotton rolls in place and feel the contraction, feel the contraction of your muscles  Now do the same thing without the pencil or without the cotton rolls there and notice the difference, you’ll notice that your anterior temporalis muscle can contract significantly harder when your back either touching and that’s essentially how the appliance works. The muscles can switch off and if your back teeth are no longer crashing against each other then they’re going to be happy, the PDL is going to be happy. You may actually get improvement in sensitivity, if that was the also due to some parafunctional issues, you’re not going to be breaking restorations anymore because the teeth aren’t touching anymore Sometimes i’ve had patients with headaches tension type headaches and i gave them an appliance like this for muscle reasons and perhaps protective reasons and they come back and they tell me how their headaches have improved and they’re taking far less analgesics and ibuprofen because of this appliance now they’re no longer getting their headaches or it’s significantly reduced which is which is great to hear but remember guys we as dentists cannot treat and should not treat headaches right i always tell my patients i’m not someone who treats headaches i treat  parafunction and even then i don’t treat it. You still parafunction. I just manage the forces so that they’re now directed somewhere which is safer and better and not damaging your joint or not damaging your muscles so that’s the idea and some of these patients will actually get a secondary benefit i.e their headaches will get better in fact the funny thing is there’s a website called solvemyheadache.com and this is not a website for some analgesics or a massage therapy program it’s actually for a splint. It’s a splint i quite commonly use it’s called the FOS appliance FOS, flexiorthotic splint and it’s the sort of the patient-facing website marketing the FOS which only a dentist can prescribe so it’s not like they can buy it themselves but it’s it’s a great concept you know. They found out that these sorts of appliances your SCIs, NTIs, MCIs FOS appliances, they really help a lot of patients with their tension headaches but as tempting as it is you shouldn’t promise your patients anything to do with headaches. Don’t even go. Don’t even go there just tell them all with headaches that they need to get an official diagnosis from their GP, you are going to treat the problem that you see in front of you which is worn teeth parafunctional myofascial pain you’re not there specifically treat headaches but you might get a positive benefit.  The other way to think about these appliances is you know that patient where you want to check their guidance right you want to check are they canine guided? Are they group function? What’s going on and you tell them can you please grind to the right and they tell you ‘yes i’m trying and they’re really just they’re locked in position and the mandible can’t move because the interlocking of their teeth is so good it’s so well meshed together the the inclines of their cusps are so steep and they just can’t move and and you think how is this possible, they’re clearly parafunctioning and going into those movements at night time because their canines are really worn so you think what’s going on here they’re locked in.  Now what locking in does is that increases resistance in your muscles therefore when you give an anterior only appliance and they’re able to skate around freely you suddenly reduce resistance you’ve actually really helped these muscles in a way that an analogy i can give you is imagine you’re lifting some really heavy weights right and your muscles are are working overdrive and they’re working really hard to lift these weights and now suddenly you decrease these weights by about 75 percent those next few reps they’re going to be really easy it’s going to be like as if all the resistance has been removed and you can imagine your muscles will be in a happier position so that’s another way to think about how these muscles do work and how beneficial they can be for your patients. Those are the mechanisms of actions and really the indications for this AMPSA type of appliance is when you have a myofascial or a muscular diagnosis you got these tension headaches which you don’t you’re not treating because they’re tension headaches but you’re really treating the signs of parafunction and you want to protect them from further wear, you may have a situation where you have a tooth that’s hurting or you’re getting some sensitivity and you just can’t explain it and you think could it be because they’re parafunctioning and that’s the cause of it. Now by giving an anterior only appliance if the pain goes away then you can to some degree of confidence agree that perhaps it was the appliance or the change or the existing occlusion or the occluding scheme that was the cause of the pain in the first place, so it can be used diagnostically of course anterior only appliances are fantastic de programmers far better than michigan appliances or tanners so definitely a strong indication for anterior appliances anytime you’re doing a rehabilitation and you want to deprogram them it’s a great appliance to give them to just reset all the muscles get everything relaxed so you can get a predictable centric relation recording. So those are the sort of general types of indications.  I guess a contraindication will be joint issues and what i mean by joint issues is someone who can’t bear load on their joints someone who’s got severe pain and really if you give someone an anterior on your appliance when they bite really hard together yes the splint at the front is absorbing some load and therefore the pdl at the front is absorbing some load but all the other load if you like is is being directed to this, is the theory by the way, to the the tmj and if you have got an unhealthy symptomatic area with lots of inflammation, where your condyle may be impinging on what we call retrodiscal tissue i’m sorry if i’m getting a bit too deep into this but really if it’s a primary joint issue then this is not the ideal appliance however some of my mentors will disagree with that and they say you know what you can get away with a lot and very few patients have true joint issues that they will not be able to accept an anterior only appliance but if you’re starting out this appliance try and stay away from joint related issues and try and target patients with more of the muscular symptoms which actually is 90% of our “TMD” patients right? How many patients like i said a few episodes ago come in with raging tmj pain, very few primarily we’re managing asymptomatic patients thankfully.  Now having said that if it could be a diagnostic event for you, if you give someone an anterior on your appliance and they come back with raging pain from their temporomandibular joint which by the way has never happened to me but that’s supposed to be pathomonic for someone who’s got a primary joint issue and perhaps you need to change your appliance to give them some “joint support”. Now again some dentists feel very strongly against what i’m saying here but i’m just giving you the theory that’s out there and of course you can also use AMPSA as protective appliances but really there are some other appliances which are cheaper and easier and simpler appliances which that you may wish to use as a protective appliance. I’ll go into a little bit more of that into part two. So now we know what answers do and when they’re indicated and potentially when they’re contraindicated and now i know that they don’t cause AOBs due to the Dahl effect but you can get an AOB from any appliance in certain patients who have certain traits right?  So I’m going to go into that a little bit more detail next episode hopefully and throughout Splintember, where i can and on the Protrusive Dental Community but now you know all that. Let’s just talk about before we go about the records you need for this type of appliance.  Now ideally if you’re starting out you should be taking gold standard records a to z.  So the first record i take is the following this is something that was taught to me by one of my mentors Dr Michael Melkers right? It’s when you use a leaf gauge and i’ll probably be playing a video of this as I’m saying this to help you understand this i’m using a leaf gauge at the front and i’ll be dialing it down to find their first point of contact within centric relations so that centric relation contact point and essentially this shows me that if this program, if this patient was to deprogram what would their occlusion look like and if their muscles were to forget how to get back into their normal bite again what would they potentially look like so would they end up with an AOB? Would they not? How this look with the patient even realize and what you do is you take a photo of the patient with the leaf gauge in place at the position where the first point of contact is now. If it’s only a couple of leaves and they’ve got enough of an overbite then really they’re low risk but if they’ve got a shallow overbite, quite worn teeth and quite a big slide and they’re more likely therefore to get an AOB from any appliance that you do then that’s the one you want to take a photo for and show them as part of your consent then you basically have to figure out is your why big enough to continue with this appliance. Does the patient understand the consequences they will They understand that they may not be able to bite into cellotape again that they may miss the ham from their sandwiches and is the juice worth the squeeze because for a lot of these patients who are suffering a lot they don’t care about this bite change they just want a solution and at least you’ve predicted it and you told them ahead of time but i can reassure you now that these patients are not too common and i don’t want to scare you but it’d be irresponsible for me not to tell you this. So that’s the first thing i do and that’s a hat tip to Dr Michael Melkers who taught me to do this.  Now of course you know already what Dr Michael Melkers doesn’t know about occlusion and splint is frankly not worth knowing and as you know he was supposed to come to london in May for occlusion 2020 and of course due to covid we had to reschedule that to November. Now a massive update i’m about to give you is that the event is still happening but we’re turning the event completely virtual it’s going to be occlusion 2020 live online two days full access to Dr Michael Melkers’ full immersion into full mouth rehab from single tooth building up to full mouth rehab and splints.  So if you want to see these protocols and slides and cases and a lot more depth, join us for this online version in the comfort of your own living room or office or bedroom or in your pjs or whatever like before i was describing this event as occlusion and lamb chops and now i guess i have an option but say occlusion and pjs right? So join us for occlusion and pjs. I’ve reduced the price to £389 because we’re no longer having a venue Now, that fee of £389 is a massive massive steal compared to the 1.5k that i paid when i went to see Dr Michael Melkers in Stockholm in 2018. So join us for two days full online immersion into all things occlusion. Everything that was promised at occlusion 2020 but now in the comfort of your own home because frankly covid is really getting a little bit concerning so I didn’t want to pull the plug on the event because so many people are excited i’m getting emails and messages all the time, so we’re still hoping to run a really educational two days so come and join us. You can go to occlusion2020.com to sign up.  By the time this episode comes out i probably would have made the ticket sales live again. The date once more is 27th and 28th november 2020 live online two days with Dr Michael Melkers.  Let’s get back on track now so that was basically what Michael Melkers taught me which was the bite record of, if your patient was to get an aob would that happen, what would they look like and then show your patient that photo. That’s the first record. It’s a good screening thing to do to see if the patient in front of you is high or low risk of getting an aob after your anterior only appliance  The second record i take is to measure the lateral excursions, protrusive and retrusive and the reason to do this is medical legally it’s a good thing to do before you give any appliance so that if in the future the patient says oh i i’m no longer able to move my jaw left and right,whereas actually you’ve probably improved their their function and you’ve improved their ability to move left and right but if you have some measurements you can objectively back that up right so what i use is a perio probe like a williams probe and i measure from the upper midline to the lower midline and i get the patient to grind all the way to one side and measure the sort of distance and then you either add or subtract based on if they have a midline deviation if they have a midline deviation obviously you need to add or remove a couple millimeters depending on which side they’re going to and essentially you make a note of this in the patient’s records and you can send that as part of your lab work as well So the lab knows what their range of movement is.  The next thing of course is a record of the patient’s jaw so i.e an impression or some digital scans ideally if you’re taking impressions take pvs it’s just better quality and less chance of distortion of the alginate for example just be mindful of getting these drags technicians hate these drags that you can get so make sure your impression technique is good. So you want to send some impressions, you want to send the measurements you want to screen the patient like i said for a potential aob. You don’t need a facebow you know you don’t need a facebow because at the end of the day it’s just biting at the front so really these appliances are quite easy to adjust and a facebow is just not necessary you don’t even need a centric relation bite because when the patient bites together they’ll eventually get centric quite easily, they’ll deprogram very efficiently so you don’t need any fancy bite records. Very few scenarios you might and we might touch upon that next episode but generally that’s all you need.  So I hope you found part one very useful that i just gave you some indications and which records you need and a bit of background about AMPSAs and why they’re potentially frowned upon and why these dentists who frown upon them maybe don’t have the best argument because really it can’t cause an aob due to a Dahl effect.  Jaz’s Outro: Now in part two i’m going to cover some of these appliances and put them up against each other like why would you choose one type of answer over another. Which is the best AMPSA? Perhaps we can cover that i’m going to talk about decisions you have to make in upper arch versus lower arch versus dual arch so you can get dual arch AMPSAs as well and when would that be indicated. I’ll share with you how many of my patients have developed AOBs. Which splints were responsible for those and how i manage those patients and i’ll even tell you when an AMPSA may be overkill and maybe there may be simpler appliances like a soft bite guard Can you believe i just said that and we’ll talk about that in the next episode. So thanks so much for listening all the way to the end and join me in part two of understanding AMPSAs and i’m hoping you’re enjoying splintember. Thanks so much for tuning in