Protrusive Dental Podcast

Michigan Splints AKA Stabilization Splints are the ‘gold standard’ occlusal splint according to many occlusal camps. https://www.youtube.com/watch?v=DIfqn2Zkjp0 Check out the Youtube channel for video versions of the podcast. At 10 minute mark there is an error – I showed a Facebow being used whilst talking about Leaf Gauges. Need to Read it? Check out the Full Episode Transcript below! Dental School told me that this Splint is the only one I will need to know and it will cure all. If this does not work…maybe the patient has ‘atypical facial pain’ 😉 Now before you all attack me…. I have to confess. It is actually a great all-rounder splint – but there are some key reasons why Michigan appliances (or Tanner for the lower) is massively overrated! Listen to this episode as I cover: What is a Michigan splint? How does this splint work? What records do you need for a Michigan splint? Do you need a Facebow? What are the limitations of Michigan occlusal splints? Why might other splints be better for many scenarios? Why you should be careful prescribing Michigan splints to primary clenchers Protrusive Dental Pearls were sent in by fellow listeners regarding patient care and rubber dam hole spacing. Have you checked out the rest of the episodes from Splintember? Here is a rough transcript: Lets face it – Dental school barely scratched the surface in a lot of areas, including Occlusion and splints – so it should come as no surprise to you that Michigans splints are not as great as you were taught they were. Michigan splints are actually a really good all rounder splint for all the main diagnoses within ‘TMD’ – quite often when I find a tricky case and I am unsure if the issue is more muscle or joint, I will recommend a Michigan – but still, it is a massively overrated appliance and is totally overkill for most of our patients. Lets start the basics – what is a Michigan splint? It is classically a hard upper splint.The lower is called a Tanner. Aka Stabilisation splint. It’s a centric relation appliance. What does this mean? I explain in the podcast (so listen up!). I go in to this appliance in a lot more detail and all the shortcomings. Fellow geeks, to conclude: It’s a great all rounders splint. And if ever you’re unsure of joint vs muscle diagnosis and you can convince your patient to spend hours in the chair, spend that money and you think they’ll comply, then go for it. It’s a great splint. But if you’re more concerned that your diagnosis is muscular, or the asymptomatic patient, and perhaps as an appliance to deprogram your patient….there are definitely more efficient ways to deprogram your patient. And that’s exactly what we’ll talk about at the next episode….stay tuned for the rest of Splintember! Click here for Full Episode Transcription: Opening Snippet:Dental school scratched the surface in so many different areas including occlusion and splints so it should come as no surprise to you that the grand michigan splint that they taught you is the best ever may not be as great as you were taught... Jaz’s Introduction: Hello fellow dental geeks and welcome to episode 40 of the Protrusive Dental Podcast, now this is the third one of Splintember and it’s gonna totally upset so many dentists. Gonna make you guys some of you very angry, very hurt, very upset and I make no apologies for it. You know this needs to be out there and let’s try and keep an open mind and learn and maybe I’ll learn something from you guys as well from the backlash but really I’ve done my homework now and I’ve come to a conclusion that Michigan splints are overrated but before we go there I’m going to share with you two Protrusive Dental pearls, two brand new ones and these were sent to me by the Protrusive Dental Community. Thanks so much, guys for listening and i want to put your stuff out there as well.  So the first one is from my buddy Sim Singh, he’s from London and his Instagram handle is @drsimba. Now, Sim is a young dentist and what he’s told me is that now that there’s so much time available because of fallow time and covert 19 restrictions and whatnot. He’s finding it so useful to call his patients after a tricky procedure or after extraction and just ask how they are you know and give them some advice and follow-up advice and telling them that you know it’s any issues I’m always here for you and he’s found a massive value from this and too fair it reminds me of my first year after dental school and I learned that lesson then as well and such a great one if you can and if you have the time call your patients and it adds such a massive personal touch and they will never ever forget and they’ll love it. So that’s a great little pearl from Dr. Sim Manga.  The next one is from my buddy Jake Garner in Derbyshire, his Instagram handle is @jakegarnerdentistry. Jake is a really good dentist. He’s good at adhesive dentistry.  Check out his Instagram profile and his rubber dam tip is that when you’re trying to get the perfectly spaced holes He found it very useful that if you have a study model of the patient that you’re about to apply rubber dam on that. You get a pen or a marker and you actually put the rubber dam over the study model and you sort of mark the middle of each tooth and then you punch your holes like that is extreme accuracy that you get from doing it that way and it’s a great way to do it the other way to do actually is you can do it in the mouth like you can actually put the rubber dam on the teeth and then get your pen and mark the teeth with the pen while the rubber dams just sort of I guess wrapped over the teeth and then that gets you perfectly spaced holes which allows you to get a better seal, better inversion less of the papilla sort of showing through sometimes So these are two Protrusive Dental Pearls shared for you by the community. So thanks so much guys for sending those in and if you remember in episode 39, the last episode where I talked about a little bit about TMD and why it’s not such a great thing to get into perhaps or a great term for that matter.  I want to give a shout-out to Dr. Anish Dhunna. Now, Anish is someone who also i’ve got to know through the podcast. I love his drive and his passion for dentistry as well it’s great to connect with like-minded dentists all over the world. Now, Anish also mentioned about adaptive capacity which very much goes hand in hand with the weakest link theory i talked about in the last episode. So adaptive capacity is another way to explain why some patients end up getting symptoms and others don’t. So for some people all the insults and the trauma that the temporomandibular joint and the teeth and the PDL have. If it’s below their adaptive capacity they will unlikely they are unlikely to get symptoms and problems however, if the threshold is low or their adaptive capacity is low if you like then they’re the ones who are more likely to get symptoms and problems and that’s a great sort of theory. It’s only a theory and the first time I heard this theory was from Dr. Chris Orr about seven years ago and I just think it’s a great way to look at things well. So a great term adaptive capacity, thank you. Anish for sending that one in.  Main Podcast: So Michigan splints, right? You think this is like the best splint ever. That’s what dental school taught us, that’s what the restorative department said is the gold standard and to be absolutely fair it’s actually a pretty good splint, okay? So I know the title I have is quite provocative and anti-Michigan but really if I’m going to be straight up with you, I’m going to say it’s a really good all-around splint I just think it’s overrated. There are some diagnoses which you might make for example myofascial or if you want to deprogram someone I’ll get into all this a bit deeper and deeper as the episode progresses but really there are better splints for certain functions than a Michigan but Michigan is a great all-round splint and I’m not going to poo-poo it just yet because there are some good points about it. I used to use Michigan appliances a lot like loads right and then for the reasons that I’ll go into a bit later in the episode. I haven’t stopped using them at all. I tend to use Michigan appliances when perhaps they’ve worn one already and they’ve worn through it and they were able to have good compliance with it and good results with it and I’ll remake them a Michigan splint or a tanner appliance. I tend to use Michigans nowadays for cases where I’m not 100% sure of the diagnosis. It’s a bit tricky there are some joint-related issues and some muscle-related issues and perhaps the joint may not be able to accept a load and we’ll go and go you know  I’ll go into that bit more and if i find that it’s more of a slightly more of a joint-related issue than a muscle-related issue, speaking globally then i might be tempted to give a Michigan appliance in that case.  So let’s just start with the basics what is a Michigan splint? It’s an upper hard appliance A lower one is called a tanner appliance it was invented or designed in the university of Michigan, they were sort of doing some experiments on the different types of hard appliances and what kind of designs would come out on top and they found that the Michigan splint as the design they came up with would be the best and I’m going to tell you what that design is basically and a lot of you already know this you know I’m teaching you guys to suck eggs, you guys are probably very well versed in occlusion and splints already that’s why you listen to this podcast but just for those students maybe or younger dentists who really didn’t get those lectures at dental school A Michigan appliance is a hard appliance okay? So the top is Michigan, lower is a tanner. It’s a centric relation appliance so it’s built into centric relation what that basically means is that when the patient bites together on the appliance, their jaw joint should be in centric relation and if you want to learn more about that listen to episode 20, Episode with Dr Kushal Gadhia if which is called if you’re not in CR, you will die. It’s a tongue-in-cheek title but check that one now we go into definitions of central relation there so basically when you bite together the condyle is in centric relation and that’s essentially what it means but what it means for you as a dentist providing that splint is that it takes you a lot of time and care to adjust to splint to make sure that when the teeth and the splint come together that the condyle is in centric relation.  It’s also a full-coverage appliance so it covers all the teeth and when you bite together you want pretty much all the teeth hitting and when you go into any sort of excursion left-right or forward you want anterior guidance and it’s basically all the principles of a minimal stress dentition so basically you’re creating this textbook occlusion which you would want to give in any sort of rehabilitation you want to get, you know, shallow guidance on canines, posterior disclusion, equally shared loads, all the sort of stuff you want to do in a full mouth rehabilitation you would give into this appliance so it’s almost like a reversible way of giving someone the perfect bite. I’m going to talk about the mechanisms of action and how it actually works but before we go there let’s talk about what you actually need to construct a Michigan or a tanner appliance. Basically, you need an impression of the upper and the lower or a digital scan whatever you prefer. Now I tend to take these in from taking impressions I tend to take them in silicon. Alginates I just don’t trust anymore even with appliances. I used to know a technician who said send me anything it doesn’t matter but eventually when you find that the odd case the appliance is fitting the model but it’s not fitting your patient it’s probably because the alginate distorted and the model is not now an accurate representation of your patient. So really just stick to PVS or take digital scans. So you’ve got your models, you need to take a centric relation bite, a centric relation bite So whether you take it with wax or again with a silicone bite registration it’s up to you but you need to give the laboratory that information if you don’t give them that information then they’re going to just make you an appliance that’s in their MIP and then it just creates extra work for you when you’re grinding away so you want to give them that centric relation bite.  Now a really cool trick I can give you when you’re actually taking your bite record in centric relation within centric relation, within the arc of it is that if you can control the occlusal vertical dimension at which you record this bite record if you record the OVD at where you want it so for example for a Michigan appliance typically you want it 1.5 to 2 millimeters at the thinnest portion at least so typically between the upper second molar and the lower second molar you want at least one and a half to two millimeters because remember you’d be grinding it away and you don’t want to make it too thin a lot of times if you’ve seen failed Michigan appliances you’ll usually find perforations in this area so you want to have that minimum thickness for strength. So when i do it, I tend to use a leaf gauge, okay? I dyed it up and I put it in the front teeth and I sort of make sure that when the patient grinds together, grinds forward, grinds back, and squeezes that the minimum space at the back is about 1.5 to 2 millimeters and once I’ve got that space I do my centric relation bite at that required dimension What that means than the magic of doing this is that when it gets transported to the laboratory and they mount it using a face bow hopefully, a semi-adjustable articulator, they simply have to remove the bike record and build the appliance in that position. That way there is no error of opening up or closing the articulator so the best way to explain that is that every time because an articulate is not the mouth and the mouth is not an articulator, so if you have to raise the occlusal vertical dimension on an articulator, you’re introducing a potential error but if you can not raise or decrease or play around with the OVD at all it gives you that little bit more accuracy and I found this for sure. So that’s a little trick I’ll give you to record the centric relation might record at your or thereabouts your desired vertical dimension.  Now, I mentioned using a leaf gauge typically another way to do this is to use a lucid jig which is made of acrylic for example something like Duralay can be used to make one or even some snap or trim acrylic around the front teeth and when the patient bites together there are back teeth separated and they can slide around and you can hopefully de-program them while they’re in the chair and get their centric relation record so i’m not going to go into too much detail because it’s almost impossible in a podcast to do that but you recorded your centric relation bite you’ve got your scans, all your impressions, you’ve sent that and as I already mentioned a face bow is ideal. Now, have i made a Michigan splint before without a face bow? Yes, I have, and do you really really really need one? Well, you have to ask what does a face bow does and I think this could easily have its own episode but essentially to put it down really really simple it’s to relate your maxillary cast.  So once you’ve got your model it’s to relate that model to the hinge axis and really what this means is that if someone has like the maxilla that’s off to cant and if you don’t send a face bow and they just put it on an average value articulator they’re going to struggle to transfer that cant for example the maxillary cant to the articulator and when you get an appliance back you might find that it’s hitting on one side and not the other so you can still make one without a face bow but hopefully if you’ve done your face bow correctly that it’ll give you more detail for your patient compared to an average value articulator because now it’s on a semi-adjustable articulator and this will hopefully translate in to save time. Whether or not this actually translates to save time or not I’m not sure if there is a study that’s been done comparing a Michigan appliance and how long it takes to equilibrate with and without a facebow, if anyone knows of one that’s a really cool idea please send it to me but really if you want to give your technician as much much as possible they will use your facebow to actually mount the casts or models on the semi-adjustable articulator and hopefully that will give a more accurate representation of what’s happening in your patient although we know already that articulate is generally are nowhere near as what said that the best articulator is the TMJ in the mouth but anyway that’s a whole different discussion.  So in an ideal world, if you’re gonna make a Michigan or a tanner, it would be a good idea if you have one available to send a facebow transfer. Now I’m just like 10 or 15 minutes into this episode and i’m already kind of like regretting it because i’m thinking are you guys able to follow what I’m saying. Now for those of you who are very experienced have been loads of occlusion courses you guys will hopefully be able to follow me but I’m very mindful that a lot of this stuff people don’t like to listen to as much because it’s a bit too heavy so stick with me if you don’t understand anything please message me or i’ll recommend some recommended reading or make some more episodes that really go down into the basics, for example, i can totally do one about Facebow all day long, the different types and stuff but just follow me now and i’m sorry if I’m losing you.  So how does a Michigan splint work? So now you’ve sent all your records to the lab they’ve sent you back an appliance you’re going to give it to your patient but how does it actually work? Well, i’ve told you already it’s going to create a minimal stress dentition it’s going to create the ideal occlusion within an acrylic appliance so you’re not having to do all this work in a patient’s mouth, so this is all reversible in the form of a splint and really it goes into the principles of biomechanics, right? If you get the patient into anterior guidance in all excursions then that’s the furthest away from the temporomandibular joint hinge and because it’s a further away it’s that whole nutcracker analogy again the forces are lower and also the anterior temporalis muscle switches off when you’re grinding on the front especially when you get to incisors by then the muscle activity is significantly reduced and you’re furthest away from your nutcracker forces from the TMJ hinge so the whole lever concept. So that’s basically how the main bulk of it works so when you bite together everything is shared when you clench it’s generally shared and on excursions, it’s all at the front not at the back to keep the muscles calm. So why do you want even contacts now it’s fairly self-explanatory right but the way my mind works is that i always think about okay what if an appliance wasn’t even contacted and I think once you understand this it really drives home exactly the role of a Michigan so for example imagine I made you an appliance and it was an upper Michigan except I got my acrylic bur and I cut it right in half so let’s say now you’re wearing a right-sided Michigan appliance and nothing on the left so that you don’t have anything between your left-hand side teeth. So now when you bite together and you’ve got equal contact on the right side and nothing biting on the right side picture this what happens when you clench your teeth together up against the splint okay so your muscles contract. When your muscles contract your teeth crash into the splint and the splint then causes the depend with the PDL of the teeth to compress because now your teeth are now absorbing the load and as you contract contract contract as you bite bite bite then the temporomandibular joint or the condyle can also give some degree of load to the glenoid fossa area or hopefully if you’ve got a healthy disc through the disc and hopefully through the middle part of the disk now that’s all happening on the right side where you have the splint.  What’s happening on the other side where you don’t have a splint? Well, you don’t have the teeth and PDL to absorb any of the load and your muscles are going hard so what happens is that the condyle is really soaking up all the pressure up against the disc and what if the disc I’m just speaking hypothetically here to help you understand what if the disc gets squeezed out or what if you’re doing some degree of trauma to your temporomandibular joint. So if you haven’t got balance think about what’s happening in each of your joints there’s a lot of pressure potentially building up on the left side as the muscles are driving that condyle up and all the force forces going up into your temporomandibular joint and not into the teeth and not into PDL that’s the theory and of course, the reason why we want posterior exclusion is that it switches off the muscles, we want anterior guidance and we prevent the back teeth taking lateral forces. We don’t want our back teeth to take lateral forces back teeth are designed for sort of to take stress down the long axis, so it prevents that and it hopefully prevents cusp fractures and stress down the cuspal incline, so that’s the idea you want to keep your back teeth out of it during any excursions. Are you following me so far? I really hope so because the next bit it gets a little bit more complicated, right?  So there’s a muscle called the lateral pterygoid and hopefully, that will be relaxed so the idea of Michigan and a lot of the spins is that it will relax the lateral pterygoid muscles okay? So i’m going to try and keep this really basic with the lateral pterygoid muscle because it can get really complex and you know like I said in a podcast version without any videos or dissections and whatnot, there’s very limited stuff I can share but lateral pterygoid muscle is basically a super muscle at a basic level, its functions are to help you open your mouth, help you to protrude your jaw forwards for example and also to wiggle your jaw or go into excursions left and right and the way that works is that when one or maybe the right-side lateral pterygoid contracts then you, your jaw will go to the right and if the left one contracts and the other one doesn’t your jaw will go to the left so that’s generally how it works with the lateral pterygoid. Now here’s the cool bit when it comes to why us occlusion fanatics care and know about the lateral pterygoid so much and why it’s such an important super muscle is because of this right? Remember in dental school when they told us that 90 plus percent of us we do not have our MIP being equal to our centric relation contact point.  Now there are so many different terms for all this and this is why occlusion can get so confusing right like there’s terminologies that are always involving, for example, centric occlusion used to mean your maximum intercuspal position but then the definitions take change and centric occlusion actually now means your first point of contact which I just referred to as a centric relation contact point so no wonder people are get confused with occlusion because of changing terminologies constantly. So 90% of us are MIP and our centric relation contact point is not the same so 90 plus the percentage of us have a slide, so we all or 90 of us have a slide from our centric relation contact point so when your condyle is within the art of centric relation and we bring or if you close our mandible within centric relation eventually the first teeth to hit will be your centric relation contact point and then your teeth will slide into your maximum intercuspal position and this slide could be horizontal, it could be vertical, it could be a little bit of both and essentially we all have a slide or most of us have a slide. So why is it that every time you close your teeth together and bring your teeth together that you don’t hit this cr-cp first and then sort of slide into your MIP? Why is it that we can almost predictably when we close our teeth together we have this muscle memory that our teeth will meet together as they should and we’re not sort of clattering on these interferences or cuspal inclines before we reach where our teeth like to meet together? There’s a reason for this and that reason is the lateral pterygoid muscle It remembers. It has these muscle engrams if you like that are almost programmed to take you to MIP hence why the term deprogramming. If you’re deprogramming someone essentially you’ve achieved the programming if you’ve relaxed their lack of pterygoid and what this means to you and me is you forget how you bite together. So if you’ve ever had an experience where maybe you’ve been scuba diving and after you come back up from scuba diving you bring your teeth together and you’ve hit someone in the back and it feels funny, feels weird, and then you sort of bite together a bit more and suddenly oh here i am i’m biting in MIP again, that’s your lateral pterygoid deprogrammed and then reprogrammed if you like so that’s why the lateral pterygoid is such an important muscle in terms of occlusion, parafunction, splints, restorative all that sort of stuff.  So bringing it back to the Michigan appliance, it is potentially a deprogramming appliance as well so that because we build it into central relation and we follow up and we adjust the splint we hope that when the patient bites together that they are in their arc of centric relation and their condyle is in its most comfortable snug position and at that point, that’s when we have an equal distribution of load and everything is in centric relation or in RCP for a very old term as well. So that’s how the appliance works as well because it’s built in centric relation and therefore your lateral pterygoid would have deprogrammed or relaxed with this appliance as well but this is not the best appliance to the deprogram like if you want to just de-program someone i think it’s a terrible appliance if that’s your main function there are so many more efficient ways to de-program someone than giving them a full coverage hard thick appliance to wear and to see them for several appointments and to grind and as their muscle relaxes you keep grinding and eventually you get to your end point it’s not a efficient way to do it and just quickly the way to think about it is that because you have this plastic this flat plastic at the back in between getting in the way of your bite if you like eventually once you wear it your muscles do forget your lateral pterygoid relaxes and eventually as your lateral pterygoid relaxes, it actually lengthens and as it lengthens, your condyle is actually going back into the glenoid fossa and reaching that magical centric relation position and as you keep adjusting it everything is now even so that’s how the appliance works your teeth essentially forget it has tricked or fooled your lateral pterygoid muscle.  So to recap it’s to create your ideal perfect occlusion in acrylic and also at the same time to deep deprogram your muscles namely the lateral pterygoids so that everything is now relaxed and everything is evenly distributed with the correct anterior guidance in place so again the minimally stressed dentition that’s the idea of the Michigan appliance for the top or the tanner appliance for the lower. It is a great all-round splint and it’s very useful in a lot of scenarios especially when I’m unsure of the diagnosis and it’s the safest one that you can give like if you’re not sure and if you want something to work give him a Michigan, give him a tanner. A lot of the diagnoses do respond well to a Michigan or tanner but there are some major drawbacks which I’m going to go into now so there’s a reason why I’ve got some beef with the Michigan or I’ve got a problem with the tanner and I’m going to go into that now and you’ll learn why i think it is an overrated appliance.  Number one so the number one reason why i think the Michigan appliance is overrated is because how many dentists are actually doing it properly like if you’re gonna do a Michigan or if you’re gonna do a tanner do it properly like DO. IT. ALL. PROPERLY. TEXTBOOK. EQUILIBRATED. Spend those hours equilibrating, verify, follow up your patient, bring them in again, check that when they bite together they are in centric relation or within the arc of the cr and that they continually have even contacts and they have a degree of freedom and centric and again i’ll go into that in some other episode and they have the perfect shallow canine guidance that’s enough to disclude the posterior. How many appliances have you seen which are actually equilibrated properly because i’ve seen loads that are just plug and play i.e hey i’m giving you a michigan splint. Here it is. Wear it. Goodbye. No care and attention has been given and there’s a reason for this right? There’s a reason why a dentist might not equilibrate a michigan and a tanner properly because of money okay? It takes time and if you don’t have the communication skills to bring that value to the patient of why you need to spend a few hours and and lots of money.  Now let’s talk about money right? When i charge for a Michigan splint I’m typically in the seven to 900 pound region sometimes more depending on the case because i have an idea of which cases might be tricky and i might need more time and more adjustments and more follow-up and which won’t be and some of my colleagues, some of my various team colleagues charge around about 2 000 pounds so you can do the conversions if you’re elsewhere in the world. This is when done properly an expensive appliance because it uses up lots of chair time and lots of expertise to get it perfectly equilibrated. So because of the fee being so high that a lot of patients won’t accept it, so the dentist sort of do a quick job if you like and give an appliance which really isn’t i mean they call it a michigan or a tanner it’s just a hard flat appliance or a hard appliance for the ramp but not built-in centric relation and there are some disadvantages of making appliance not in centric relation which i’m going to hopefully go into in one of the episodes soon but basically one number one beef i have with these appliances that most of them that I’ve seen and from what i hear of are not equilibrated properly for that reason oh and by the way i almost forgot to mention you know that rule that we have as dentists that whatever your technicians or laboratory is you multiply it by a factor of three, four or five and that should be your fee to the patient that’s absolutely rubbish okay because it completely throws out the bus your hourly rate. So you should charge not by this random rule that’s been made okay yes for some things it’ll work but really you have to think long and hard about your hourly rate and you could be making a massive loss if you’re doing michigan splints and you’re putting in the time effort and care to give them the best appliance and if you’re not charging appropriately respecting your hourly rate is very very important so bear that in mind.  Number two reason of why Michigan splints are overrated, okay? It’s a big one, okay? It’s one of the reasons why i noticed and i moved away and i started to really seek some answers i wanted to know are there any better or more suited appliances to achieve what i want to achieve, to protect my patients from the force of parafunction than a michigan and its compliance? Okay, i’ve told you already in previous episodes i’ve been embarrassed before when i’ve made someone an appliance and i’ve spent a good few hours to adjust it and then six months later when they come back the patient’s embarrassed because they’re not wearing it and i’m embarrassed because i feel terrible that i put them through that entire process and charged them a good amount of money and they just weren’t able to wear it because you know it’s not a comfortable appliance to wear. It’s full coverage is hard, it covers all your teeth and it’s thick, it’s not a sexy appliance none of them are to be honest with you and if you have one yourself you should be able to appreciate that i mean i had one made for myself because i wanted to sort of experience what it was like and it’s not great you know it’s not fun, it’s not sexy compliance is a major issue and going back to a couple episodes when i talked about which is the best splint remember the g-splint is a splint which is best suited for your patients diagnosis, so compliance is a massive issue. So who is going to comply the best? The patient that will comply the best is the one who spent a lot of money with you to do a rehabilitation and you’ve told them at the end that if you want to not have to repeat this process or full mouth rehabilitation again you must wear this splint and you give a Michigan splints to them they might wear it okay because they’ve just been through the pain of maybe a year and a half two years worth of dentistry, lots of units, several thousands of dollars of pounds and then at the end of it they think yes i better wear this if i want to avoid having a rehab again or my restorations fracturing right? So they might wear it or the chronic pain patient and this chronic pain patient who you feel that the michigan is the best appliance for them, they wear it and then they start to see some therapeutic effect and they’re out of pain wow they will love it and they are the ones who will wear it for life or as and when they need to so those are two groups of patients where you might see good compliance but how about most of our patients who are asymptomatic and you had already a difficult time convincing them that they have para functional issue and that they’re grinding their teeth and they had no idea about this and now you’re going to get them to wear this michigan appliance which i’ve told you already so bulky yeah good luck with that. This is why compliance is so poor we’re giving it to asymptomatic patients who may not be 100% convinced and their why is not big enough. So let’s recap, so far number one was it’s time consuming and expensive to equilibrate it. Number two was compliance.  Number three is to do with clenching okay? If you have a patient who’s a primary clincher and you give them a michigan how is that going to help them? Yes it might help their jaw joint some degree but if they’re a headache patient, if they’re a myofascial patient and you give them a michigan and they’re able to clench really efficiently and hey they have something between their back teeth between their second molars and remember the nutcracker analogy you’ve got something right at the back of that nutcracker really amplifying the forces and the muscles going to overdrive then that’s not great right maybe your clenching patients is not the ideal patient to have a michigan maybe they are the ones that should be having a different type of appliance.  So the patients who clench this is not the perfect appliance it may not give them any therapeutic benefit if their main issue is myofascial or muscular related and why would you want to increase the efficiency of clenching now we talked about a few episodes with Dr Andy Toy about the posterior guided occlusion or the PGO splint like if there was a reason that you wanted to increase their clenching intensity look for that splint.  Michigans are neither here nor there and really for primary clenches it’s really not indicated and actually those are the patients i’m convinced that it’s the primary clenchers who come in and the back of their appliance has fractured right if it’s only about a millimeter half thin around the back then they can come you know they can clench right through that so your primary clenches is another reason why michigan appliance is overrated you’ve got to get your diagnosis, right? Okay guys, we’re almost to the end of these disadvantages of the michigan appliance and you’re gonna love this one this one’s gonna blow your mind it blew my mind when i started to reflect on this okay?  So the fourth disadvantage of a Michigan appliance is the following right when you provide your patient with the care and the time to equilibrate this splint, bear in mind that most or all of the adjustments are happening when the patient’s lying down which makes sense right because obviously they’re going to be wearing it when they’re sleeping usually and you want to recreate that so all of the adjustments are done when the patient is supine and laying down. Now what about you when you’re sleeping what position do you sleep in do you sleep perfectly on your back? Some of you might. Do you stay like that the whole night Do this little trick for me, bring your teeth together, bite together, i probably shouldn’t speak while holding my teeth together but anyway bring your teeth together right and now what i want you to do is as your teeth are together i want you to tilt your head to the right okay if you tilt it right so now just sort of focus in on which teeth are contacting right and now head back to the middle and now tilt your head to the left and head back to the middle and now tilt your head forwards and all the way back stretch up okay and back to the middle. 97% of you will realize that actually the way that your teeth were meeting together was different every time right so isn’t it funny that we make this appliance when the patient’s laying down and peace you know people sleep in funny different ways right? They do funny things with their necks and pillows and they might be sleeping on their hand you know whatever they might be doing these funny things So how do we know that all these adjustments and all these sort of things that we’re doing while the patient’s laying down the chair is actually translating to how they sleep. Isn’t it funny when you think of it that way?  Now i don’t know how much truth there is in this argument i’m making but it just gives you some food for thought right because the other way to spin it is that actually it doesn’t matter which position they sleep in because when they’re clenching, grinding all the muscles sort of contract and stabilize everything and it really is irrelevant because the muscles win.  That is a suitable argument and i take that point but it’s just some food for thought, we adjust the appliance when the place is laying down but what happens when they sleep they may be sleeping in funny different positions which may negate or delete all the hard work of what the appliance is supposed to do for your patient. Jaz’s Outro: Guys you finally made it to the end well done that was a really really heavy episode and i really appreciate that you listen all the way to the end and i’m going to conclude by saying that actually the michigan appliance or the tanner for the lower is a great all-round appliance but it has some massive disadvantages and it may not be the best appliance it’s good for when you’re not sure if it’s a joint or a muscle issue and you want to sort of cover all bases but really if it’s a primary muscle issue or it’s an asymptomatic patient or if it’s someone who you just want to prevent their teeth wearing away anymore then really there might be some better appliances that you could consider and that’s exactly what we’re going to talk about in the next episode. Join me as we talk about anterior midpoint stop appliances and the various other types of appliances there are as we go deep into that as well. Now in the nature of this podcast I saw, i feel as though i went deep into it and i hope you gained some value from that but there’s so much more i have to offer about this appliance so i’m gonna try and if there’s enough demand i can go into a bit more about you know facebows or whatever but i hope that gave you a good general overview of the functions of a michigan or a tanner and why they have a place in dentistry but really they are an overrated appliance and they’re not as awesome as they told you they were in dental school

Why do some patients have painful joints, whereas others get headaches? And why do MOST of our parafunctional patients not get any symptoms at all? Why do some peoples teeth wear away, whilst others teeth are riddled in cracks? https://www.youtube.com/watch?v=amdss07uN9s Need to Read it? Check out the Full Episode Transcript below! In this episode, I talk about the pros and cons of devoting your career in Dentistry to treating Temporomandibular disorders. Treating ‘TMD’ can be a complex field because it deals with all the complexities of chronic pain. However, it can be a very rewarding area. I also discussed why the umbrella term of ‘TMD’ is not really specific enough. We can do better as a profession to understand the diagnoses within ‘TMD’ a little better. Protrusive Dental Pearl: check out the Otter app for transcribing your voice, lectures or any audio/video! This is great for anyone who wants to convert audio in to notes, for students, and for content creators. I have uploaded the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) PDF file on to the Protrusive Dental Community group as promised to the listeners. If you enjoyed this episode, check out Myth Busting Occlusion and TMD with Dr Barry Glassman. Click here for Full Episode Transcription: Opening Snippet: Hey, I mean it. Stay away from TMD. Hello everyone and welcome to the second episode of splintember this one's called stay away from TMD. Now it's an interesting title and I appreciate that and I really really gave it a lot of thought before I came to this title because I wanted to take Splintember in a certain direction. Jaz’s Introduction:Now if I dived straight into talking about different appliances, different splints without first covering the context of the temporomandibular joint anatomy, the muscles the teeth and there I even say the occlusion and the role that has in it probably lacked a lot of direction and context right? So I’m going to go back to basics. I’m going to talk about anatomy and its relevance to the different so-called temporomandibular disorders that we see and hopefully that will tie in with the future episodes and you can sort of follow along in a more logical manner. So that’s what this is about. So the reason I pick the title stay away from tmd is because I genuinely mean it like, stay away. Do you really want to get involved in tmd patients unless you genuinely have a passion for it and you have a genuine passion for treating chronic pain now it’s a serious question because it is something that you need to be waking up on Monday morning going to work and you gotta say to yourself okay today I’m excited to go into work today to see my six patients who all have severe chronic pain and they’ve been going from one specialist clinic to another specialist clinic and they’re finally going to see me and I’ll solve all their problems. This is really complex dentistry and it’s very niche density so that’s what I mean by chronic pain and tmd. Do you really want a practice built around that And of course don’t take my word for it if it’s something you generally want to do then that’s totally cool but what I found is that I molded my practice and the type of care that I provide I don’t advertise on my patient-facing website or in any sort of public-facing YouTube sort of content I make for patients that I like to treat tmd or that sort of stuff it’s something that I don’t advertise myself because I don’t want to be swamped with these patients because they are challenging and complex a lot of these patients are chronic pain patients which is a whole different field. In fact a member of the public or a prospective patient actually commented on the first splintember episode on my YouTube channel and she commented saying ‘hey I’m not a dentist but I’d like to know are you going to be covering the treatment of an anteriorly displaced disc?’ So I sort of said no I’m not going to be covering this it’s quite a niche thing and it’s not something I’m into so I’ll explain a bit more about that and the relevance of that but this is something that I don’t want to be swamped with and maybe nor should you. Protrusive Dental PearlOkay just so before I start talking and delving deeper and deeper into this concept of staying away from tmd, I want to share with you the Protrusive Dental Pearl, it’s a really cool one I’m recommending an app I don’t get paid for this in any way I just think it’s a freaking awesome app. So if you’re a student, you will love this, if you are like me you’re driving and sometimes you want to create content like sometimes when I plan a podcast episode or something like even a long email I want to draft I’m using this app. It’s basically a transcription app. There’s so many different uses for it even if you wanted to record a lecture with the lecturer’s permission you can use this transcription app and it has been the best transcription app I have found. Okay it’s called otter, O-T-T-E-R. And literally it’s just brilliant you can either upload some audio content that you have and it will transcribe it for you or you can be driving or in a lecture and as it’s sort of listening and recording the audio it’s also transcribing. Now the thing I like about it is that you can actually add your own words in as part of the dictionary because obviously a lot of the dental terms it won’t understand but you can sort of add those in there but generally with someone who’s got a clear voice and you’re pronouncing things well, it’s actually really accurate. So I would recommend checking out otter.ai, that’s the website otter.ai, oter.ai. I believe that’s the website and you can get this on apple and on android. I have it on my android and it has been just fantastic for transcribing so any scenario you can think of whether you’re a student doing a postgraduate training, recording lectures, or if you want to maybe blog like if you’ve got a practice blog for example and you want to make content and if like me you hate typing on your phone and you hate typing in general and you like speaking then you. What I tend to do is I sort of speak to my phone and I rely on otter to transcribe things for me and I just do the little corrections and hey presto I have my own text that I need so I think it’s great transcription service so check out otter if you think this will be useful in your life. Treating temporomandibular disorders is very niche and you have to really love it. It’s not something that you know. It’s not like I don’t enjoy it. It’s very satisfying. It’s very cool to be able to get these patients out of pain but how many of these patients do you actually get like in a new patient examination? How many tell you that I’m really really finding a lot of pain in my ear and my joint? It’s something I’m suffering with a lot. You get the occasional one but it’s not something that you get in a lot of. I mean maybe I get about one every couple of months who may have this sort of presenting complaint so they’re not very common patients to find it’s not very common issue to find to be honest with you tmd patients are out there but they only seek out those who advertise themselves as tmd dentists if you like. You see I decided that my niche and what I like to do is just good quality, general dentistry and I want my patients to have beautiful healthy smiles well-aligned teeth, treating tooth wear which sort of goes hand in hand with it orthodontics and how that the whole ortho-restorative dentistry I love that side. So I don’t want that to be displaced by a swarm of chronic pain, tmd patients. So be careful what you wish for so in short I like to build things and I like to protect them and that’s where splints come in. Come into it for me really, how can I protect people’s dentitions from getting worse? How can I protect them once I’ve carried out a rehabilitation? Now one of my mentors Michael Melkers once taught me that the past is prologue. Now what that means is that whatever the patient has done to their dentition in the past so you have these patients who really want things down right and they’re going to come and see you and you’re going to make them look fantastic and obviously you’re going to pay a lot of attention to waxing it up so it’s “functional” you know that’s a quotation marks functional because I’ll tell you why I have a problem with the word functional as well but anyway so everything is working canine guidance, disclussion posteriorly the whole mutually protected occlusion. Because when you’re doing rehabilitation you want to set them up for success. You want to minimize the stress so it’s called the minimal stress dentition but what the past prologue means is that whatever all the things that they used to do with their teeth before you did the rehab. Your rehab will be subjected to the very same forces to the very same destructive chewing patterns and grinding and that sort of stuff so you have to protect them. It doesn’t mean that once you’ve done the rehabilitation and you’ve improved that occluding scheme that that’s going to be the answer to all their problems because you know fast forward 10, 15, 20 years you’ll also get chipping and wear on your rehab. And of course you don’t want that after patients, after the patients spend a lot of time and money in your chair to to build a beautiful healthy smile, you want to protect it against the forces that destroyed it in the first place so that’s why I think there is a huge role for splints after rehabilitations. There are some sort of theories out there that once you rehabilitate the patient that you don’t need a splint right? Because you’ve set them up for life with their canine guidance and mutually protected occlusion and smooth excursions and that sort of stuff but really what I’ve learned from my mentors is past is prologue so remember that and that’s why splints have a massive role in your after care of your patients after you do the restorative density to get them where they want to be. Now if you want to set up a tmd type practice then you can be extremely successful like if you’re in a state in the US or a part of Australia or anywhere in the UK and you sort of advertise yourself as a TMD-based practice and that sort of content you put out, then you get patients coming from miles and miles away to come and see you. You’ll get dentists referring to you. You can easily build a really good reputation for yourself because these patients find it difficult to get the right care. So if you want to do that and that’s your passion I think go with it. Okay this is going to be a fantastic field for you but it’s not for me because I love all the other things that restorative dentistry has to offer for my patients. So I don’t want that to be displaced by a swarm of tmd patients. As I said before these are chronic pain patients and often they require multidisciplinary care and to give you an example some of these patients may need MRIs to actually have a look at the position of their discs. Now for me to get my patient to spend 800 pounds for an MRI, yes of course it’s more likely if I’m in a specialist type practice doing this type of stuff day in day out and the patient has sort of looked out and has been seeking out for this type of care but the type of referral pathways especially where I am to actually get the patient to have an MRI have it interpreted and sent back to me it just seems like a lot of work for a general, a humble general dentist like myself. So this is where I think if you are going to be a TMD type practice then go for it but make sure you’re working in a sort of multi-disciplinary team to manage these very chronic sorts of patients. So all those reasons above are one half of why I named this episode, stay away from tmd and I genuinely mean it. Now there is a second reason of why I named this episode stay away from tmd and it’s basically from now on I want you to make me a promise and the promise is that unless you’re going to be talking about in a very broad umbrella term, I want you to stop using the term tmd. So the next time you’ve seen your patient you’ve done your history examination and you’re about to write your diagnoses please do not write tmd because tmd is an umbrella term it’s not actually a diagnosis per se and we’re going to go into the classifications and different sort of diagnoses within it but you just have to appreciate that tmd is a very weak term. Every time I see someone posting on social media and they say guys my patient has tmd which is the best splint for this patient, they’ve got canine guidance on the right and group function on the left they, have a crown on the upper left seven what splints the best? The whole you know so much wrong about that sort of post but the diagnosis from the beginning is an issue because tmd is an umbrella term. I’ll be using the term tmd now and again very much so as the umbrella term and it contains so much I mean there’s actually so many diagnoses within tmd and I put the whole classification in the Protrusive dental community facebook group so you can download it. But really when you break it down it involves three main sort of global themes. There’s a few more but there’s three main ones right and the first one to consider is not even the most common one but it’s a bony. Let’s think about bones, right? So you’ve got your condyle up against the articular eminence there’s usually a healthy meniscus or a disc between it but sometimes things go wrong and over time you get a degenerative type condition sort of like osteoarthritis so think of the first sort of term or the first broad genre of diagnosis to do with the bone. A lot of these patients when you palpate their temporomandibular joints, you get to open and close you will get something called crepitus this is like the grating sound that you get and it’s unmistakable the first time you hear it like ah that’s what they meant at dental school, that’s crepitus. It’s completely unmistakable. It’s not like a click or a pop and that’s generally a sign of it but a lot of these patients actually are asymptomatic. It’s a chronic thing and it’s degenerative so it’s something that’s there is sort of built up to that so that’s the first sort of key theme within diagnosis is there something wrong with the bone? So I wanted to mention that one and really get it out of the way because it’s not that common and something that there are bigger fish to fry when it comes to the umbrella term of tmd and the most common one actually is what we call myofascial pain or myofascial pain dysfunction syndrome and it’s basically something to do with the muscles so that’s the other part of the anatomy right? There’s something not quite right with the muscles, if there’s any sort of muscular you can sort of elude to the fact that is a myofascial pain or muscular in origin okay so it doesn’t get confusing right so far I’ve said it can be bony or it could be muscular and if it’s muscle you can put the term myofascial as a sort of general term for something’s not quite right with the muscles. Which muscles? It’s of course the muscles of mastication, masseter, temporalis medial and lateral pterygoids. It’s generally these ones, you can get the accessory muscles involved as well but these are the main players when it comes to myofascial pain. These are your headache patients. These are your ‘oh my neck is stiff, my shoulders are sore’ sort of thing these are the sort of referred pain from the masseters. If you listen to episode 11 communicating with the bruxist, we sort of talked about that with Barry Oulton, the referred pain element. So this is all under the second umbrella term of myofascial pain. Now if you read Dawson’s textbook, the term occlusal muscle is also used right? So occlusal muscle disorders and this is very much myofascial in nature. The reason why occlusal muscle is not the best term in the world is the following: now stay with me I don’t want to confuse anyone. Occlusal muscle sort of implies that the occlusion is at fault right? But the problem is it’s not really the occlusion per se and I’ve talked about this before it’s the occluding right? It’s the fact that this patient is parafunctioning and bruxing in the first place and they are parafunctioning and bruxing on an occlusal scheme or an occluding scheme which is not perfect and what I mean by perfect that is you know what you read in the textbook about the canine guidance, no non-working side interferences and posterior disclusion all these things okay they might not have that. And if they’re parafunctioning and they’ve got all these interferences involved and it’s not really set up in a minimal stress dentition then they could be having muscle pain hence why the term occlusal muscle. So that’s also within this sort of myofascial pain diagnosis. So of course if the patient wasn’t occluding so much they wouldn’t be having these problems. Their muscles wouldn’t be so sore in the first place and of course their existing occluding scheme may not be helping them. So occlusal muscle is not the best term but it’s commonly used so that’s another term that’s used and that’s totally fine if you want to use that. Now the next stretch structure and really the third structure we’re going to be looking at is intra-articular okay? Intra-articular, that’s what’s happening within the temporomandibular joint space okay and this is most commonly something like a pathology involving the disc, so for example clicking so internal derangement is a term that’s commonly used and we’ll go into that in future episodes but internal derangement with or without reduction. So let’s just, okay we can cover it now with internal derangement okay with or without reduction what that means basically is that the disc that sat on top of the condyle, the meniscus right? If there’s a derangement, it’s usually the lateral pterygoid that’s sort of pulling the disc forward to the condyle and with the reduction basically means that the disc is able to jump back on and that jumping back on is the click or the pop right? When the patient has got this disc forward but it never jumps back on. We call that internal arrangement without reduction, so actually reduction in this case is a bit like a fracture of a bone. When orthopedic surgeons or maxillofacial surgeons when they’re reducing a fracture they’re bringing the fracture line back together. They’re bringing the two fragments of bone if you like back together so that fracture is now reduced. So very much in the same way the disc is reduced so it’s internal derangement with reduction if they have the disc jumping back on and that usually manifests itself as a click or a pop. So sorry if that bit got a bit confusing and I will sort of break it down in future episodes but really it’s either bone pathology, it’s muscle pathology or it’s something to do with a disc as a broad term. I’m really trying to keep it as simple as possible so that’s generally what tmd involves. The three main structures bone, muscle and what’s happening inside the joint space, which is exactly why I want you to now stay away from the term tmd and wouldn’t it be so much better for our patients, for our profession, for us ourselves when we’re trying to choose the correct treatment treatment modality to actually be able to pinpoint the diagnosis ,is it something to do with the bone? Is it something to do with the muscle very commonly or is it something to do with the joint space as well? Something to do with the disc intra-articular? Now if I went really deep here and talked about every single little diagnosis within the classification like Retrodiscitis, Capsulitis, Synovitis all these sort of things it can get really deep and really confusing but if you stick to the basics of respecting these three main diagnoses within tmd you can’t really go wrong. It’s a fantastic thing to be able to sort of understand tmd in that way it really helps you to eventually because what I’m telling you is it’s not going to make you a tmd expert I’m not a tmd expert but I respect the anatomy and I know the anatomy and when you start thinking about diagnosis of tmd in this way it really helps you to understand what’s happening.  You can exhibit that you’re a good practitioner if in the notes you can write if it’s something to do with myofascial pain, if it’s an intra-articular diagnosis or something like osteoarthritis, thankfully that’s not too common. Now the other thing I want to tell you about is something that it’s a theory I really like and I want to share it with you. Now it’s something that I’m not sure if it has enough evidence or not to be honest with you but it’s something that my mentors have always taught me so hear me out and if there’s any evidence to disprove this and I’m totally open to so reading it but I told you already from before the evidence in this sort of area is quite poor unfortunately but this theory is called the weakest link theory. So far I’ve talked about parafunction, bruxism and how that may affect bone muscle or intra-articular but there are other structures that are also affected by the forces of parafunction, bruxism. Now they are of course the teeth themselves and the periodontium which makes sense right you know the teeth can take a real beating and you’ll see you would obviously see where are the teeth or cracks and of course the periodontium in the Dawson textbook it does of course mention that due to the forces of parafunction someone can get recession, someone can get sensitivity, so in some respect it can also involve the pulp if you like so that we can we can include that within the term of teeth obviously, so teeth and periodontium are also affected by the forces of parafunction. Now an interesting observation that I was taught by Dr. Pasquale Venuti, an italian dentist I follow and I really respect one of his lectures is that you know those patients that have really worn down their teeth, all their posterior teeth are flattened including the anterior and when you take photo of this patient with their teeth apart like everything is like completely flat everything is like machined flat right? An interesting observation is that these patients, okay yes they have lots of wear but seldom do they come with lots of cracks. They are not the ones that come with cracked teeth whereas those patients that have very steep cuspal inclines, those patients that when you get when you ask them to grind left and right they’re almost locked. They have this like very well defined interlocking and you get them to grind together and they’re like yeah I’m trying I’m trying and you see no movement of the mandible right? So those places are locked in and actually you may notice that those are the patients that usually come in with the cracks in their teeth. Isn’t that an interesting observation that some of those patients with generalized wear because they’re able to glide across quite freely that the stresses don’t build up in the teeth and the teeth don’t respond with cracks they respond with wear and there’s another group of patients whose teeth don’t wear away but their teeth flex and they crack. Now as well as cracks and wear the teeth can also become sensitive. I can give you some examples of my own patients where I experienced this in dental school for example. I remember a couple of cases whereby I placed a resin bonded bridge and it was a canine replacing a lateral incisor and it was like a mesial cancellator so you can imagine this sort of bridge design and what I had checked was the occlusion to the degree of my knowledge at the time as a student I got the patient to bite together and I saw that everything was meeting together roughly at the same time and I was happy got the blue dot everywhere done right? Now this patient came back with a main complaint that their tooth was very sensitive so this was something that confused me at the time I was thinking why is this too sensitive? Could it be recurrent carries that has happened in the last two weeks? Could it be some dentine hypersensitivity? Is there some recession? Did I make things work worse by? Did I over etch something? Like I was confused at the time as to why this patient was getting sensitivity then my tutor came along and this tutor was very switched on and she told me that actually it could be something to do with the occlusion or the occluding, right and what I didn’t check as I told you was the excursions. I didn’t check the dynamic occlusion and when we checked it at that appointment on the review visit I found that I had lots of excursive load on the pontic. Now what this does is excursive load on a cantilever bridge it really amplifies the talking force in the abutment tooth and this is how a tooth can respond with sensitivity with pulpitis so what I had done is I adjusted the pontic to get rid of that harmful excursive contact and when I reviewed the patient again in four weeks all the symptoms had gone so this is an example a common scenario where maybe you’ve been thrown up, thrown away or thrown out and you didn’t realize you didn’t check as thoroughly as you could have. The excursive movements and the patient have come back with some sensitivity. So that’s another way that the forces of parafunction bruxism can exhibit in your patients sensitivity when you have when you place a new restoration and you haven’t checked the excursive guidance. Now I also did this embarrassingly a few years ago on a patient who has extremely worn teeth, I can show you a photo of that patient now, actually it’s on the screen now and on this patient I replaced I believe is the upper left second premolar crown again I cemented it I thought I’d check the occlusion but I didn’t check the excursion as well as I should have because I’ve got a phone call from this patient saying that every time they’re eating now and again they’re knocking into this tooth and they’ve also told me that they’re getting a lot of sensitivity from this tooth so what’s happening here? So same as that other patient with the resin bonded bridge. This patient was getting sensitivity because all that excursive load was now on this very steep cuspal incline of a new crown which was not harmonious with the rest of his wear facets. So one thing I mentioned in instagram live recently I did with Allen Smith from precision dental was that the best technicians in the world. What they will do is they will always check the wear facets on the adjacent teeth and try to match them up. This is to make sure that everything is harmonious when you’re checking the occlusion. Now this is a mistake made by me and the technician and the patient suffered with sensitivity. Now as soon as the patient came back and I adjusted that very steep cuspal incline which didn’t suit this patient I made it flatter or the sensitivity went away. So these are two examples of how parafunction and bruxism and a clinical mistake in terms of checking the occlusion resulted in sensitivity. So one thing I can tell you about both those patients I mentioned is that both those patients were parafunctional bruxist patients. What I’m trying to say is that sometimes you can make a mistake in your restoration and I guarantee it happens all the time and a lot of these patients will never complain they won’t get sensitivity they won’t get any problems and you’ll never hear about it why is that right? If your patient only brings their teeth together for 17 half minutes a day which is a classic sort of Graf study I believe in 1964 and again I’ll put that in the protrusive dental community, then they won’t have an issue but if their patients parafunction with some force and for some time and they’re rubbing their teeth together and they’re sort of amplifying that your clinical mistake, they’re the ones who are going to get above the threshold of pain and those are the ones that you’ll hear about or the restoration will fracture or something will crack and something will give right? So this is a really interesting theory that actually you can get away with a lot in occlusion and you probably have with your patients right you can jack things open you can give have complete disregard for the occlusion you do a rehab arbitrarily and you don’t get the perfect guidance that you intended and you send them home and they come back and guess what? Nothing’s broken, nothing sensitive so don’t you think it could have something to do with their parafunctional status or how long they keep their teeth together for? If they’re the classic sentient half minute chewers and they don’t really exhibit that much force then they’re probably not going to have many issues interesting theory though and this is something I actually share with my patients as well those patients who are parafunctioning and I find evidence of this I sometimes find it very useful to tell the patient ‘hey did you know that our teeth should only touch for about 17 minutes a day?’ and most patients and actually most dentists in my experience are shocked by this. They think whoa that’s interesting and when they come back to see you a few weeks later or at the next recall those positively parafunctional patients with all the signs and sometimes the symptoms they will suddenly tell you after you told me about the 17 minutes of touching I’ve noticed my teeth touching so many more times and I think you’re right doc I think I am grinding I think I am clenching and something that I’m now so much more aware of compared to before when I didn’t know this. So it’s a great thing to tell your patients who sometimes may not be 100% convinced of their parafunctional status just tell them did you know our teeth should only meet for 17 minutes a day and just give them that information and let them sit on it and when they come back they will give you that feedback that actually they have noticed that their teeth are touching sometimes it’s all to do with having that awareness and of course the way you’ve communicated with this patient all along is that you would have showed them their photos you would have shown them their wear facets meeting up together like we discussed with the the episode with dr Barry Oulton and you may have told the patient like what we learned from episode 21 with Dr Manrina Rhode was that you’re chewing your own enamel I really like that term that Dr Manrina used you are chewing your own enamel the other term I like describing to patients is something I learned from Dr Steven Phelan which is damaged enamel. When you have got severe wear sets I show the patients their photos and I tell them this is damaged enamel because that’s such a powerful term and patients really understand that this isn’t normal, they’ve chewed their enamel and now it’s damaged so these are all communication hacks I’m giving you so tell them that our teeth should only touch for 17 minutes a day and even then with not that much force only when we’re swallowing maybe that’s too much detail but you sort of gauge what the patient wants to hear. You tell them or you show them they’re damaged enamel and tell them you don’t want them to chew that enamel away and all these things are very powerful as well as telling them that they’re dentine and obviously you show them the photo, their photo of the exposed dentine and you tell them that their dentine is six times softer than the enamel and it wears away quicker. These are all great things for the patient to know medical legally you’ve covered yourself and eventually when they do come back and they realize they’ve been parafunctioning they’ll have so much trust in you because quite a lot of times you’ll be the first dentist to tell them and don’t be disheartened if they don’t fully understand or they don’t fully trust you at that point because no one’s ever told them before. Okay so we talked about the joints, muscles ,bone periodontium and the teeth when they can be sensitive and which patients they’re more likely to be sensitive so let’s go back full circle now and I was talking about the weakest link theory right? So why is it that some patients that parafunction they have painful jaws whereas other patients who parafunction have pain has painful muscles, they have headaches, they have spasms in their muscle, they have neck pain, shoulder ache all these sorts of things and other patients they don’t have any symptoms in fact most patients I’d say that have signs of parafunction on their teeth and periodontium and whatnot they don’t have symptoms they don’t hurt, they don’t have painful especially for males they don’t come complaining of headaches for example. So why is it that some patients don’t have any of those symptoms but all they exhibit is worn teeth or maybe they have cracked teeth or maybe they just have other signs in the periodontium, sensitivity, referred pain. Why does parafunction have different sort of signs and symptoms in different patients? Well maybe this is something to do with the weakest link like what is your patient’s weakest link? And I love this theory because it helps me to sort of figure out a little bit about the patient for example sometimes you get a patient in and you can tell they’ve got these massive massive masseter muscles and they’ve got generalized wear posteriorly and you know that they’ve been parafunctioning all the way offsets match up one of those patients and these patients have no signs of pain or problems from their joints or from their muscles. And actually their periodontium is amazing even though they’re all hygiene may not be amazing but their periodontium is thick, it’s thick and strong and they may even have lingual tori and all these exostoses because one of the theories is that the body lays down more bone in response to all this sort of additional force that it’s absorbing. So these patients have these big strong thick gums and they’re almost immune to periodontal disease, they’re the ones whose biggest problem will be wear, whereas you have these ladies coming in who don’t have much signs of tooth wear and they have thin delicate gums with recession and maybe they’re the ones who are complaining of a clicking painful jaw joint and really their weakest link is the joint, whereas you have other patients whose weakest link may be the joint and the muscle so sometimes it’s to do with what is the weakest link, is it the teeth? Is it the joint or is it the muscle or any one or a combination? So the weakest link for any patient could be determined by genetics biology anatomy all these sort of things and to me occlusion has a role but really it depends on what is their occluding scheme and the magnitude and the vectors of the parafunctional forces. Now don’t worry if that’s really confusing I will put on some diagrams in the future to explain that but as long as you understand that tmd is an umbrella term and I want to stay away from that umbrella term and really if you want to make a practice and living from treating these chronic pain tmd patients then go for it you’ll be very successful but if like me you just want to do your bread and butter general and cosmetic dentistry then maybe that’s not the best area for you to go into. So I hope this episode gave you some food for thought. I wanted to make it like quite a broad thing so it sort of sets us up for future episodes to talk about different appliances because I wanted to put in some communication hacks in there. I wanted to put in some diagnosis in there so you sort of know what’s going on because when I talk about the different appliances in future episodes you sort of have some background about what is tmd that’s an umbrella term and why some patients may be affected more, why some patients due to the weakest link theory might have this funneling type bone loss and mobility around certain teeth whereas others will come with jaw pain and popping, whereas others will have headaches and some people all they’ll ever have is cracked teeth and that’s all and and that is something that will hopefully be helpful in designing the correct appliance for your patient. So catch you for the rest of splintember. Really appreciate you listening all the way to the end. Thank you so much.

2021 UPDATE: This blew up! I was inspired to create a flowchart to help with Splint Decision Making – download the flowchart by clicking here Which is the BEST Dental Splint? https://www.youtube.com/watch?v=BsXjNkmQf9s Best splint on YouTube – or listen on the usual podcast channels Need to Read it? Check out the Full Episode Transcript below! It is finally SPLINTEMBER and we kick it off with an all time important question – which is the best splint for your parafunctional/bruxist/TMD patient? Surely it’s a Michigan…right? Or maybe it’s a Gelb appliance? Or the humble soft splint…? Did I just say that?SURELY it’s a A- Splint, B-Splint or a C-Splint?! Well, I have an answer for you…it’s called the G-Splint! The G-Splint* is the best dental splint there is. There are so many factors that will determine this. In this episode, Dr Jaz Gulati explores many of the factors to consider for appliance therapy in the form of dental splints: What are you trying to achieve? Is the patient symptomatic? What is the ‘purpose’ of the splint? (Hat tip to Dr Michael Melkers) What is the goal? What about access, cost, airway, orthodontics and compliance with splints? Protrusive Dental Pearl: A quick way to remove temporary crowns and onlays using a haemostat! Tune in for the rest of Splintember where I will go deep in to different splints! *The G-Splint is just a metaphor for splint provision based on the history, exam and diagnosis for your patient! Remember to hit subscribe for updates and join the newsletter on www.protrusive.co.uk Click here for Full Episode Transcription: Opening Snippet: The best dental splint in the whole world is _splint. Hi guys and welcome to splintember It's finally the episode about splits been waiting for starting off with which is the best splint... Like this is such a big question which splint is your go-to splint and basically you know you’re gonna hear about my journey with splints. People who have influenced me mentored me but I’m gonna get right into it very quickly when i was gonna tell you what are the factors which i look for to determine which is the best splint for a patient i have so since i posted about Splintember on Facebook and Instagram everyone’s been sending me a lot of love and everyone’s looking forward to it which has been so amazing it’s a really confusing topic for me, my interest in splints grew out of frustration I’ll talk about that in a moment but thank you so much for everyone sending their love. One of the listeners Taha Alibi actually messaged me on Instagram say no i really like the splinter idea but for october can you do Orthooctober or Orthodontober to try and get all the orthodontic systems to sort of almost debate against each other to see which is the best orthodontic system and I thought that’s pretty clever it’s a great idea but I might say that until next year for example when everyone has enough time to prepare and stuff but thank you so much everyone for your suggestions. The Protrusive Dental Pearl even though it’s a splint episode I’m going to give you like a a non-splint appeal and this is something i posted on my Instagram just a few days ago check out @jazzygulati for the Instagram and this is how I like to remove temporary crowns and temporary onlays. I use a hemostat or mosquitoes or archery forceps lots of words for them and if it’s a posterior one like to use the curved ones and basically you squeeze your temporary crown or temporary only and that breaks apart any bonds that you have so for example for an onlay I would use a zinc polycarboxylate cement such as duralon for example is a popular brand and I would squeeze the only that would just compress it and that compression actually causes tensile stress at your sort of bond layer or the cement layer and that just gets really weak and suddenly you can just so very easily shake it off if you’ve got a really thick crown you know like normal even if you use conventional techniques like you know using what i used to use like a big excavator a mitchells a carver or something like that and try and flick up it’s not so pleasant it’s not so successful in my hands and sometimes just i’m able to get the temporary crown off so you have to section it so sometimes for a really thick crown you’ll struggle and also be careful with thin teeth like lower incisors or quite weak teeth because you don’t want to put all those sort of talking loads especially for a crown rather than only those are so much easier to you know with their innate lack of resistance form. So I hope that Protrusive Dental Pearl helped you and i look forward to sharing more with you.  So let’s go straight to the episode now right so which is the best dental splint so i was incredibly confused by splints for many years and to some degree there’s so much about splints you know that we all still have so much to learn as a profession the evidence base for splints is poor and i think that’s a big reason why that we as a profession get so confused about splints and why there’s so much opinion out there so i i think it starts at dental school where if you go to your restorative lectures, your lecturer will tell you that the Michigan or the Tanner splint is the best and that’s the only acceptable appliance there is any time ever that’s it and if you don’t know what any of these appliances mean any ones I mentioned don’t worry we’re going to cover all those in future episodes so yeah restorative will tell you that the Michigan and Tanner is great and restorative will tell you that anyone who gives an anterior only appliance so let’s call them anterior midpoints stop appliances so AMPSA is an evil dentist and bad things will happen to the patient. Patient will spontaneously combust or get an AOB for sure and temporary mandibular disorder and all that sort of stuff you know so I was always taught that you know stay away from anterior only appliances.  Now in that same dental school when you had your oral surgery sort of sessions or oral medicine sessions and they would make the diagnosis of “TMD” then everyone would get a soft splint and the Maxfacts or surgery department would swear that you know it’s a partly raising appliance and it has a very high success rate and you don’t really need anything else so already coming out of Dentistry school we have these mixed signals and then coming into practice and actually trying to make appliances because you want to best serve your patients you want to sort of help them out you think they’re bruxing and you think that the splint might even stop them bruxing so that’s what you think you know give them a splint and they’ll stop brexit even patients say it patients say to you oh I had an appliance once or i was given a splint once to help me stop bruxing and I correct the patients I said you know what nothing will stop you bruxing except maybe fixing the root cause but I don’t go that deep with them we’ll talk about the root causes of bruxism and Parafunction and that sort of stuff only because it’s interesting it only helps you and I say this to a patient it only helps you to manage your grinding you’ll still grind but to do it on a piece of plastic is so much better than doing it on your own teeth so that’s why I say to patients. Trialing splints on patients and having some failures early on failures all sorts of different types of failures and we’ll cover the different type of failures there are and then really losing faith in splints and then really still being so confused as to which is the best splint and then you come across some very well-respected clinicians and lecturers who educate on anterior-only appliances and you think have on a minute this is the same splint that dental school told me to stay away from what is going on so before I go any deeper I just want to pay respect to some of the the splint mentors I have some of the people who have influenced my thinking on appliances some people who really mentored me and helped me and helped me to understand a lot.  So before I continue any further, I want to thank Dr Pav Khaira from the UK who sort of started to get me think that anterior only appliances or AMPSAs are not as bad as people say they are. Then i was influenced by Jim Boyd and Barry Glassman who I believe they’re the ones who came up with the NTI appliance so I placed a lot of those and that they really influenced me they had a lot of sort of educational content for free on youtube and whatnot which at the time maybe four or five years ago when I started getting into this that was all there was really i’m hoping to change that obviously but that was really helpful for me at the time also helpful to me has been Dr Michael Melkers, okay? Who’s obviously coming to November for occlusion 2020 at the end of november that’s 27th and 28th of november for occlusion 2020 program two-day workshop which we’re really looking forward to but what he you know taught me about splints is you know just unparalleled with anything else. He really took out that next level for me and also clarified a few designs which I use very commonly now so Dr Melkers, thank you so much I know you listen to this so thanks so much for helping me in my journey with splints and lastly Dr Kushal Gadhia, who’s a restorative consultant here in the UK who taught you know everything I know about michigan splints you know it comes from him and he’s taught me so much so well on his courses but I love that he’s so humble because when I met him on his course, he knew that I was doing a lot of anterior only appliances and instead of like some of the consultants that I’ve come across for who really you know look down on you and poo poo he really kept an open mind you know he said ‘Jaz , you know i’m gonna listen to any episodes and try and figure it out even though I don’t provide anterior only appliances’. He really wanted to understand my viewpoint and my experiences and sort of was happy to do that myth busting session i think it was episode eight myth busting about anterior only appliances do they call it AOBs and whatnot. So i respect that so much that someone at his level will give up some time to try and understand where young dentist is coming from with his experience of splints so a massive shout out to him we need more people like you Kushal, who will keep an open mind.  Now before we dive into the meat of the episode I’m gonna tell you straight up which is the best splint a lot of the sort of best way to think about splints was actually covered in episode 15 ‘your occlusion questions answered by Dr Michael Melkers’ and I’m going to play you this two minute or three minute extract from this episode where Dr Michael Melkers gives the best summary for splints I really want you to hear again it’s just fantastic so listen to this bit and it’ll get you get you thinking about what is the role of a splint. One thing i want to speak about before we talk about your upcoming program is splint therapy my gosh people are so confused about splints. It’s one of the most controversial topics it gets a lot of questions when anytime anyone posts on social media about splints and there are like all parts of dentistry and occlusion as well there are very polarizing views and we can go into the whole anterior midpoint stop appliances and those who are really against it and whatnot but but one thing i want to kind of just talk to you about is that or tell you is that your DAASA so dual arch anterior midpoint stop line protocols that you showed were was amazing and the way the cases that you showed and the application of confirming centric relation prior to rehabilitation and you talked about the different indications that was great and I’ve been using that in you know in a lot of my patients and it’s been a real game changer for me so [Michael] I’m glad you’ve had success with that [Jaz] I’m using that all the time in practice you know in the right indications and seeing great success with it so can you tell us just you know briefly to anyone who’s not familiar with these sort of appliances is why you think they have a place in practice. Is that too broad? [Michael] No, but i would actually probably even want to make it broader is why would you use any appliance to begin with it’d be and that’s where i always want to start i always want to start with the why. We get into arguments as you say and we get into disagreements because people have their what and their how and they want everybody to do their same how like you have to do my how, you have to use my how, my appliance is the right one my mind this this but in so many of those discussions we’re missing the why. So why do we use orthotics, why do we use occlusal splints, why do we use bite guards and night guards whatever you want to call them there are just a few very simple reasons why we use them. We use them to get people out of pain, we get use them to help protect things and we use them to help figure things out. Palliative, Protective, Diagnostic.  So if someone is hurting and they could be hurting in their teeth they could be hurting in their muscle or they can be hurting in their joint they need a palliative splint. I don’t care what design it is. If someone is breaking their teeth or breaking their restorations and they want to keep those restorations intact then they need a protective splint. Now if we need to figure something out whether it’s in other camps that want to figure out chewing patterns or my approach if we want to figure out parafunctional patterns or if it is important a joint position then it is a diagnostic approach and you can use full arch appliances for all of those applications and you can use anterior midpoint stops for all of those applications it goes back to the exact same thing that we were talking about at the beginning of this chat is we have a lot of tools but we have to have goals and then we have to balance efficiency with them. [Jaz] So there we are protective, palliative, diagnostic that’s it. If you can just categorize your splints in those three sections everything becomes so much easier so almost the sort of the you know people a lot of people on the Protrusive Dental Community ask for a flowchart of this and you’ll see in this episode why it’s so complex to make a flowchart but at the very top you should always bear that in mind whether your split is protective, palliative or diagnostic and we’ll get into that a little bit more as the weeks come by so doctor. Thank you Dr Michael Melkers for inspiring us with that so it’s just a simple and beautiful sort of viewpoint on how to choose the best splint. So the best dental splint in the world is called a G-splint the G stands for my surname Gulati and i’ll be telling you all about the G-splint. I’m very much against having giving blanket prescriptions or splints but hear me out for a second why the g splint may be the best splint. Okay so in no particular order let’s look at the first factor i would consider, again this is random order i’ve got you know four or five different points which makes the best dental splint.  Okay so number one the g splint is the best splint because it’s the one that actually addresses the diagnosis. So too many people give blanket prescriptions of everything you know i will do a vertical preparation for all preparations because they are the most conservative or whatever or i will do a one specific type of procedure for every scenario because it works in my hands or whatever, so a lot you know dentists who will only ever give a michigan or a tanner and that’s it nothing else and you know what they’ll have a reasonably high success rate in general but you have to ask yourself is that practitioner sort of prescribing it based on individual needs and diagnoses or out of habit. So the first thing is diagnosis like is it a joint ,is it a bony issue, is it a muscle issue or are you trying to just put something between the teeth to protect them. So what are you trying to achieve maybe it’s two or all three of those things and maybe they’re just completely asymptomatic and they are just chipping and wearing away their teeth and they’re concerned. So really it depends on your diagnosis the health of the joint, health the muscles, the sort of initiating factors. Are they a daytime or a nighttime para functional patient, are they bruxing during the day? Night? All these factors are part of your diagnosis and that’s an important thing to consider don’t you think? Number two, compliance. Now this is a huge one okay many years ago i used to do lots of michigan splints and tanner splints and you know once again if you don’t know what these are these are full coverage appliances, hard acrylic traditionally. Now you can actually do the Bilaminar type a lot of dentists are against these but they’re soft on the inside and hard on the outside and have the whole canine ramps for disclusion and whatnot but essentially you know these splints are supposed to be made ideally using a face bow and you know two or three long appointments to get them perfectly equilibrated but the number of appliances that I’ve seen that patients own that come from other practices you know and i asked them oh you know tell me about how this splint was made it was oh yeah just one appointment they gave it to me i went home that’s it done and you checked their bite and they’ve almost got like an AOB on this splint and you know it’s supposed to be a michigan retainer so how many of these appliances are actually really truly and properly equilibrated i don’t think very many. So compliance is a huge factor when i used to give these michigan and tanner appliances with all the best intentions, all the best experience and really trying to get the best for my patient it was so disheartening and embarrassing for both me and the patient when the patient would come back for recall and i’d be like hey how you getting along with that splint we spent a good few hours on that you know we checked your bite over ever again. How are you getting on with it and then you know they say you know i tried for the first couple of weeks and and too fair i you know i couldn’t get myself to wear anymore. I kept removing it in the middle of night and now I don’t even know where it is anymore. So compliance is such a huge factor because you can have the best splint in the world, the best equilibrate splint in the world if your patient doesn’t wear it then it’s completely pointless so that is another factor to consider. So the g-splint will be the one that will also help with compliance for the patient and and that depends on patients. Some patients will comply better than others and that might be a personality type trait. That might be just something innate about them so something to you want to suss out about them. Okay number three, the best splint is the one that will also consider their orthodontic status. Now, so many of our patients receive orthodontics like did you know in the uk when they sort of budget in the national health system and they allocate some funds to to children’s braces and orthodontics under the NHS they budget that one in three children will require orthodontics. One in three, that’s huge. So imagine the patient of tomorrow one in three of them will have had some comprehensive orthodontics from the NHS and a significant chunk of patients would have paid privately because maybe they didn’t meet the criteria for IOTN so maybe up to 40% of our patients in the future may have had some degree of orthodontics at some stage so don’t you think before you give an appliance that you should ask if they’re currently wearing retainers at the moment whether they have had orthodontics before and whether they need retention or not and perhaps an appliance or a splint that not only addresses the diagnosis the the sort of the reason for giving a splint is diagnostic, is it palliative, is it protective but also factors in a degree of orthodontic retention if it’s necessary. So that’s another thing that the best splint will actually address. Does the patient need orthodontic retention? The next one’s also very important to consider is it’s airway, you know i recorded some episode episodes ago with professor Ama Johal about airway and our role our growing role in the future in dentistry to help patients with airway issues and there’s a huge correlation between airway issues. I’m talking sleep apnea, the inability to get enough oxygen when you’re sleeping because it collapses the airway the soft tissue airway and basically this is one of the implicated theories of why people brux and parafunction because if you’re not able to get the air in then your muscles mastication they sort of go all over the place to try and allow you to get more air inside and the other thing is a gas gastric esophageal reflux disease is also implicated in bruxim and parafunction because it’s trying to move your jaw around to get more saliva so these are some of the theories but there’s a huge link that if you treat someone’s airway with a CPAP for example one of those positive continuous air machines that they all stop parafunctioning, isn’t that so fascinating.  So shouldn’t you consider that yes you have a dental appliance you want to give it to them but their airway is important because if it’s their airway causing the issue then perhaps going down that path and perhaps them not even needing an appliance anymore or if you just ask him and typically if it’s like a 50 year old man who’s looking a little bit thick around the neck and then you sort of discuss with them and you have to sometimes be frank and ask them if you already have it in your questionnaire then great but if you don’t have it you sometimes have to ask them do you snore and then a lot of times they’ll say yes. It’s a huge problem in my life my wife is about to divorce me because of it or whatever it’s a massive massive issue usually for the spouse rather than the patient actually snores but it is actually as you know a marriage breaker and if i find out from my patient that snoring is a huge issue and i’m seeing signs of parafunction then at the very least i might offer them an anti-snoring appliance because hey if that’s in the way of the teeth then they can’t damage their teeth anymore. If they can help their snoring and help their spouse get a better night then the g-splint will be one that also considers their airway.  So have a think about that in the future i mean i think one of the reasons in the UK and we discussed this in the previous episodes is that we lack we really sort of lagging behind Australia and the USA in terms of managing airway and dentistry is that we don’t have the correct pathways or referral pathways set up like we always have to send to the GP first who may not know much about sleep apnea and they are the ones responsible to send them to ENT or something and they might just say to the patient oh you know just lose some weight or whatever which is good advice but it’s not going to be a you know helping these sleep studies which i needed and all these sort of issues. So i think that’s why we sort of lag behind the UK. So there’s so much more i need to learn about airway as well but something i would definitely consider when choosing the best splint so consider the airway when you’re prescribing the best appliance for your patient. Okay the next point to consider for the best appliance is how much do you trust your patient and how much does your patient trust you and what i mean by that is obviously we want to have a very trusting patient-dentist relationship but not all of your patients trust you as much as your favorite patient maybe and you don’t trust all your patients as much as you trust your favorite patient. If that makes sense so trust varies amongst different patients and how much the patients trust you like they might trust you enough to do a composite on the lower six but they might not trust you enough to do a full month rehab for example or anything cosmetic whatever. So trust is a huge factor because if you’re going to prescribe an appliance that has very specific instructions for example only where this appliance at nighttime not in the day then can you trust your patient to follow this advice because if the proverbial hits the fan and things go wrong then you want to be able to have a patient that actually followed the instructions because when patients follow the instructions of an appliance and you have put thought and care into the correct prescription of the correct appliance for that patient and you’re not going to run into any issues but when there’s a lack of trust i.e between you not trusting the patient to do things correctly or massive one is patient not trusting you. If i have a patient in front of me and i’m getting these vibes that you know they’re listening to me but i don’t think they’re taking anything in so for example one of those patients there that you show them their photos and you show them all their signs of severe parafunction completely flat incisors that you know four millimeters of you know incisor height left and then they’re looking at you they’re listening but they’re not trusting you they’re not buying into it they don’t agree maybe this is the first time maybe that you know someone’s telling them about their bruxism habit and they don’t know whether to trust you or not so that patient who might not certainly might not necessarily trust you if something was to go wrong because you know any appliance can cause a occlusion changes any appliance can cause changes in the temporomandibular joint and at the dental level so be careful when prescribing any type of appliance not just anterior only ones and so if the patient doesn’t trust me i might give them the cheapest most simple appliance that is the safest and not likely to cause any issues because it might just do enough for the patient because the patient doesn’t trust me that i don’t want to give them my everything because if things go wrong then already you’re on the back foot. So trust actually is an important factor when it comes to prescribing the best appliance for your patient. Okay the next one is an interesting one is ease of access and access in general for example the other week i had an 80-something year old delightful lady just an absolute comedian. She was just brilliant, full of life and so funny but she did have early to moderate alzheimer’s disease and her son would bring her in and she lives a fair distance away and really we you know we spoke with her and her son and we thought that because of the distance she lives away she her main goal is to stay stable and to do the least amount of denristry possible but also to minimize the need for her to come to the surgery. So minimize and emergencies and whatnot and other than lots of wear on her teeth which you may expect It’s common but not normal like you know she’s obviously been parafunctioning at high rate throughout her life and she knew it i mean it’s one of those patients that tell you one of those rare patients that tell you that they’ve been grinding a lot and she actually came with a a chipped composite on the anterior which i fixed for her and then i spoke to her son i spoke to her and we decided to go for a splint. I’ll tell you in the future why we did this and how we did this. We decided to splint that was really low maintenance easy to wear and will not need many adjustments because if she lives a long while away and she depends on her son and she really wants to minimize the number of appointments and number of times she has to see me and i want a low maintenance appliance that doesn’t need a lot of close sort of reviews and just checking how things are developing. So for her which is a protective appliance which i’ll describe in future episodes hopefully with except with some examples i can show you these types of appliances but the g splint for my patient there was one that factors in the fact that this patient cannot come to see me for stringent follow-up protocols and i need to give a plug-and-play appliance that’s going to be easy for her to wear and compliance is almost guaranteed So how far away your patient lives and how how easily they’re able to access your care will also affect which is the best splint for that patient.  The next one is one that considers if your patient will be requiring any further dental work in the near future like you don’t want to be giving appliances to your patients who you know have poor oral hygiene, have lots of large restorations with constantly fracturing cusps. You want to get your patients stable enough so that they’re not going to be you know you’re not anticipating in doing lots of treatment on them in the future. You’ve stabilized all the caries, you’ve got everything pretty much stable enough because you don’t want to give an appliance and spend so much time on it and then suddenly you know three months down the line they need a new crown and then restoration and a root canal and then things keep changing and a lot of appliances once things change they don’t fit so well or they need a lot of work and it’s not as predictable they’re better off just having a new appliance. So you need to get a patient who is stable most of the time now sometimes if they’ve got lots of work that’s required but all of it is conformative so we’re sort of sticking to their occluding scheme and all of that work is going to be posteriorly for example and maybe you need an appliance just to prevent them for doing any further damage then maybe in that case an anterior only appliance may be the best splint that could be the g-splint for the patient So factor in that if they will be likely in need or maybe they’ve already got a treatment plan that they need to complete and just being a little bit slow but that’s all planned treatment So think about the type of treatment that they may or will need in the future and how that may impact a constant need for new appliances is there a clever way that you can do it so for example one of the appliances i’ll talk about in future episodes called the FOS appliance, F-O-S and i love it because if i’m going to be doing a DAHL type case where i’m building up the anteriors I just gouge it out once i’ve built up their teeth and realign it to their teeth it’s the same splint they’re already used to it but now i’m able to do new dentistry for them yet still keep them on the same appliance. So have a think about if they need any further work. Are they stable? We should really be doing appliances for most time appliances on stable patients Now obviously if you’re trying to deprogram them like a diagnostic appliance so get their sort of muscles relaxed prior to centric relation records for a future rehabilitation that’s different and again if this is a mumbo-jumbo to you don’t worry we’re going to cover it slowly and shortly in the next few episodes but bear in mind at the need for any future dental work and the last point to consider i’m sure there are more and i’ll probably cover them throughout the next few episodes in splintember but the last one i want to consider is the best splint is the one that actually gets the job done and what i mean by that is i mean a recent patient experience triggered this sort of point and it’s a patient i saw recently who has a lower left molar which is pretty much last chance saloon like it’s so weak and every year she comes in she breaks it and it gets restored and she saw me as an emergency so the first time i saw her and i said look this tooth really needs to come out and she’s like look i’m so desperate she’s about 23. ‘I really don’t want to lose this tooth, it’s not causing me any pain please please please can you patch it up again?’ I’m not into patch up dentistry you know i already try and convince my patients that look let’s get it sorted once and for all now. She’s a child minder and and funds are not in the best place at the moment so we think what can we do to minimize the risk of this tooth continually breaking away.  Now she’s really good at not eating on that tooth which i know is a massive shame and i really hope she gets it fixed properly but she wears an appliance as well and her main issue is got she’s large muscle mastication and she’s a you know a strong parafunction or very strong signs of bruxism and she’s aware of it. Again one of those places that really know you know they really do it when they’re aware of it right?  So her appliance is an upper one so it just doesn’t make sense if her weak tooth is lower one, lower molar and her appliance is the upper one that when she’s parafunctioning that weak tooth even though she’s protecting it during the day by not eating on it. That weak tooth is parafunctioning on plastic but it’s still receiving the lateral loads of parafunction because she showed me the appliance and i had a look and every time she’d grind left to right she’s grinding on that weak tooth no wonder it’s breaking away despite her being so careful on it. So for that patient don’t you think a lower appliance to actually cover over gently that very vulnerable tooth would have been the better appliance? So it’s got to be something that gets the job done. So those are some of the seven or eight factors which i think are important and those are all the things that make up the g splint.  So if you haven’t started already i was only joking there’s no g-splint yet i’m joking. There isn’t, there’s no Gulati splint that was like an analogy, a comparison a way to think. So the g-splint is one that suits your patients needs the g splint is individual to every patient that’s what i was trying to get to basically there’s no one splint for every situation and now all those people that ask for a flow chart i’ll still try and make you a flow chart but can you see the problem with having a flowchart in this sort of topic? Because there’s so many different variables and i think I’ve only just scratched the surface with this episode about which is the best appliance because I’m going to talk about in-depth each and every appliance in the future episodes coming very soon but can you see the complexities and how even if i make a flow chart there’s too many ifs and buts and you know how far away do they live? Have they had orthodontics before? Do they snore i mean these are things that are so unique to every individual to decide which is the best appliance for that individual.  So really i hope that gives you food for thought about which makes the best splint, it’s the g-splint it’s the one that’s best for your patient in front of you based on their individual needs so i hope you found that useful and check out the next few episodes of splintember I’ve got so much lined up for October as well I’m recording a couple times this month as well for future content to come out in November hey if you’re looking to come to the Michael Melkers course 27th and 28th november please check out occlusion2020.com and let me know i’m still recording these in september as i’m going along so if you want to know anything specific about splints please help me to to sort of add that content in to the sort of series on splints probably three or four episodes to come this month and i hope you’re enjoying splintember and join me for rest.  Thanks so much for tuning in all the way to the end on this episode which i know wasn’t what you were expecting you were expecting me to say the michigan’s splint or a b splint or whatever is the best splint but no there’s so much more to it than that and that’s what makes this field so exciting and just for getting to too much i think but in the future episodes bear in mind that splints are great and they can really help your patient but you don’t want to be doing splints and that’s it you want to be doing the rehabs well you’re going to you want to be doing the fun dentistry splints are just part of it because guess what every time a really well known dentist does a full mouth rehab they’re pretty much always getting a splint afterwards. So splints are also important but they’re not something that quite often is it you know have the splint and you’ll be sorted for life although it they can work that way a lot of times the patient still need our dentistry so that sort of flavor will be going in the future episodes and please subscribe to the newsletter on protrusive.co.uk. Thanks so much for listening all the best

It is the one you have been patiently waiting for since I announced it on Instagram….Personal Branding with Shaz Memon who wrote the BOOK ‘Instagram for Dentists’. https://youtu.be/R9tU-lLlLlY What Shaz, from Digimax Dental, does not know about branding as a Dentist is not worth knowing. Protrusive Dental Pearl: Are you Google-able? Are you one page 1 of Google when patients and potential patients search for you? This is so important and is the reason companies pay MILLIONS for ‘Search Engine Optimisation’ or ‘SEO’ (not to be confused with SOE Exact!). A great way for Dentists to harness the power of being found in Google is to collect verified patient reviews using Doctify Collect verified reviews and add a widget to your clinician website Join our interview where I probe Shaz about all things personal branding: Should you have a logo as a Dentist? Learn about the hilarious error I made with an old, secret, stashed-away and destroyed logo that I am embarrassed about now! Is a Dentist website page, independent to the practice website, appropriate? What does Shaz think about doing it on the cheap via Fiverr or Canva? What makes a good dental website – BONUS: Shaz critiques my website (completely unexpected!) What are they keys to success for branding yourself online? The funny thing is that all the advice Shaz gave me on my Dentist website …I have still not updated/improved it based on his advice. That is one of the pitfalls of doing everything yourself. Getting the advice, unscripted and ‘live’ during the show was the highlight of the episode! If you enjoyed this episode, please support the podcast by subscribing so I can continue to make this type of content!

In this episode we listen to Alan’s story. His name is Alan Burgin and he’s also known as The Cornish Dentist on Instagram. https://youtu.be/oF-yyrwPfm4 Need to Read it? Check out the Full Episode Transcript below! His story involves themes of mentorship, challenges, overcoming adversity, gaining a work life balance, (so actually going abroad to Australia for six months)….I don’t give too much of the story away, but it involves so many real-world themes. And actually, it also involves a bit of luck and something that we touched on in Episode 34 with Richard Porter on emotional intelligence was the element of luck in your career trajectory is actually very important. The Protrusive Dental Pearl is about how to make cementing crowns less messy using Vaseline! I hope you enjoy listening to our reflective chat! NEXT MONTH will be Splintember! I will cover all things dental splints to simplify this confusing area of Dentistry. Listen to the FULL episode via direct download or via the following platforms: Spotify Apple Google Podcast Subscribe on Android Click below for full episode transcript: Opening Snippet: Yeah, so probably the biggest thing I've learned about bigger cases in private practice is a lot of people say about getting to know your patient. And I've had a few cases where I've moved into they didn't need much doing initially, we've been able to move into the sort of full mouth stuff quite quickly, and haven't got to know them at all. And it doesn't mean just you don't have to sit and chat with them for ages. But now I'm much more structured in my treatment approach in that I will do a stabilization phase and then a definitive phase... Jaz’s Introduction: Hello, everyone, and welcome to Episode 36 of the Protrusive Dental podcast. Today we are talking about a journey and a story of a very talented young dentist. I’ll tell you in a second who it is. And it’s all about resonating with his story. Now his story is very unique. And that’s why I’m going to bring him on because life doesn’t always go as planned. And in dentistry, as you’re a young dentist, sort of career path that you map out, may not exactly go to plan. And there are some great lessons you can learn from stories and journeys. So the pathway that we’re going to describe say is specific to one in the UK because of the some of the names, the posts that we mentioned, like maxfacts, SHO positions, or DCT positions or whatever. So that’s applicable to UK but I believe all over the world. Be it Australia, US, wherever you are listening to this, that there are parallels you can draw within your system. If you’re a young dentist, we sort of going up in terms of training pathway so we can have like residency programs, for example. So that is applicable, no matter where you’re listening from. So we’re gonna listen to Alan’s story. His name is Alan Burgin, and he’s also known as the Cornish dentist on Instagram. And his story involves the themes of mentorship, challenges, overcoming adversity, gaining a work-life balance, so actually going abroad to Australia for six months. I don’t wanna give too much of the story away, but it involves so many themes. And actually, it also involves a bit of luck and something that we touched on in Episode 34 with Richard Porter on emotional intelligence was the element of luck in your career trajectory is actually very important. It shouldn’t be overlooked. So before we join into the journey with Alan Burgin, the Cornish dentist. And speaking of journeys, my wife and I celebrated our fifth anniversary yet well, it’s actually today. She’s not working out and I’m at home this morning. So I’m actually recording the intro for this episode. But we celebrated our anniversary over the weekend. We went to this fantastic Turkish restaurant called Gökyüzü. And when my wife first told me that we’re going this place for to celebrate, I thought as a Japanese restaurant going by the name, but actually, it was a phenomenal Turkish restaurant, some of the best Turkish food I’ve ever had. Even better, dare I say that when I went to Turkey a few times, it was in Finchley where we went in London, but I believe there are a few branches around so if you ever in that part of the world, definitely check out and Gökyüzü, It’s amazing. And don’t worry, this is not the Protrusive Dental pearl. I was just sharing. You know, I know some of you are foodies, so I thought I’d share that little nugget with you. But the Protrusive Dental pearl is coming in the second. I just want to share some very exciting news with you that September is no longer going to be named September it will be Splintember. Thank you Ricky Bhopal for giving me that suggestion of a name. But basically September all the episodes I’m going to release are going to be to do with splints. They’re different types of Splints I want talk about Michigan, SOF, Tanner, anterior deprogram, anterior midpoint stop appliances, anterior repositioning splints, I want to talk about all of them. Now I want to re-break it down, simplify it. I posted on the Protrusive Dental community recently like what do you guys want to know? Like, how can I help you in your journey with splints and some of you had some great suggestions points. So some of them were like, ‘can you please produce a flowchart?’ ‘Can you show some like A to Z videos?’ So I’ll try and do that as much as possible for splintember. So join me in September, splintember for loads of splint content I want to share with you all and if there’s anything specific you want to know, please reach out to me message me, email me and let me know and so the Protrusive Dental pearl I have for you before we dive into the episode is when you are cementing crowns. So this could be temporary crowns or definitive crowns, when you’re cementing them in quite often aren’t you cements in you get loads of mess everywhere. You have to spend some time actually you know getting a scaler or something and scaling the facial surface of the crowns so that patient isn’t walk out this horrible white cement or definitive cement and also the gingiva, you have to clean up the gingiva as well to remove the excess cement which is very time consuming and annoying. So a tip I absorbed over the years is you get a micro brush and you dip it in Vaseline so once you’ve tried your temporary or definitive crown inside, you’ve checked everything and you’re ready to cement, everything’s dry and ready, you’ll get some Vaseline. And you’ll paint this Vaseline a little bit on the gingiva, a little bit around the crown on the outside surface, obviously don’t want to put on the intaglio surface or on the facial surface, for example, the crown, and you have to be very careful this one put a very thin amount on the adjacent teeth of proximal surfaces, you don’t put too much because as you seat the crown, the Vaseline can creep inside the crown. So this has to be like a very thin film. So now when you load up the cement and put it in, it’s gonna be the easiest cleanup ever. So that’s the pearl I have. And also additional pearl I have for you is I’m very much a fan of using long handled pink tepe brushes when I’m cementing posterior crowns, to just clean out the embrasure space and clean out any excess cement as well as flossing. So floss is great at cleaning the contact. But sometimes to get the bulk of the cement out, I use a tepe brush and interdental brush long handle. And I think for the sake of you know a couple of pennies, it makes my appointment go quicker, smoother, and never had any cement stuck between even I can verify that radiographically since I’ve been doing this, so it’s a great thing to do. And even if you have a really bad day, and it can’t happen, sometimes it’s tricky situations and you actually leave some cement and you can’t floss, you know that the patient can tepe and we can talk about that another time. You know, the the chewing action will actually break down the cement in between the teeth. And eventually you can sort of work at it or use those serrated saw and stuff. But ideally want to prevent all that. So the Vaseline can really help you to prevent that and also a much easier to clean up. So I hope that was useful. And let’s join in and listen to the stories and the lessons and the themes with Alan Burgin, the Cornish dentist. Main Interview: [Jaz]Alan Burgin. Welcome to the Protrusive Dental podcast, my friend. [Alan]Hi, how you doing? [Jaz]I’m doing great man. I’m just want to tell everyone about how I found out about you. I connected with you. I think earlier on in this podcast. We, I think it was an episode about splints or something. And we sort of say, you know, Instagram messaging each other about splints, I think? [Alan]Yeah, struck a few chords with the we’re looking at, we’re doing the same sort of thing and Dawson style. So yeah, lots of similarities. [Jaz]That’s right. And then later on, and I put a reading list out recently and he sort of bounced back. And so I think we’ve got quite a few similarities. And what I noticed about you was you were not when I sort of connected on Instagram with you, your dentist Instagram profile that the Cornish dentist is literally like dental pornography and nothing short of it. [Alan]Thank you. [Jaz]Honestly, it’s a great profile. And I mean, one of the things that we can talk about is that the amongst other things I want to bring you on for but just for those listening right now, can you tell us a little about yourself, where you qualified and your career journey? Because a lot of what we will be discussing today will be career focused about what decisions, I mean you have made in our career so far, and how we can get into full mouth dentistry, comprehensive dentistry without necessarily specializing? [Alan]Yeah, sure, sure. So I trained in Cardiff at Cardiff Uni, graduate in 2012, and loved Cardiff, and then decided that we’re gonna stick around that area. And my year was actually the first year that had to apply for DF1 online. So they went they changed from the central, change to the central recruitment scheme, rather than just you know, having a room full of people and mixing in that way. So everybody applied online. And my application actually didn’t go through properly. And so when I phoned them up, I said, you know, what was the situation? They said, Yeah, I can see all your information, all the details and everything. But the form hasn’t come through as submitted. So we take late submissions very seriously. You have to apply again next year. And yeah, I mean, that was it. Literally. That was the end of my DF1 before it even started. So I basically had this, I pretty much had one job that I could apply for, which was a DF2 12 months maxfacts post. And the reason all the other ones were off the cards were because they had a six month community or post attached, which you had to have a performer number for. So by complete fluke coincidence, I was due to do a two week post at that maxfacts unit, the next month. And so I pretty much just turned up and said to the consultant, you know, on the first day look, just so you know, I’m going to be putting my name in the hat for this job. And he sort of said, he didn’t realize that everyone else applying for this is going to be one, two, maybe three years qualified. And he said what you know, you haven’t even got a degree yet, I saw I said, Yep, that’s the situation. And he said ‘okay. Let’s see how your placement goes.’ And so I was just like, threw myself into that placement, just doing everything I could, put my hand. [Jaz]I mean, that placement, Alan was pretty much like a two week job interview, right? [Alan]Pretty much. Yeah, pretty much. And yeah, I loved it, I actually really enjoyed the post the placement as the main thing as well. And then right at the end, I went into the consultant sort of said, you know, if we see you again, and he pretty much said to me, You know, I don’t think I’m going to give you any favors. We’ve got this is one, this is one of the most popular posts in the area. So it goes and I got the position, I got the deal. [Jaz]Amazing And that was just one post? [Alan]Yeah. So I did that first of all, and then went on to do DF1. And when I went to the meet the trainer thing, I kind of found out that all the trainers, it had sort of gone around rumor mill that, that I hadn’t actually filled the forms. And that’s sort of what they’re told everybody. So that’s a bit like, okay, that’s fine, I just got to prove myself. And then the maxfax background went down pretty well. And so I worked again, then in Ronda Valley, is a pretty high needs area. Some awesome patients, lovely people I worked with, but you know, again, you just get stuck in. And so of a lot of high needs. [Jaz]What was that like Alan going from Maxfact, and then into practice? Because a lot of people sort of worry about going into maxfax. And then going back into to practice. How do you do? I mean, your story is very unique. That you almost did the other way around. But how did you? It’s amazing, actually. So at one point, you know, maybe in the middle of fifth year before you went over study leave whatever was the last restoration, you did maybe and suddenly you go through all this maxfacts. And then you’re now doing your DF1, How’d you find that transition? [Alan]Not too difficult, actually. Because the one thing I think maxfacta does for you, is it pushes you to your limits, and also gives you a bit of real world realization. And whilst you can still then reflect and be, you know, think about all the procedures you haven’t done. At the end of the day, you’ve seen some pretty intense situations in the hospital, and you can kind of think, actually is just the tooth. Let’s not get too over the top about it. And some of the scenarios you treat in maxfacts, you end up being quite glad just to take a tooth out or do a filling. And yeah, I didn’t find it too difficult. And it was still DF1, you know, so there was as much handholding as you needed. But I did. I was getting a lot of extractions ending up on my list. And my boss did not like to take a deep out. So it’s just sending all this stuff my way. And I think yeah, I think it worked out well for both of us. And yeah, it was a great year, actually. And then after that, my wife, we will work she was working in Cardiff as well. And [Jaz]she’s also a dentist? [Alan]She’s a therapist, hygiene therapy. And she said, I’ve always wanted to go traveling, we never went traveling. And I was okay. You know, I’ve been offered another position in Australia after the DF1. And we kind of looked at and said, You know, there’s no other time that you’re going to have a definite break that you know, you get a one year contract in DF1. So I said yeah, sure. Let’s do it. So we went traveling for six months. And we just went all around Asia, Australia and New Zealand. And my worry was the same as after maxfacts, you know, I’m going to come back and everyone else is going to have got ahead, I’m going to be left behind, how am I going to catch up again? And actually, it wasn’t a problem that kind of got back and found that you know, things hadn’t moved on that much and we had a great experience [Jaz]You don’t play by the rules do you? You’re just like doing something different. I like it I like where it’s going. It’s very good. I think it’s gonna help a lot of people who are in, I mean you hear about people in very unique situation. I like your story, it’s very different. And you also touched on the having that break and almost you get FOMO, you get the fear of missing out and then they all going to be going ahead, What if I get left behind but you know, I can tell from the type of dentistry you’re doing that you certainly have not been left behind. So how do you fast forward to the Cornish dentist that you are now? How do you get to the type of dentistry that you’re doing now? [Alan]So we moved to [Barth] after we went traveling. And the I was in a mixed practice there. And my thought process was, you know, I really enjoyed maxfacts, implants is going to be my thing. And so I did the implant master’s degree through Bristol, I was in quite a fortunate position there where my practice was placing quite a lot of implants. So my boss was willing to somewhat mentor me Hold my hand a bit. Because one thing you find on the MSC is, it’s an incredible course. And I really, really enjoyed it, but you don’t have a huge amount of hands on. So or that’s not quite fair, actually, I suppose it’s you don’t do a lot of cases. So you have quite a lot of hands on, but it’s just one or two cases each year. And but those cases are done to the textbook gold standard. So you learn a lot, you just haven’t repeated your skill set that much. So that meant that in practice, once I was into the second year, my boss said, great, you know, you can start placing simple implants with me, I’ll be there if you need any help. And that was a really good way to be able to do that postgraduate because it meant that you could still practice. And I know some friends of mine who were on the course, they had to pay quite a lot to get mentors in to observe them, and just makes it more difficult. And it was in that position that I sort of decided, I saw these posts on Facebook, it’s amazing cases. And I thought, that’s what I want to be doing. I want to do that sort of dentistry. And the one thing everyone was advocating was photography, and taking decent photos of your work. And that’s how you can reflect and improve. And so I’ve already been taking photos quite a bit, but I just saw trying to up that. And at least trying to get before and after or during procedure photos, maybe not full protocol. But that’s why I started to be able to just self critique my own work. And not just to work, critique your photographs, your ability to take a decent photo. And the reason then I wanted to do that was to build a portfolio and move into private practice. And then about two years ago, an opportunity came about actually, it was longer than that, because this opportunity came up for a private practice job that just came through one of the guys on the implant course said, there’s an implant position in Cornwall would you be interested is just as big as that. And I was on holiday with my wife and her family. And I didn’t tell her because she’d mentioned she I knew she would want to go back to Cornwall one day, that’s where her family’s from, so dragging my heels because things are going well. And but and so I applied for this job. I didn’t tell her. And the guy messaged me back saying, Yeah, sure. Any photos of your work and some x rays or whatever. I mean, by a pool in Portugal. Yeah, I got loads of pictures. And so I just picked out my favorites and send them off. That was my first sort of realization of, you know, actually the power of a portfolio. Just kind of build from there. And then the only problem with that was that when I got down to Cornwall I didn’t have that impetus and that drive to actually take photos anymore. It’s quite as much because I wasn’t going to necessarily be building a portfolio because this practice I was in, you know, the staff. I didn’t ever dream of being in the practice that I was in. I actually wasn’t even going to apply for the post when I found out which practice it was because they do a lot of work that I you know, almost didn’t feel worthy of [Jaz]Did you feel as though you had a term called and have you come across it imposter syndrome. [Alan]Know what, I don’t know if it was even imposter syndrome because I think imposter syndrome is where you don’t believe you’re kind of as good as you are. And I think I was you know, actually wasn’t good enough at that point. But I actually had the job offer 12 months before the job became available, which is a bit odd and so I just decided in that 12 months that I, if I don’t improve and get as good as I possibly can, in my basic dentistry, I’m going to sink when I get into this new job. So I took that 12 months and just nailed the basics, nailed Rubberdam, nailed my photography. And I just took it from there really And, yeah, the Instagram page that was purely I just started it because it was my new impetus to take photos, you know. And I said, a webinar the other night said, you know, there’s nothing like having a few thousand dentists see your cases and your photos. And, you know, it makes you just try that little bit harder to get, do those extra little bits that you think no one would see. And everybody benefits Really. [Jaz]Absolutely. I mean, I think a lot of people say this, and I and I wholly agree. The quickest way to improve your dentistry is by taking photos and blowing it up and zooming into the single teeth, putting it in social media, because you sort of have to get really got your comfort zone the first time you do it. I mean, I remember the first time I posted online, I was crapping myself. So what do people face out the way? Absolutely. So then the next question I’ve got for you now leading up to the saucy stuff of this episode is one thing I look at your cases [Alan]query about the money on it, just have a good time. Learn something from it. And it might not go to plan but something will and then you can [Jaz]this about getting started. Just put something on put something on social media and not because everyone else is doing it because it will actually make you a better dentist. Jaz’s Outro: So thank you so much as always for listening all the way to the end. Join me for splintember. I think I’ve got got a couple more episodes for August coming out some good ones. Next one being on personal branding. We’ve got Shaz Memon from Digi max talking about personal branding, should you have a website as an associate? Should you have a logo? Do you have the audacity to have a logo and you only one year qualified? We’re gonna be talking about this sort of stuff. And don’t worry, the answer is not very harsh at all. So we are going into deep into websites and that sort of stuff. So join us for Next Episode and of course splintember in September, which I’m really looking forward to. Thanks for those of you who’ve signed up for the waiting list on occlusion2020.com we’ve got a few non people there will be contacting closer time and have an awesome week guys. Thanks for joining me

Case Acceptance – sounds dirty doesn’t it? Well its kind of important. We can make a huge difference to the lives of our patients and do more of the Dentistry we love to do. But only if your patient sees value in your treatment plan and believes you are the right Dentist with the right solutions. I spoke with Dr Gurs Sehmi who shared all his secrets! (I kind of forced it out of him!) Need to Read it? Check out the Full Episode Transcript below! The protrusive dental pearl for the episode is a video I shared on Protrusive Dental Community (FB page) using a Endodontic tool to squirt peroxide gel deep in to the access cavity to treat an internal bleaching case (see images below!): Before internal bleaching. UR1 sustained trauma – it was root filled with an MTA plug and GP by my Endodontist, Dr Cesar Munoz After internal bleaching. What a difference! Unfortunately no Video podcast for this episode (technical error on my part!) but for anyone inspired by Dr Gurs Sehmi’s protocols, do check out what he has to share: Here is the link to register for the mentoring program: https://accelerator.dentalnotebox.com/ This is a link where people can sign up for live cases https://dr-gurs-sehmi.lpages.co/live-case-stream The Dental Notebox Instagram/ FB link is: https://www.instagram.com/dentalnotebox/ https://www.facebook.com/DentalNoteBox/ If you like this episode, you will love Communication gems with Dr Zak Kara! Click below for full episode transcript: Opening Snippet: All this knowledge is out there Dentists have the knowledge, but it's getting the patients to say yes to a comprehensive treatment plan, which typically where we work can range from anywhere from 10,000 pounds to 30,000... Jaz’s Introduction: Hi guys, and welcome to episode number 35 of Protrusive Dental podcast. I’m your host Jaz Gulati. And how awesome was that last episode with Richard Porter, I mean, wow, his sort of take on warmth and competence. I love that. That really is the magic formula to be a successful clinician in my opinion, and Richard as well, warmth and competence. So do check that out if you haven’t already. Today is about something a little bit different. It’s about case acceptance. Specifically in smile design. I’ve got Dr. Gurs Sehmi, who’s just phenomenal. He does so many cosmetic cases, which I love seeing and he sort of breaks them down. He teaches dentists how he does these, he actually teaches patients how he goes about this process, and they find so much value from this. So he’s just a great guy to talk about it. And I’m really excited to share this content with you today. But I have to say that case acceptance is a bit of a taboo subject, because people think oh, it’s like very salesy and stuff, but really is such an important topic, I think, and we shouldn’t be embarrassed to talk about this or listen to this. Because however good of a dentist you are, no matter how awesome your hands are, how passionate you are, how much of a difference you can make to your patients life. If you cannot get the patient to understand the treatment plan and understand the value of it, then they will rather spend their money on a kitchen or holiday or handbag, things like that. But if you can really emotionally create a spark within them to see that look, during this piece of work will really make them feel good about themselves. And that you get to do dentistry that you love doing is what you’re trained to do that that’s the win win formula. It’s serving your patient. And I guess sales in that, in that sense, is it serving your patients. So I make no apologies for making content like this with Dr. Gurs Sehmi, I think he’s really gonna give you a few thinking points and a few gems to go away with. Now before we dive into that episode, I’ve got a reminder and some updates. So the reminder is that a lot of these episodes, I’ve got a video as well. So sometimes when you hear me listening to the guests or speaking to the guests and and we’re like, oh, do you see this margin over here? What would you do? Well, actually, there is a case that I’m showing them. And you can see that too. So a lot of the videos are on YouTube, they’re definitely on dentinal tubules as I’m getting around to uploading them. And the benefit of that is that you can get one hour of CE or CPD depending on where you’re from. Verified. So wherever you are in the world, you can get verified CPD points are an hour when you listen to a podcast episode, and you will have to answer a few simple questions to make sure that you actually listened. Now the other reminder is, is an interesting one. I was supposed to be hosting in May 2020, occlusion 2020 event with Dr. Michael Melkers. And obviously, they’ve got COVID. And now the new date as we’ve known for a while now is November 27th And 28th. Still at Heathrow Sheraton skyline hotel. And it’s still a sold out event. And I am really, really hoping this goes ahead and we don’t get a massive second wave. So we’re kind of at the mercy of like, you know, the governments in the USA and the UK. Yeah, what’s your space, but as far as I can tell you right now, we are hoping to make this event run. And it’s encouraging to see other course providers, also advertising some courses in November. So that’s very encouraging. There have been around about five people, five delegates who can no longer come to the occlusion 2020 event, because of various reasons. And so if you’d like to come instead of these five people, then you just need to go to occlusion2020.com and sign up on the waiting list. And I’ll be in touch when the next phase of tickets are out. You guys can listen to Episode 15 again with Dr. Michael Melkers, and about how much he has inspired me and helped me in my understanding of occlusion. So if you think that you want to learn more about how to break down simple cases, all the way to more complex multi unit and even full mouth cases, then Dr. Michael Melkers was a huge, huge inspiration to me. So do check out occlusion2020.com for that. And lastly, I have to make an apology to you all that I kind of copped up while making this podcast episode. And I didn’t have a video of this episode, but don’t worry, the whole thing is on audio and you can be listening to it on the podcast. I’ve also made like a video soundwave file with the audio in the background. But unfortunately, this isn’t one of my video podcasts could be an audio only. So back to the roots. And of course Protrusive Dental Pearl I have for you is about an internal bleaching case that I shared on my Instagram and on my Facebook page. The Facebook page is Protrusive Dental podcast Facebook page, and the Instagram is my name @jazzygulati, check it out. It’s a super internal bleaching case, if I may say so myself, because I look at this case. And I think, Wow, I’ve made such a huge difference to someone’s life. This is a mid 20s guy. He studies at Princeton uni in USA, and he’s back in the UK for a short while. And since the age of 12, he’s had this black upper right one, and the rest of his teeth were pretty much yellow. And the difference you see now going to an A1, B1 shade all over like all the teeth, including the the black tooth is just amazing. I mean, this is single tooth dentistry at its finest. And I’m really proud of the result and I was really, really happy. And so was he. So this is the kind of case that you can, you know, make a real difference. So I shared a little bit about how I manage that. But the Protrusive Dental pearl I have for you today is a tool I used to deliver the peroxide gel in to the access cavity. So it’s a two-part pearl one is that whenever you’re doing an internal whitening case of a central incisor, or lateral incisor, make sure that you refine the access cavity to include the puplu horns you’d be surprised how many times I’ve had to open up and extend into the pulp horns and find a necrotic tooth tissue. So you need to get that otherwise discoloration persists. So that’s one tip and the other one is to deliver the peroxide gel into the tooth, an endodontist they use this like little gun that you can put like a little tip that you can put inside a composite gun, and is a very fine long tip that you can insert peroxide gel into and deliver it all the way inside to the deepest part of your access cavity where you want the peroxide gel to go. I found this so so easy to deliver the peroxide gel inside. Way easier than using the whitening gels. So I made a video of using this little tip is one that endodontist typically used for MTA plugs. So I’m sorry Cesar, if you listen to this, I use one of your tips. He’s my endodontist. So I shared the video based on the Protrusive Dental community Facebook group, check it out. And let me know what you think. So I’m not gonna blab on any longer. We’ve got Dr. Gurs Sehmi in case acceptance in smile design. I’ll catch you on the outro. Enjoy. Main Interview: [Jaz] Gurs, Welcome to the Protrusive Dental podcast. [Gurs] Nice to meet you. Thank you for inviting me. [Jaz] It’s finally good to have you on – I remember meeting you a few years ago at a charity event. It was a BSDO charity event. And even before then I knew about your online presence. But even since then, I have seen some really amazing video content that you’ve produced and you’re a very good educator in the video content and recently, you came to mind when people were asking me, ‘Jaz, do you know any resources or where I can learn digital dental photography, and your teachable course came to mind straight away and I shared that. And that’s why I reached out to you – some amazing content that you produce. [Gurs] Cool. Thank you. I’m glad you like it. [Jaz] Tell the listeners a little bit and people now who are watching on YouTube, tell them a little bit about yourself, where you practice what kind of work you do. [Gurs] Sure, okay, so we’re a little bit of a specialist. I work with Rahul Doshi who a lot of people will probably know he owns The Perfect Smile – I’ve been working there for the last 10 years or so. Recently, in the last three to six months, I’ve started just doing a little bit and just opened up a little bit closer to home. And when we do the more complex cosmetic kinda treatments that’s really how we are, we’re pretty focused on completely, but people who are looking for a really robust, comprehensive solution. Those are the kind of people who we kind of attract and, and those are the guys who we normally treat as well. So typically larger cases as well. [Jaz] Well, what comes to mind and the reason I, the ‘mission’ I’ve given you today is the case acceptance because you could have all the knowledge up here, and you can have all the great hand skills, but until you can get the patient to be on board with the plan and have the same sort of expectation, same sort of vision, you’re not going to get happy patient and you’re not going to get to do the dentistry that you want to do. So the first thing I’m gonna ask you straight away off the bat is describe a little bit about what you’ve created now in our last 10 years working there. You’ve set something up now so congratulations with that. But what is your ideal patient journey and how does that feed into ultimately getting to the type of Dentistry that you want to do. [Gurs] Yeah, sure. Okay, so that’s like a super complicated question right? With so many different aspects. So let’s, let’s kind of take it and break it down. You did you mentioned getting the patient on board – this is 90% of the full proccess of what we do is giving the ownership of the treatment plan to the patient. Now, in addition to your, you’re absolutely right that most dentists, right, there’s not a lack of knowledge or lack of courses out there, right? Everyone, well, if you start going on courses on occlusion courses, you know what CR is you know what CO is, you know how to prep a veneer, a crown / onlay – you know all this stuff: Ortho, you know, implants…. all this knowledge is out there – Dentists HAVE the knowledge, but it’s getting the patients to say ‘Yes’ to a comprehensive treatment plan, which typically where we work can range from anywhere from, you know, £10,000 to £30,000. And you need to also have the confidence in your own skills that you know how to do this, because when you go to all these courses, all you get is theoretical knowledge, really. I mean, a lot of you guys probably know, Prem Sehmi and sometimes I speak to him and I’m like, dude, you know, you run all these courses like veneer, prep courses and everything and people get to try out a veneer prep. But the models you guys try out on there all that best case scenario, these guys, the models don’t need veneers. They’ve already got a perfect smile. So you’re learning to do preps on perfect teeth. You know, things like this. It’s not real life is when you start taking that theoretical knowledge, putting it into real life. And honestly, you make mistakes as well, and learning from the mistakes and it’s only through physical practice. Do you actually get better and better you know, so I mean, the whole process, it starts from the marketing, your online presence. Okay? So you have to, you have to have the guts to be polarizing online. So what I mean by that is, you have to be honest with your own voice, right? And say, look, I’m really good at treating this kind of situation. Okay, so whether it’s like, I know All-On-4 or something, let’s say you just pick one. And then you’ll become like, a million times more attractive to that kind of customer who’s thinking about All-On-4 because you’re the person to see for that treatment, you know, so there’s a whole bunch of people doing this here, align beach and bond. I’ve got no interest in that. So you’ll never see me talking about that kind of stuff, which is fine because the all-on-four guys don’t want to know about align bleaching bond. So, number one is position yourself in the market to attract the kind of patient who you want to attract. Then when that patient comes in, there’s like a two hour process two to three hour process that we go through. from, you know, it starts with information gathering, you know, find out what the patient wants, find out emotional triggers, present the treatment planning session, we carry out the whole consultation in certain way, and, and then ultimately get a case acceptance. Okay, so it’s very different… [Jaz] I am just going interject for a moment. So you talked about having that correct online presence to essentially target the right type of patient for the right type of care that you want to deliver. And I think you really beautifully described that and to position yourself in practice, but something that I think you said, which I think will help a lot of young dentists is along the way, along the journey, you WILL make few mistakes here and there, and how can you pick yourself up so let’s see a couple of years qualified and you try t o be a little bit more ambitious with your treatment because that’s where growth happens if you stagnate and you don’t challenge yourself you’re not going to grow right? And that’s a couple of mistakes and hoping nothing too big. What advice would you give to that dentist before we then pick up the conversation so what actual advice would you give that dentist because you know that was you some many years ago, that’s someone else now. What advice can you give us? [Gurs] Okay, so first of all, get some kind of mentor – someone who is better than you at the stuff that you want to do. This doesn’t necessarily need to be paid mentoring, but when I was young, we spent 1000 pounds a month on mentoring right, getting my head straight, and you know, saying we did it for a year. So that’s what’s that £12,000 plus VAT that EDUCATION that came with that mentoring has paid for itself like so many times. So having someone to talk to about cases is going to minimize your mistakes, okay, because each case is different every time you pass a case on to a mentor, they’re going to see things which you’re not able to see straight away. Okay? So it’s all about minimizing your mistakes, and then be completely upfront and honest with the patient. If it’s the first smile design you’ve ever done. Say, Hey, look, you know what? This…I’ve been to like a million courses. I know exactly how to do this. But I want to be completely upfront, okay? This is what’s complicated in your case, which I haven’t done before. But this is how we’re going to minimize that. And any risks of anything because you want to, you want to, you don’t want to scare the patient off by your inexperience, but you do want to level with them and say, Look, this is all the bad stuff that can happen. And this is how we’re going to minimize all of that happening. [Jaz] I think that’s a really good point. I think sometimes dentists are afraid to tell the patient that this might be the first time you’re doing a procedure but it’s all about the correct setup. The correct way in which you communicate that. So I think you said that really well, like, Look, I’ve done the courses, and here are the mistakes that can happen, here’s how we’re going to mitigate them. But by the way, this is the first time but don’t worry, I’m really looking forward to doing this. And I’ve got a whole plan and structure for you to give that patient the confidence and to be fair if that patient is not on board…then that’s not the kind of patient you won’t be treating for your first case anyway. [Gurs] Yeah, because they’re going to give you more problems later down the line. What you’ll find is most patients are so nice. They’re so genuine understanding. Most Dentists have already built up a lot of rapport with their patients as well. So when they’re in the mindset now that they want to do something a bit more comprehensive, there’s a level of trust that’s already there. And you say you’re in general practice and one of your patients has got all this tooth wear and now they’re ready to do something. You need to change that trust from being your general dentist to being someone who’s really good at this complicated situation and for wear cases, for example, and I know that like, okay, a real life example last year or maybe the year before this guy came in, and he had this wear pattern to it, I didn’t know what was causing it, right? But when it comes to like, occlusion and everything, I know that if I generally open the bite up and you’re in CR, then things would generally be okay. But I’ll just straight up honest with it. I was I look, we’ve treated like so many weird cases, but yours is slightly different. These sets of teeth which have worn and certain teeth, which are like, perfectly new, you know, so I’m not 100% sure how this has happened. But what we’re going to do is build everything up in temporaries first, make sure that everything is right in the temporaries because we can change whatever we want. We can change the aesthetics, change the bite, we can change anything we need to and only once we’ve got it right and temporaries are going to move forward. Okay. So the risk with wear cases is that you restrict envelopes of motion, you don’t make the bite harmonious with a patient’s jaw. And then you get fractures, right? And when patients are paying 1200 a unit, then that’s an expensive problem. And they’re paying a lot for the security that, you know, problems shouldn’t happen. So, yeah, in that case, I was like, Dude, look, look at your wear, this is not something we see every day. But this is how we’re going to do it. We’re going to address all of this, make sure it is correct on temporaries, that gives them the confidence to say, you know what, yeah, we can move forward with this. [Jaz] And then that’s the ultimate consent process as well. So thanks for going on that little detail with me because I think people who would have listening would have picked up on that. And you mentioned it, I think that’s gonna really help people. So we’re now back to the TWO HOUR process. So you’ve now done your correct marketing for the right type of patient for the treatment that you are known for. So the example you gave was all on four So the patient now turns up, what is this two hour process? [Gurs] Okay, so first of all, first of all, there’s an hour before the two hour process, okay, so the patients would inquire via the website, they would come in for a free consultation, typically free consultation with with the treatment coordinator who is a team member who knows a lot about the processes and the ethics of the practice. So, patient comes in talks to treatment coordinator and gets an idea on cost. Okay, on my website and my sort of videos that I do online, I try and just be open and upfront about the costs. Yeah, there’s no point in hiding that. But earlier, a patient knows about the cost, the easier the sale is going to be. Okay? Because you don’t want you don’t want to get to the point where you’ve invested so much time in building a relationship. And then you say that’s going to cost this much and the patient’s like Whoa, I wasn’t expecting that. [Jaz] So because if the if the number that you…. if the sort of fee of the treatment that your practice has, and the patient’s expectations are not at the correct match, then that can be one reason that you won’t be getting to do that dentistry because the patient genuinely either could not afford it or does not value it at that level. So it’s good point, actually, and something that I try and do as well, even on any sort of Instagram inquiries that I get. I know, some people are like, oh, when you come to the clinic, we’ll have an open discussion and always difficult to give a price because everyone’s different. Whereas I’m like, Look typically £3-4,000 for a course of Invisalign, whitening, whatever. So I’m very open. Is that Do you think that’s a better way? In your opinion? [Gurs] Yeah, I mean, there’s so many people who are just shopping around and that’s cool. You know, if you want to shop around, that’s absolutely fine. But there’s plenty of people who kind of know how much it is. Okay, so if someone’s looking, I had an inquiry on Instagram the other day and the lady was like, Yeah, I’ve seen like veneers cost roughly this, this kind of figure. And I think, and I just said, Look, if you want veneers, it depends on how many to roughly £1,000 a tooth. How many do you want to do? You know, you don’t say how many do you want to do, but that’s essentially what you’re saying. So the patient effectively chooses how much budget is, you know, by how many teeth that they want to do. [Jaz] So that’s something that the TCO will explain? [Gurs] Yeah, I think legally, you’re supposed to have your prices on your website as well. But the thing is, it’s very difficult for a patient especially the kind of patients that I see where they’ve got multiple issues, maybe they need root canals, maybe they need perio treatment, you know, all this stuff they can’t do until you’ve seen them, you can’t diagnose them, right. If you’re selling them a product like Invisalign, or all-on-4 or, you know, something like that. Then it’s very easy. They’re almost like picking off the shelf, hey, I would like this. But when you’re trying to sell a comprehensive solution to that, you know, we know your math is terrible. Thank you for trusting us with that, I don’t know how much it’s going to cost by it’s going to be roughly between here and here. You can see he can give a range just to make sure you know, they know roughly what they’re in for. And then once they have the assessments, you know, we’ll talk about the assessment how we do that, but they then understand their problem and then they’re building up trust and then you know, there’s it’s much easier for them to say yes, if they know the price, because the price is it is a stumbling point. It’s not the only one, but it can be significant for a lot of people. [Jaz] So in the one hour with the TC, they’re discussing prices, discussing different types of treatments – essentially in a few sentences, what’s the aim of the TC? [Gurs] to see if we’re the appropriate practice for the patient and To get the patient to pay 200 pounds for a clinical consultation, [Jaz] Brilliant, okay, so then now the all on four patient comes in, they’ve had a lovely discussion with your treatment coordinator, who I imagine will also show examples of other cases that you’ve treated. Just answer any queries because you would have trained your treatment coordinator to a high standard they can they know, they can just, you know, off the shoulders give all the answers because they’ve done it so many times before. And then they’re like, you know what, I think I’m interested in this. I like to go ahead with the consultation, and then they pay the 200 pounds and then they will come back to you on another day. [Gurs] Yeah, definitely. [Jaz] So is this the best time to now talk about that appointment? [Gurs] Yeah, what’s next one? The actual clinical consultation? Yep. Yeah. So what you mentioned about the TCO, absolutely right. They need to have all of the information right loads of before and after photos. If they’re talking about implants, they need to know the difference between immediate delay advantages, disadvantages, all the kind of nitty gritty, nitty gritty because they have to build up a lot of value, especially, you know, we charge 200 pounds for the consult. That’s a lot compared to a lot of other practices. So, again, they need to be able to build up enough value to sell the 200 pound assessment. So once they’ve done that, the patient comes in. [Jaz] And just a quick question for you – is your TC taking photos for you? [Gurs] No, this happens at this appointment. [Jaz] Okay, so you don’t have any photos to go by? [Gurs] No, it’s a bit hit and miss. It’s very difficult bringing the photo element into the TCO. Because especially if there’s limited number of cameras in the practice, I think the practice has maybe two cameras. To the clinicians, me Sam, we have our own cameras. So it’s just a logistical thing. You know, if the photos are taken at that TCO appointment, because remember, some of the people who come in from TCOs won’t go ahead with a full assessment, they realize that maybe we’re not the right people. They may, you know, for whatever reason, so dedicating a camera to them is a little bit tricky. Sure. So when they come in for a clinical consultation, that’s when the photos happen. So, the first half an hour of the clinical consultation, I’m either seeing someone in a different room for just a small appointment to review something like that. Or this is really important. I’ll be chilling out upstairs with a coffee, okay? Because getting your mindset in a calm and positive way, like before that new patient consultation is really important. Right? The vibes you give off in those first three seconds that’s make or break really. So while I’m chilling out my nurse or someone is taking photos, and quite often, especially if we’re looking for implants or a comprehensive treatment plan, which we know from TCO Cons, we’ll have an OPG taken as well. Okay all of these things are printed out two copies of each photo and, and a Sharpie pen. Okay that Sharpies pen is the practice’s best sales tool. Okay a little two pound pen or whatever it is you can do it with you know iPad pros or touchscreens and stuff like that a little bit flash but to be honest, I like the rawness of a pen and paper. So if you want to interrupt me at any point, do it okay, because I will just talk about this process. [Jaz] No, I like. So it’s back to the roots, you know, pen and paper, the feeling and the patients that are in front of you. I like where this is going. [Gurs] Yeah, absolutely. So know what the patient’s in for I’ve got the TCO notes. I know a little bit of history then the Nurse will bring me up the photos before I see the patient. So I’ve got a bit of an idea on what going on. [Jaz] How many minutes allows between the nurse? How long does it take your nurse? nurses to do all that? You know the OPG, the photos or chitchat? [Gurs] About half an hour [Jaz] 30 minutes on average. [Gurs] Yeah, cool. So then they’ll call me down. And let’s say the patient’s name is John. Get your mindset in the right way before you go into the room. Okay, head up, positive tone of voice going. Hi, John, how are you doing? My name is Gurs, I’m going to help you today. Okay, that’s it, shake their hand. And that’s really important because you need to portray confidence. You’re, this is like a show. Okay, this is the theatre production. You’re the star role here. So you’ve got to make a little bit of an entrance. And then I come the way our surgery setup after walk around the patient and sit down him on my side, and even the angle at which my chair is at the beginning of the consultation and the end of the consultation is stuff that I’ve already thought about. Okay, so I’ll sit down the patient and I’ll be like, hey, John. Thanks for coming in today. I’ve read all your notes he came to see now me the other day and, you know, I’ve got a whole bunch of photos as well and x rays. I kind of know why you’re here. But is it okay? If you just tell me your whole story in your own words? Okay. And, and then you listen, right? That is my standard line and my standard entrance for every single consultation, right that it doesn’t matter what they’re in for. I just want to hear their story now. But you want to also acknowledge that they’ve told their story before. And the last thing you want to do is annoy them. You’ve probably called a bank or something and you get passed from person to person to person, and each time they don’t know what the first person’s in the message hasn’t been passed on. That’s super frustrating, right? So we have to acknowledge that they have told a story, but you want to hear it again. Okay, so this bit takes up almost 15 to 20 minutes of them telling me the story again. Wow, it’s really important. The way that we listen as well. It’s we use processes called active listening. So I don’t know if you’ve covered this in other podcasts as well. [Jaz] We haven’t No, please tell us about active listening. I mean, I feel as though I’ve done a bit of this but sometimes people who may be listening between passive and active what the difference is, please, please tell my listeners. [Gurs] So you want to keep the conversation going, but you want the patient to to know that you’re listening. And you want the patient to also know that you care, right? And the way you do this when the patient is telling you a story, you don’t you don’t interrupt them. Okay, but you do. Make kind of noises like ‘Um, Yeah. Oh, yeah, totally agree’. You know, just stuff like that to keep the conversation flowing. It also shows the patient that you are listening. The key points in the conversation is always going to be a couple. You just repeat back to them what they just said. Okay, so let’s say Oh, yeah, John. Yeah, that’s, that’s terrible. So when he was six years old, this Dentist had his knee on your chest? [Jaz] So you just like every patient, Gurs, that’s like every single patient! [Gurs] Yeah, yeah, absolutely. So, you know, you got empathize with him, and he can’t he definitely don’t tell them that they’re wrong. Okay? The patient must never. Okay, it’s not that the patient is always right. But they must always be, they must always feel like they’re right. Okay, so we empathize with them. And we say, hey, look, you know, this is terrible, and a lot of them have had a terrible story and a bad experience leads to a lifetime of neglect, which leads them to our practice, right? That’s, that’s the typical process, then the patient will get to the end of their story eventually. Okay? And then we need a way to turn the conversation around. So I then have a couple of questions which I can ask them to basically switch it around. So I can be… instead of a listening role, take it into an educational role. Okay, I bet you will know those questions. [Jaz] Can I guess what it is? I want to guess that, like where this is going, but is it asking permission for the patient to then go to the next stage and therefore they feel in control? Because I think that’s a really important thing for patients to feel like that even like when I’m giving oral hygiene advice, like, Can I have your permission to just give you some feedback on how you’re brushing like even little things? I like saying it that way is anything to do with that. [Gurs] Yeah, so that’s, that is part of it. So it depends what the patient is in for. Okay, so if a patient is in for like a full mouth rehab, they’re really embarrassed about this smile and it’s more of a functional issue rather than an anesthetic issue, then you want to pick up the emotional trigger points during the information gathering when they’re talking. So, let’s say the thing was, look, I’ve lost so many back teeth that I can’t eat properly with this crappy old denture that I’ve got, and I can’t even go out for dinner. Okay, so then, you know, that’s their emotional trigger point. That’s the end goal, their angle isn’t a perfect set of teeth to look amazing in the mirror. They just want to be able to go out, okay, this is the results of the treatments that you can provide. So, what you can do is, okay, look, John, so I think I know a couple of ways in which we’ve helped a whole bunch of people in a similar situation. like yourself, to be able to have a good solid set of teeth, so they can go out to eat wherever they want. Okay, do you mind if I just show you a couple of these now? So that’s the ‘Do you mind?’ bit, that’s the getting the permission. But sort of prepping up to that question is, hey, look, we’ve seen your situation before. I know a couple of ways to fix it. Do you mind if I just show you those now? They always say yes. Right? And then I call this a control question because it switches the control of the conversation to the clinician, and this is the moment to shine so you’re not selling at all. It’s really look, you’ve got option one, option two, option three, whatever, you know, these are the different pros and cons of all of these. And this is the rough, you know, the kind of price points in which we don’t overcomplicate things as well. You know, when it comes to full arch implant cases, there’s probably about 20 different ways that you can restore it different materials different sort of immediate / delayed, all this kind of stuff. Just keep it really simple. If we’re looking for full arch implants, for example, then I’d say look, we can have something which is removable. Ultimately, what clicks into to dentures, it’s really fixing implants. It’s super solid, and it will let you have the end goal of what you wanted. But some people don’t like the fact it’s, it’s removable. So we got a fixed one, I can see again, you’re saying, Do you want something fixed or semi fixed? You know, what would be better for you. And then you can go into more detail on the fixed solutions or the semi fixed solutions. So I kind of think of it in my head like a tree. At the top of the tree. You’ve got like 20 different solutions, but each one’s got us branch. So you’re asking just them to decide on little stuff and eventually You make your way to the ideal trial treatment solution that they’re looking for. [Jaz] That’s a good point. I think one one thing that people, dentists and this is not just young dentists, Gurs, this is all dentists, at some point struggle with in communicating is that the whole satisfying the GDC about has every single option being explained. But my argument for that is, if a patient has come to you, for example, and they’re missing an upper premolar, for example, and they want to have that replaced and they’re presenting complaint is, you know, I really when I smile on the side, I get really embarrassed, I really want this tooth replaced, okay? Yet what you find in every single treatment plan is do nothing – A. Do nothing. That is a completely inappropriate plan that yes, they should know that. Yeah, you know, technically you can have nothing but that’s not why they’re here today, in the same vein, because that’s a very simple example. What you’re describing usually is very complex dentistry. But there are some things which based on the story they’ve given you, you know, that they’re not going to a denture will not be appropriate for this person because they want a more fixed solution, so automatically whittles away these choices, so you don’t have to explain the 732 combinations. You listen to the patient, you find out what they want. And you describe the things that are most appropriate for that patient. And then in terms of goals, and what’s biologically possible, I suppose, I think I just want to say that point because I think people get hung up on explaining every single damn option. [Gurs] Yeah, absolutely. So you don’t need to explain it in a lot of detail. So I do always mention it. I’ll be like, Okay, number one, you could have a denture I know you’re gonna say no, but you can have it. Right. You move on again. You move on. It brings a saying something like that also brings a bit of humor and lightheartedness to the whole consultation. This… you got to try so hard to make this consultation as comfortable to the patient. Essentially, when in communication… is depending on what kind of book you’re reading, you can split the brain up into two main bits, the emotional brain and the logical brain, okay, we have to please the emotional brain first, in order to even talk to the logical brain, which is going to make the end decision. So making them feel good, getting them a cup of tea, getting them the room at the right temperature. You know, the team members asking how their day was, you know, ‘was it okay getting there?’, all this kind of stuff, making them feel at home. Really important in getting that ultimate case acceptance. If then if the patient doesn’t like you as a clinician, say you’re you’re scruffy, you walk into the room, your shirts half half tucked out, right? And you smell a fag or something like that, you know, they might, you might be working in the best practice in the world. You might have the best team in the world, but you’re not the right person for them. They’re going to choose that so they’re going to go somewhere else. Everything from the practice to the team, to the treatment plan that you present. All has to work for that patient, right so you can’t overemphasize on the treatment plan thinking, you know what, this is the best option for you. Everything matters, right? We’re looking at case acceptance, we’re not looking at what dentists are generally looking at, which is just the treatment plan. Right? We would really treat the patient as a human. So yeah, kind of meandered off a little bit on that. [Jaz] No, this is all very very good information. So you asked the sort of control question about you know, where they want something fixed or semi fixed and then you down that decision tree and then I started talking about the fact that you know, not you don’t you know, you have to be careful in how you explain things because there’s a million ways to do it has to be appropriate for the patient. So the let’s say the patient and said okay, and the taking down the road that this is a treatment they want How does it continue from there? [Gurs] Okay, before I go into that one, let me just show you the other control question which is for aesthetics cause similar pattern, but the guys in for aesthetics, they emotional trigger point. is a slightly different, and you need to switch the conversation to show that you know everything about smile design, okay? Because if you’re talking about (just) smile design they’re going to be like, ‘What is this guy talking about? This is not appropriate.’ So the way I do that we listen to the patient and we’ve done our active listening, so it’s, hey, look, John. So I know that we can make your smile look amazing. Okay, that’s the first thing just build up the confidence. And hopefully the patient said, I want my smile to be amazing. So you pick that emotional hot trigger, and you say, they’re just like all the photos you see in the waiting room, you know, every single smile. We’ve done every single one of those. And there’s a certain process that we go through when we’re starting to design a smile. Do you want me to show you a couple of these things now? Okay, so again, we’re, it’s on the emotional trigger point, say that you can satisfy that Emotional trigger points and can I show you how we do this okay and sometimes I share this on my Instagram is those pictures where you know you’ve got a small photo and you’ve drawn over the that small photo with a perfect smile and even that is so rehearsed that there’s certain principles of smile design I mean I didn’t go over was 20 3040 principles, there’s no point in going over all of them but you want to do the most appropriate ones and suddenly end up with this nice smile on this photo. And the patient is thinking I could have that and I want him to do it because he kind of knows what makes a perfect smile. [Jaz] So this is your sharpie pen on their just maximum smile photo..on the ‘E’ photo? or is it on the lip at rest? [Gurs] We just have a smile and smile retracted. Okay, so just smile and smile retracted. Those are the two key photos for this stage. And if the patient goes ahead with treatment, I’ll normally just take a full series. But we checked things like the E, lips at rest and all of those kind of stuff. FMV sounds all of that during the clinical part of this assessment. Okay. By the way, that clinical part of this assessment is a maximum of 10 minutes. Yeah. So, whereas most Dentists, that that is the bulk, that’s the least important bit of this assessment. [Jaz] Very interesting. So where’s it going? I’m very intrigued in terms of the sort of process because it’s all about the right process. And the theme so far I’m hearing is that, yes, it matters what you say, but not as much as how you make them feel because a patient will never forget how they felt when they’re with you. So that’s a message that I’m hearing from you about how the patient generally feels about the environment they’re in also what you’re making them feel about potential treatment. [Gurs] Yeah, so when you’re talking about treatments you want to be energetic and enthusiastic about it because this is a Big deal for the patient, right? You can’t be like, yeah, we could do something is gonna be like logic or that look, if you’re excited for the patient, and you can see that transformation in your head before it’s even happened. And you really want the patient to go ahead because it’s gonna completely change their life, you know, let that emotion be seen to the patient. Again, it helps them. But to be honest, that bit comes a little bit with confidence when you’ve done a couple of cases and you can truly see what can be done. Then, then it becomes easier and easier, the more you do, the easier it becomes right? [Jaz] That’s right. And, yeah, the more experience you get, the more people’s lives you influence, the more confidence you get to influence other people’s lives in that way. [Gurs] So then, I mean, the next stage is we’ve taken control, we’ve done a bit of education. We also want the patient to be clear on costs at this stage. So it’s a veneer case, I’ll ask when he came in to see the treatment coordinator did they go over the kind of costs for this kind of stuff? And typically they’ll be like, yeah, they did. So I’ll just reiterate, I’ll be like, Okay, look, if we’re looking at veneers, it’s just over 1000 pounds each. So if you have four veneers, it’s gonna be between four and 6000. We have eight veneers somewhere between eight and 11,000, something like that. So they’ve got a rough idea in their head, how much this plan is going to cost them. Okay? With implants, it’s slightly trickier because although an implant is say £3,000, if it’s as a single front teeth, you can then have to build in value of the sometimes there’s a root there so we have to take the root out and then we got to use guided surgery to place the implant got to make a good temporary, we then have to come back and the type of implant we use. All of this stuff, you know, typically adds up somewhere between around £4,000 between four, four and a half thousand something like that, which is a big difference to £3,000, right? So now we have to also build in value for the kind of treatments which we do. So at this stage, I’m probably about 45 minutes into the whole consultations, we start talking about costs here. And let’s say…let’s say we’re talking about guided surgery, I will literally take five to seven minutes explaining to the patient what guided surgery is right and why it’s such a cool thing. How we take digital x rays of a three dimensional X ray scan, plus the oral scan, we merge them together, we plan the implant treatment on a computer. And we have this really cool guide made 3d printed which will help us precision get this implant in exactly the right place. [Jaz] So are you showing them a visual? [Gurs] We almost always – yeah, we’ve almost always we’ve got a guide, right? Some patient’s guide is in the background. And you can – it would be good to have visuals of this stuff readily available. Most patients have seen an X ray. So seeing a 3d X ray doesn’t really change stuff is for them to see the difference between 2d and 3d is and isn’t a big thing. Even the scans, they’ve had impressions, so I think I don’t actually use visuals. And I think maybe the case acceptance might be higher if I did, but it’s not bad. Not using the visuals. And I think I get away with a lot of it because of the energy and the confidence. So it’s [Jaz] About you. It’s about you. [Gurs] Yeah, yeah. So again, you don’t have to differentiate yourself from every other dentist out there. So assume the patient’s been to like five of the consultations, right? And typically they have and we’re not the cheapest. So why do they pick us rather than all the other people? Well, one, we’ve spent a lot more time with them. So we’ve got more of rapport with the patient. But also, because we explain everything in a lot of detail. If we’re doing a smile design, again, we’ll explain that we do everything in temporaries, we will get this picture which we’ve drawn on this piece of paper in your mouth. And we don’t know if that’s going to be your perfect smile. You have to go home and test it out. you test it out, you come back, you tell me what you like, what you don’t like, we refine it until you’re happy. Then we make the porcelain, okay, so again, what that’s doing is that’s eliminating risk. Okay. So there’s always an element of risk in a treatment plan, right? Things could always go wrong, but what are you doing to eliminate risk? Okay, so again, it’s showing that you care showing that your practice has procedures to, to minimize risk and acknowledging that these risks are there. [Jaz] I love that. I love that. You’re, you know, what we’re all doing is I’m hoping we’re all explaining the risks, but I love the fact that you go one step above that and say, This is a risk for example, I mean, let me give an example you know, not so cosmetic dentistry related, but real world dentistry, you’re removing an upper molar and I always warn my patient that look it’s close to something called a sinus and sometimes there’s a link between the mouth and the nose, but then just that one extra sentence: ‘but don’t worry, the gentle way that we’re going to do the cutting of the teeth, the roots will mean that it’s going to be as gentle as possible and then we can stitch it off if needs be, and we’ll give you all the care you need. Just that reassurance for example, can can make a world of difference. I really like that. [Gurs] Also, especially for like implant stuff – I will always, once the clinical consultation or this chapter is coming to a close, I’ll be like, Okay, look, I’ve told you all the really cool things that can happen here. Do you want me to try and talk you out of this right now? Okay. So again, just lightening the whole thing up. But it’s at that point I do honestly say, I’m going to try and talk you out of this right here are all the bad things that can happen. Okay. And within implants, we’ve got a policy that once we agree on a plan, we’re going to cost, no matter what complication happens, we’re going to sort that out free of charge. Okay. So I do say you know, it most of the time is plain sailing, but implants might not stick, we might get infections stuff may happen, right? It’s not going to cost you anything else, but it is going to increase our treatment time. It’s going to be a pain in the ass as well. But you know, there’s definitely no cost. So again, it’s reducing risk, okay. Nobody wants to be you know, you’re getting a House extension and they’ve quoted you £20,000 but coming in at £40K. You know, once you’ve started the work your backs against the wall, you’ve literally got no choice. So you don’t want that patient to ever feel that they’re in that kind of situation. [Jaz] Very good. So then you’ve explained all that and the patient seems to be on board, are you sending the patient away with like, a 20 page letter? What happens next? What’s the final part before you actually and then what happens between now and then actually, them coming in to get their implants placed or their hygiene started to get, you know, biologically ready to have the treatment? [Gurs] So at this stage, I haven’t even looked in the patient’s mouth. [Jaz] Wow. Okay. [Gurs] So we’re having all of this conversation from photos and x rays. Okay, so, once have pretty much got the plan, which I think the patient’s going ahead with. I’ll be like, Look, this all sounds good on pen and paper, but it’s okay if I just have a quick look in your mouth and see if this is possible. Okay, and then patient is tilted back a little bit, we start having a look in the patient’s mouth, we start extra orally, the nurse will name out each and every muscle that we’re palpating we check for tenderness, the jaw will palpate the jaw, the nurse will say out loud, is there any clicking? Is there any popping? Is there. Any crepitus or any of these things? Right. So, during this whole consultation, there’s a massive checklist of about seven pages. And the nurse is reading everything out and I’m responding. Yeah, yes, no, whatever is appropriate. And that’s again, building value. Right? The when the patient gets up from this, the patient’s always like, I’ve never had a consultation that thorough. They probably have but there hasn’t been the show elements involved, right? We say it out loud because the patient is always listening to everything. [Jaz] That’s amazing. I was just going to say that I really like that and someone, a previous guest on his podcast, Zack Kara, who by time this one comes out, would have been on one more time as well he calls this ‘show your working out’. You know, like in maths, so you do a complex equation and you get one mark for the answer, we get three extra marks actually showing you’re working out, you’re showing you’re working out with a patient and that’s, that’s got great, like you said, quite a building value that you are thorough, but like, everyone’s done it everyone always checks for mouth cancer. When we do our soft tissue exam. I actually say to my patients Okay, now I’m looking for signs of mouth cancer. Okay, everything’s good. And then they’re not Oh, wow, they’ve they’ve checked them out cancer was everyone’s done it. But you know, if you don’t tell them you’re doing it, you’re not building and so that’s, that’s really cool. [Gurs] Yeah, so we go through the whole whole process that you know, it takes us about 10 minutes, but then we’ve got a cosmetic analysis at the end as well, which I use for those patients who have cosmetic emotional trigger points actually being in that, you know, it’s heavily a cosmetic improvement that they’re looking for rather than functional. So that’s when, you know, verbally will say, Oh, do the teeth fall in the smile line is the midline, coincidental with the middle of the face, you know, all these things. This is where the F, v noises and all of this stuff comes in. And we’re also communicating with the patient because it’s like, one of the questions how many teeth are on show? Okay, so I’ll be like, okay, John, just smile for me. Okay, I’ll take the smile photo, I’ll be like, okay, so when you smile, this is the number of teeth that we can see. 123456 You know, so again, it’s, it’s very, it’s not so much a consultation where you’re just looking at stuff. It’s a conversation. It’s like I.. hate taking your car for an MOT especially I’ve got old cars, right and there’s always that stuff that needs to be fixed and it’s a horrible thing. To take a car for an mot and realize you got to spend £800 on something. But what my garage started doing and over the last couple of years is sending you a little video, right showing you that they’ll be like, hey, look, you know, check this, this rotor right there. So you can see that it’s really thin here. So it’s like, oh, yeah, there is a problem. How are we going to fix it? It changes the dynamic to the dentist saying, look, you need to fill in here. And the patient being and that’s 200 quid or being Okay, look, your tooth has some decay here. Right? We could do a filling here. Would you reckon? It’s a completely different dynamic one of those, the patient is being forced into having a feeling the other one is like, Hmm, okay. Yeah, if a feeling is the best solution, let’s go with that. [Jaz] Co-diagnosis comes to mind with that, doesn’t it? [Gurs] Yeah. So it’s, there is co diagnosis, but also you need to kind of guide it. So a typical situation a patient’s got a post crown, it’s been there for forever in a day never cause a problem. There’s a slight PA area on there as well. So you need to be able to explain to the patient that that tooth is weaker. Right? And typically what I do you see it on the X ray. It’s a whole load of white on a little bit of tooth. So I’ll draw the outline of the tooth. And I’ll say like, Okay, look, everything whites on this tooth is, is manmade. Okay, it’s not adding any strength. How much of your own tooth in percentage do you think you’ve got there? Right. So but getting them to say, oh, probably about 30%. I’ll be like, yeah, I’ll probably agree with you. Right? So this tooth is probably only got 30% of its original strength. Okay, so they already know that. It’s not the best tooth in the world. So if you’re doing a smile design, and you’re including this tooth, they know there’s a risk that you Do this smile design and 2,3,4, 5 years down the line, it could break and because they’ve been involved in the the assessment and they understand the health of each tooth that it’s not surprised when it breaks and quite often I’ll be like – Look, when it does break, it might be a three- four grand job to fix it. So again they know that it’s like when a suspension brakes on my car, I know it’s £1,000 job, because my garage has told me so if you [Jaz] You like your car and mot analogies don’t you? [Gurs] Mate.. if you have old cars! [Jaz] Fine. So you’ve done your clinical exam now, and I love the whole checklist process and you’re getting the patient involved. You’re not telling them they need fillings, you’re showing them they need the fillings. What happens next? [Gurs] Okay, so you’ve pretty much got the treatment plan from the beginning. And now if you’ve confirmed that that’s appropriate, so I’ll just be like, hey, look, so I need to give you these treatment plans. Okay? And if you give me 10 to 15 minutes, I can do it for you right now. And what I’m going to give you is this, this treatment plan. Okay, so we’ve probably spoken about seeing the hygiene a couple of times, and they know what the cost of that is. So that’s one treatment plan that I’m going to give you. Another treatment plan is and I’ll give them the options of the kind of stuff which they would interest showing more in. So if it was, say all-on-four fixed for the top, I’ve been like, Okay, look, I’m gonna give you one plan for all on four, I’m going to give you another plan where we use implants and locators. And, you know, and then you can decide what you want to do after that, you know, so give them a couple of options. For veneers, you can give them an option if you’re not sure where they set price wise how much they want to put into this, you can give them an option of that. Six veneers, eight veneers, 10, veneers, whatever. [Jaz] And that so they’re really different sheets of paper for six, eight and 10. Or? [Gurs] yeah, so veneers are slightly different it is three sheets of paper, but it’s usually the six veneer option. And then if you choose to add two more, this is how much it would cost. Yeah. Okay. And then if you so instead of giving them you know, an 8 – 10 – 12,000 £ piece of paper where they can add up that’s the ridiculous thing that they’re adding up your what you get is that eight 8000 plus the two and a bit thousand plus two and a bit thousand. So it’s like, if I upgrade from six to eight, this is how much it would cost extra. [Jaz] And by this plan this is not like a text heavy plan. This is like an estimate or is this actually a description? [Gurs] Yeah it is. Not. It’s um, he put everything on in your practice management. Software. However, however it works, and you can just print a plan. Okay, and so yeah, really all they want to know is the cost of the thing, right? And there is a, like a letter which goes out, which is got lots of different templates. So that goes out after the Yeah, that’s, that’s nothing. So if you’ve got those situations where you’ve got this post crown, and you don’t know how long it’s gonna last, those things need to be kind of documented a little bit differently. [Jaz] Fine said you’re gonna give them some time. So what it sounds like is they go away with this, these estimates, like have plans in their hand. And then you also are going to follow up with a more comprehensive written plan. Explain the risks that are relevant to that specific patient. Are they paying a deposit towards some time with you yet? Or are you giving them some time to sort of speak with their partner’s/ family? What was the final bit involved with they can finally come and see you – who discusses the financing with them? Is it the treatment coordinator again? Or how’s that work? [Gurs] Yeah, so the end of every consultation clinical consultation, this time booked into the TCO, diary. Okay, the treatment coordinator diary. And I’ll say to the patient at the end of the clinical bit, so you know, give me 10-15 minutes, we’ll have a coffee, and we’ll take it from there. So nurse takes the patient upstairs to where I was having my coffee at the beginning, and, and just make small chitchat. Now my nurse is so cool. She, she, she gets the feedback off the patient. And she can pretty much tell me if they’re going to go ahead or not right from just taking the patient off the stairs. And if they need to, like build up trust and all that the nurse and the patient can just chat for a little bit. So after about 10-15 minutes, we meet in the treatment coordinator room. And just before I tell you what goes on in there on you mentioned, do they need to go and speak to a significant Other to make the decision – at the initial treatment coordinator appointment. Quite often, we will ask if there’s anyone else who needs to be involved in the decision for going ahead with this treatment. So we’ll get the details of the decision maker, really. And we want that decision maker to be in on the clinical consultation. Okay, because if you go through all this effort, and they need to ask their partner before they can even go ahead, it’s a waste of time, all that value is just going to be all that patient is going to give the decision maker is the pieces of paper, right with the cost. So that’s, yeah, that’s not the value is not there. So you do want to make sure that the decision maker is there. And when you’re talking, you’re talking to the patient and the decision maker okay. Then we come together in the TCO room, okay? And you would think this would be high pressure thing, but this all the effort goes in right at the beginning. It’s like an inverse triangle, right? If you, if you imagine the information gathering at the top, that’s how much time information gathering takes. And you know, discussing treatment plans underneath that clinical consultation is a lot less This is effectively the closed part of the sale. This is literally five minutes of my time, if that’s right, and it’s so chilled out. So patient comes in. If the decision makers there, they come in as well. Treatment coordinators there and I’m there as well with all treatment plans. We’ll show them the treatment plans. I’ll be like, hey, John, look, to before we go in to this, did you have any questions while you’re upstairs? And typically the answer is no, I was just checking my emails. Okay. So that’s a good answer. Because if every single question has been answered in your clinical consultation. They’ve got nothing to think about, they’re thinking about something else, right? their visit to a dentist, which is normally a high stress situation for them. So we’ve taken them from typically if they’re stressed out about going to the dentist that we’ve taken them from a highly stressed, frame of mind, to a much calmer frame of mind. We’ve fed their emotional needs, we’re now communicating through logically because the sale – selling the dream is all emotional, but the close is all logical. So now we’ve got these treatment plans or facts and figures, you know, all printed out and I’ll be like, Okay, look, the first thing is see the hygienist for a couple of sessions. We spoke about it, this is what it costs. And then these are your options. This is what it costs. This is what it costs. Okay. So there is two parts. There’s the clinical closure, and then there’s a financial closure. The clinical closure happens typically in the surgery. Have I found the right treatment plan for you? Okay, And you’re going to gauge that from what the patient says? Or are these the kind of options that you’re looking for? Right? And the patient will say, yes, they may not be able to make a decision right there and then they may need to think about it. And once you’ve done the clinical pleasure is just the bad money then. Right? And then it’s like, Look, this is what this option cost us about that option costs. Does this all make sense? And they’re like, yes. When can I start? Okay. You surprised at the number of people who, who say, when can I start? Okay, if you go through this process, it’s long winded, right? But you’re selling much higher treatment plans right. Then when I was working in the NHS, I’d get excited when wegot a white filling, you know, but here we’re doing full mouth. You’re not selling a little product for a little tooth, we’re selling much more than a smile this is going to change someone’s life. [Jaz] How many years Have you been doing it this way for? [Gurs] Yeah, and you know what? There’s no shortcuts as well. [Jaz] Sorry, I got cut out, cut out there. Sorry. [Gurs] So about 10 years, okay. And there’s no, there’s no shortcuts. Okay, so we’ve tried eliminating one little section because if you imagine it’s very time consuming, and if you can reduce the treatment, the time investment here, you can do more treatment because this isn’t, this is not necessarily profit generating time. Right? You spending so much time with the patient, the only reason we take 200 pounds is to show that the patient is serious about this. Yeah. And it’s, it’s a loss leader, right? This is hardly covering the wages to keep the practice open. So we will try and take this out, but it just doesn’t run as smoothly you don’t get the case acceptance. So it’s actually a false economy, trying to rush these things. And remember all of our patients well. The vast majority are self referrals that people who’ve seen stuff online, they want, they want us to solve their problem. Okay? So it’s a slightly different dynamic if you’ve got a referral practice, because if your dentist says, hey, look, go and meet my mate, he’s really good at implants and you send them across, that guy can easily sell a 10-20 grand plan because all the sale has been done by the original referring dentist. Okay, all the trust is already there. And typically, they’ve talked a bit about money, so they know it’s a bit expensive. So we’re taking cold patients who’ve never seen us before. And at the end of this process, those guys are saying, Look, when can I begin? Yeah, then the treatment coordinator can go through the money side of stuff, all the finance options and literally everything like that. Typically they will booking for a hygiene session and just pay for that themselves. And this whole process. So if you notice, there’s no pushiness about it at all, you know, the patient has to opt in, the patient has to be like, yes, you’re the guys for me, this is the plan for me. I want you guys to do this. Here’s my money. You know, that’s, it’s weird, because years ago, you read sales books, you learn about closers, and you know, all this verbal ninja work that he can do. Right? But I found the more you close your patients in, the more you say. You do this by this time and you get discounts. They just cheapen you. Right. And you don’t want that. At the end of the day. We are just humans, the patient and me. We’re just humans, right? I just have a bit of a skill that I can fix teeth. The patient can probably do a million things that I can’t do. So, okay, it’s like how can we make this work? How can I fix your teeth and Yeah, we’re all happy. But at the very broad sense, that’s what’s going on here. [Jaz] That is, Gurs, that is absolutely fantastic. I really appreciate you giving you a time to really deconstruct the entire patient journey. And, you know, some people listening to this right now watching this right now, you know, they’re thinking, gosh, I don’t have a treatment coordinator. I don’t have that much time to allocate – my principal is going to kill me if I start doing it for this long. But I think if you take away the principles that you said, and eventually, you know it, you know, Rome wasn’t built in a day, it took you some years to get to this point. So everyone’s on a journey, take your time. And I think the best thing that you could do if you’re not quite set up to replicate the amazing journey that you’ve produced, is by back to the very, very, very, very first point is deciding who your ideal patient is, and making sure that they’re the ones coming in. I think if you focus some of it on that, then I think that Part of the inverse triangle, the broadest part is even broader and more appropriate. Would you say that’s a fair thing to say to someone who, who can’t quite have the setup that you have the moment? [Gurs] Yeah, absolutely. So here’s something really cool. Okay, we’re filming this right in the midst of this COVID lockdown, right? It’s like Easter bank holiday. And in this lockdown period, I’ve had, I think, six consultations with patients online and not been able to do any of this process. And on average, these treatment plans which these people online have been introduced to are between 10 and £15,000 Okay, so I think I am totally up is about 60,000 pounds and potential treatment, people who have never seen in my life, okay. contacted me via the website, or Instagram on social media, whatever, it doesn’t matter how they get in contact with me. And what I did was just took this information gathering bits okay just feeding the emotional side of the sale right and introducing them to cost and options and I just did that and verbally you know the patient’s already knew how much it was roughly going to cost and they’re all ready to come as soon as we’re able to go for this lockdown. So another way you could do this is – you want to position yourself properly right so what I mean by you know, market positioning What are you good at? What is that tiny little segment of the population? who are looking for this one specific problem? How can you serve them best understand their needs, communicate this through effective marketing and get inquiries. Okay, then, if you’re doing this a few a day, you know, maybe six o’clock these these consults by the way, I’ve only taken me half an hour, these video consults because we don’t have to take photos before We don’t have to do the clinical consultation, we’re not doing the close, all we’re really doing is taking a lot of time out of surgery and, and doing it online. Now, the downside is you don’t make as much of an emotional connection. I don’t know how well this would work in a non lockdown scenario. Okay, but a lockdown scenario is the best that we’ve got. So that’s what we’re, that’s, that’s what I’m doing. I’m really surprised at the results. But it is working. And it’s only taking up half an hour at a time. [Jaz] That’s fantastic. And I’ve had one patient consultation myself via zoom and I’ve got three more lined up and patients are raring to go with the orthodontic treatment. Thankfully, a lot of the work had been done before in terms of and the next point I want to make is that you know, you need to have your entire team on board as well. So you can’t do the kind of stuff that you’re doing. If you haven’t got the right receptionist, the right nurse – Everyone needs to be in on it from the person who’s reading out your checklist to the warm and friendly environment as created by reception. So it’s generally a team effort. I think it’s fair to say as well. [Gurs] Absolutely, absolutely. So you can do that if you’re an associate. Right? First of all, you’re usually got one nurse, okay? So if you’ve got one nurse, they know how you can work but can you can train your nurse to do this whole checklist and this process and get them on board. And also, people think that leadership in a practice is top down. Okay, so practice owner will take the lead everyone else, but there’s upward leadership as well. Okay. So, upward leadership is when the associate can actually go to the practice owner and say, hey, look, you know, I’m going to try and push and it’s going to generate, you know, X amount more potentially, but I need six months to try and implement this. Is that cool? So you effectively had to sell the idea to your practice owner. Right? Taking into account their possible hesitations in terms of lost clinical time, then you have to catch up on those UDAs, all that stuff. So, [Jaz] Yeah, leading from the bottom is leadership. Absolutely. That’s fantastic. Gurs. That is a so many fantastic gems there that you’ve given us a really. Appreciate it. Thanks so much for coming on. And for those who want to be able to learn more from you, please do send me your website link so that they can get in touch. Because I know you’ve run the photography course online, which people have been signing up to, which is amazing. If you’ve got any more resources, I’d love to send them to everyone, please send them to me. And it’s been really nice chatting to you today. [Gurs] Cool. So I’ll tell you what, what we’ve got going on. Okay, so please, all this period of time we’ve been working on basically this everything I’ve told you now. Right, building it into a course it’s called the ultimate case acceptance course. Okay, details every little aspect you know from body language, what you say, how you say it, the information gathering stage all the different stages it kind of lays them all out so it’s really transparent okay? And how to deal with individual situations. We’ve got a an online course on occlusion, okay, understanding the basics of occlusion how we take a very complicated case 10 into a simple case, we’ve got the photography, we’ve got restoring dental implants, and I’m sure there’s like one or two other little mini courses that we’ve got going on as well. And we’re, we’re building this all under the kind of the Dental NoteBox accelerator brand and people who sign up to this kind of like an online mentoring scheme, and they get all these courses for free. Okay, so I think it’s like 5000 pounds worth of courses or something that you can access for free and there’s just like a monthly subscription, which is a lot less than what I used to pay for my mentoring, but it’s getting to the stage where where I’m at now wasn’t about the knowledge we covered this right at the beginning, it wasn’t about the the knowledge, but it’s about the practice and constant refinements and improvements that you’re gonna make. And it’s a lot easier to get to where you want to be if you’ve got someone helping you and who’s done it themselves. So I’ll give you the links to all this stuff and [Jaz] I love to check it out. Thank you. Thanks so much. That sounds really really fantastic. All those all things and also going into deep I mean, you gave so much value in this episode, but to go in even deeper, as well as the whole implant side and occlusion. Sounds really awesome. Thanks so much, Gurs. Have a lovely time with a remainder of this. lockdown, take care, stay safe, and it’s great it’s been great having you on the show today. [Gurs] You too. Thanks for having me. Thanks. That’s really great. Jaz’s Outro: So there we have it, guys. I really hope you enjoyed the episode. And as always, thank you so much for listening all the way to the end. If you found value from this episode, if you came away, energized from this episode, and looking forward to writing some notes and listening to this episode again, just to get full value from it, please let me know. And please leave a review on the platform where you listen, be it iTunes or wherever, because that’s how my podcasting grow. And then I can attract other guests like you know, My dream is to get Pascal Magne on this podcast one day, and he ain’t gonna do it unless there’s a load of five stars on the podcast reviews. So please do be kind enough to leave your comments. I’d really appreciate it. As always sign up to the newsletter on protrusive.co.uk for updates, and I really look forward to the next episode, and I’m gonna let you guys decide what you want listen to my Facebook and Instagram. Thank you guys.

If there is one piece of content I produce in my LIFE which I think MAY have a massive impact on your life – it might not get much bigger than this one right here! I will put the video up shortly, but you can catch it on Facebook premiere tonight at 8pm on Protrusive Dental Podcast Facebook Page. Video: https://www.youtube.com/watch?v=HZ8yKV0MTr4 Do your grades at dental school influence your success as a Dentist?Is your IQ important? I would be surprised if any of you answered ‘yes’ for these questions. So what do Richard Porter and I believe is the most important predictor of success in your life, relationships and work? Two words: Emotional Intelligence. Find a quiet place, close your eyes* and take a dive in to the world of Emotional Intelligence as applied to Dentistry: *not while driving!! Need to Read it? Check out the Full Episode Transcript below! We discuss: How important is luck in your life and career What is emotional intelligence and what tangible examples can Richard provide relevant to Dentistry? Why does high emotional intelligence mean more ‘successful’ and even higher earning Dentists? Are you born with Emotional Intelligence, or can you improve your EQ? Why is Emotional Intelligence important for Dentists, Dental Therapists and the entire dental team? How can you find out your level of EI? Richard suggested The Big 5 Ocean Assessment – such as understandmyself.com Resources as promised: Harvard Happiness StudyDunedin study Learn with Richard Porter and Aspire If you liked this episode, you will love 12 Rules for Dentistry Click below for full episode transcript: Episode Teaser: Obviously, the nirvana. Is if you have high EQ and you can use your hands and you can use your brain, your cognitive part of your brain, and you can deploy all three. And that really is like the triple threat weapon of the truly successful dentist. Jaz’s Introduction: Throughout my career so far, I’ve really tried to stand on the shoulders of giants. And I’ve tried to learn from my mentors, learn from people who’ve got significantly more experience and people and dentists who are successful, quote unquote successful. Now. What does it actually mean? And what did it actually say? Well, we’ll get to what that means a bit later, but all these dentists, when I asked what makes a great dentist, they all say the following things. They say empathy. They say communication skills. They say soft skills. They say the ability to explain to patients in a way that they can understand it. And the ability to build fantastic rapport with your patients and all these sorts of things, basically. So it’s very much the soft skills. Now, if I was to summarize all these things in two words, It would be emotional intelligence. And that’s what this episode is all about. We’re going to talk about how to be successful, not only in dentistry, but in life. Because I think what I truly believe from reading more and more and more and listening to people is that it’s emotional intelligence, which is actually far more important than your IQ. So I’ve got someone awesome to talk on this topic with me today is Dr. Richard Porter, who so many of you asked to come on the podcast back when there’s some episodes. I asked who you guys wanted to come on the podcast. And so many of you had messaged me on Instagram to say you wanted Dr. Richard Porter. So we’ve got Dr. Richard Porter on today and I won’t take too much of your time. Protrusive Dental PearlI’m going to give you the Protrusive Dental Pearl and we’ll go straight to what hopefully will be a really impactful and dare I say life changing episode for you. The Protrusive Dental Pearl I have for you is a lesson that I learned as a dental student and recently speaking to someone who’s recently qualified has resurfaced as like a lesson that I’ve sort of almost rekindled with in a way. So, it’s a lesson I learned as a dental student. I was there. Treating a lower premolar as a DEM student and that you know how every stage you you get it checked by your tutor. Now my tutor was Dr. Abz El Mougi who’s now I think he’s a restorative specialist by now. Actually his story is quite cool. He did 11 years as a GDP I’m hope I’m getting this right Abs. He did 11 years at GDP and then he applied for his specialist registrar training in restorative dentistry and you got the place and while I was doing my DCT in Sheffield, he was then a registrar in restorative dentistry. But anyway in his days as a tutor on the restorative dentistry sort of floor as we’re like fourth year students I was treating this heavily carious lower premolar and typically students and young dentists, the mistake that we’d make is that we spend too much in caries removal. Like, it should be a fast thing. We should be very precise. We should know where our foot pedal is. We should know where we should have good hand piece control. And we should be able to remove caries quite quickly now. But as a student, definitely at that point, it was like you remove a bit. And then you reflect and you think, oh, should I remove some more? should I do a little bit more here? Should I stop and show my tutor? And then of course you got away about half an hour until the tutor comes around. Right. Anyway. So I have this tooth, which is heavily carious and there I am removing caries and every sort of few minutes I’d show Dr. Omugi, like Dr. Omugi, have I removed enough caries? Have I done enough here? And really at the end of that session, once I placed my restoration and it turns out that tooth needed a root canal and it needs to be done by a specialist because it had a split inside. So some lower premolars, they have a split inside the canal. So really it’s in the realm of specialists, especially at that point. So, it was referred to the specialist unit, but the feedback that I got was amazing. The feedback that I got from Dr. El Mugui, which I’ll never forget is don’t be shy with a tooth of poor prognosis. So that’s don’t be shy with a tooth of poor prognosis. And it’s exactly the conversation I was having with a colleague who listens to podcasts, Neil. Hi, Neil. I hope you’re listening. And I hope you don’t mind me mentioning. I won’t mention your surname. And Neil will send me a case of an upper central incisor, which was pretty much kaput. Like it was a trauma case. The palatal fragment was loose. It was completely unrestorable, right? And he was telling me like, what should I do? Should I refer it for a specialist? Should I try and do the endo while we sort of bury it? As we sort of came to conclusion and I borrowed some knowledge from Dr. Robertetti, implant dentist, about how we should handle this situation. And what we went for was to do a root canal. Bury the tooth because she’s 20, she’s a little bit on the young side for an implant and get five years or so from a Resin Bonded Bridge. So we talked about doing an immediate Resin Bonded Bridge, right? But that tooth was a tooth of poor prognosis, hopeless prognosis. And the lesson I wanted to pass on to him was exactly what I learned from Dr. Abzel Mugi. And that is, don’t be shy with a tooth of poor prognosis. I mean, what can go wrong? The tooth is kaput already. So, I told him, look, do the root canal, explain to the patient that The tooth is hopeless. And the secondary lesson from that is something I’ve mentioned before on many episodes. Never make the patient’s problem your problem, right? Sometimes we stress more. And we take that sort of burden and anxiety on us. But really, the problem is very unfortunately due to trauma, the patient’s problem, and you can dissociate yourself from it and become someone who’s there to help them. So the main pearl here is don’t be shy with a tooth of poor prognosis. Tell your patient if a tooth is very poor or hopeless prognosis and just go for it. Don’t be shy with a tooth of poor prognosis. So I hope you enjoy that and really excited to sort of present this episode to you about emotional intelligence, how to succeed. I’ve given it quite an ambitious title because really I do believe this is the most important thing in your career and in your life. So let’s join Dr. Richard Porter to learn all about emotional intelligence. Richard Porter, thank you so much for coming on the Protrusive Dental Podcast. It’s an absolute honor to have you on. [Richard] That’s very kind of you, my man. An honor I don’t deserve, but it’s great. [Jaz] No, no, 100 percent do. In my journey so far, I don’t, like I said, I don’t know how much of the podcast you’ve tuned into before in terms of my story and my background, but certainly you were a huge, and you still are of course, a massive inspiration to me in my journey. From about third BDS, when I started reading some of your literature, then your blogs, then I used to follow your Twitter account and I saw you set up a spire and I was so close to actually joining a spire. But because at the time in my journey, I was doing other things. Like I was doing a dental core training post in restorative. So I wasn’t in the right place for that, but certainly it’s absolutely amazing that I have you on today. [Richard] Well, it’s very kind of you, mate. That’s very kind. And everyone comes to their learning stage when it’s the right time for them. So, yeah, well, that’s very, very kind. And I’m glad I’ve played some small role in the great things you’re doing. [Jaz] Massive role. And I’m not just saying that it’s been great. And a lot of people when I ran about episode seven or eight, I started to say to the listeners, who do you want on the podcast next? Literally, I can, I have to stroll through all my messages and a number of people that said, we want Richard Porter. We want Richard Porter. So it’s all these people. [Richard] All my extended family for pretending to be dentists and putting those numbers. [Jaz] That’s no word of lie. Honestly, lots of people wanted you on and I can see why. I mean, the first time I saw you speak live was you were doing and you won’t remember this at all. I think you were just starting up aspire at the time and you were doing a lecture about occlusion. And I don’t know where it was. I feel like it was Watford or something like that. It was somewhere in London. It was one of those section 63 type BVA. [Richard] You remember up in North London? [Jaz] Yeah, I think it might have been. Yeah, yeah, yeah. [Richard] It was in a hotel. [Jaz] Yeah. Okay. There we are. Then that was many years ago now. And I remember you seeing you speak first time there and your charisma was just amazing. Your energy as a speaker, as an educator was amazing. So the topic we’re going to speak about today goes very much hand in hand in that. And that’s emotional intelligence applied to dentistry. So before we get into that, I’ve done a little mini intro about how much of an inspiration you’ve been to me, but just tell the people out there watching, listening a little bit about yourself. [Richard] Okay well, I sort of fell into dentistry as like a, I didn’t really know what I wanted to do. And like a lot of people, I was influenced by my parents and it’s a bit cliche, but you’re given the choice by your parents of whatever you could be. And it was dentistry or medicine, and maybe pharmacy or something like that. And so I rebelled as much as you could. I fell into dentistry. I found it interesting academically at first. And then I got really despondent through dental school. I found it, it was almost like a hazing initiation, and that it was, I didn’t find it inspiring. I didn’t find my teachers inspiring and I didn’t have a sense of purpose. I recognized I was good to patients. And I say that with, I say all of this with due humility. I really do mean that, but I recognize it’s good with patients. But I was at guys and when you’re at guys at the time you were told, you’re a guy’s boy. Don’t worry about it. The world’s your oyster now. And I got into practice and I had not a Tory time, but I felt like a fraud, total fraud. So I went back and just thought, well, why would anyone ever come and see me for dentistry if I’m not the best person in that town or wherever I was? So I did a lot of additional training and I was blessed. I genuinely. Luck played a big role in it that I met the right people at the right time, where I got loads and loads of hands on training, and I became a consultant at Restorative Dentistry and I was lucky that I got on a few specialist lists. And then I wanted to start plugging some of the gaps I saw, perhaps the ones I experienced and started doing lots and lots and lots of teaching. And that’s what I spent a lot of my time now doing. And I find the more we can understand each other’s minds, the more productive I can make that teaching. [Jaz] Amazing. [Richard] So that’s what we are. [Jaz] Yeah. Brilliant. Well, two things I want to pick on your journey, on your story, on your background. One is that I’d read on a blog post you wrote once, very vividly, and it just shows how much I look up to you. I was reading about this judo champion or thereabouts that used to treat or karate champion, and then you did a molarendo or something like that, and then he had to pay it and how bad you felt. And that was a spark in your career. [Richard] It was a massive spark actually. He was a really nice guy. And I mean, this is a genuine story and this is Jaz. I’m a bit older than you. So, if you look at the UFC now, it’s weight regulated and there’s lots of safety. And when it first started it was far less so. So someone who weighs 50 kilos might be fighting someone who’s 120 kilos. And these guys were just getting the octagon and do whatever the hell they wanted to each other. And nobody knew what the best form of martial arts was, Brazilian Jiu Jitsu with some striking seems to win it now. But at the time, nobody, and this guy was the British champion. And I exposed on his lower right six carious exposure cause he had decay. And he was a lovely gentle man, thank God. And I started doing endo on it and you’re a guy’s boy. You’ll be able to do endo and I was, but by any definition, I hope it against trouble for saying this. I was incompetent. I was incompetent. And a week later he was in the John Radcliffe hospital with a big fat face and he had to pull out of the tournament, the UFC tournament that he qualified as the only British contestant. And that was his big chance. He was at the top of his game and my lack of competence led to his perhaps stifling of his career even, I don’t know. And that for me is, is something I’ll never forget. So why would someone come see me for dentistry if that’s what I’ve got to offer and that was, I was either going to get good or get out. It was, you know, there was nothing in the middle. So that’s really sparked me on. [Jaz] Well, I hope you don’t mind that I mentioned this because that story, just reading that story as I don’t know if I was a student or in DF at the time, just reading that story was really a breath of fresh air, that someone is so kind to share a failure in that way. And to from that failure, something good came out of it. It became a driving force in your career. So just for those young dentists out there who weren’t familiar with that aspect of your story, that’s why I wanted to mention it ’cause it inspired me so much and I’m sure people out there will, will think wow, one adverse event and how it led to something good. [Richard] Which, you know, Jaz and I think it’s a little legacy, which I hadn’t thought about till you bring it up. But the most, we do try and assess our educational delivery. Like, you know, there’s all well and good us. Me and Raheel, who I work with, thinking when we teach that it’s all going well, but you have to assess it, or get someone to objectively assess it. And the videos we show of clinical procedures, the best ones that people get the most out of is when we cock it all up. So, me putting on some veneers years ago and the etch goes everywhere and you’re struggling with the rubber dam control and you’d split the teeth together, I’d actually seeing those mistakes and talking them through and how you overcome them is more educationally valid than anything else. If you just watch a perfect procedure, you don’t see where the flaws are. There’s this famous quote, which no battle plan survives first contact with the enemy. So if you learn a procedure, A, B, C, all the way up to Z, as soon as you deploy on a patient there are subsets, there’s nuance and things you haven’t thought of. And so seeing those things that other people haven’t thought of, I think is educationally valid. So we’ll probably remain eternal students for the rest of our lives, hopefully. [Jaz] Absolutely. And the other thing I want to pick from your story was you mentioned luck in being a factor. Now let’s just touch on that. How much of that do you actually believe? Cause I’ve got two belief systems when it comes to luck. So, because when you look at like Malcolm Gladwell’s work on circumstances and that sort of stuff, but then also there’s the harder I work, the luckier I get. So tell us about, because people who listen to this podcast are very much into where do I go next in my career? And same to people who, listen, read your fantastic blogs that you write. They’re very much thinking in that where to take the, how to get a fulfillment from my career. So you, when you mentioned luck, can you just tell us what you believe? The role of luck is. [Richard] Yeah. Yeah, I can. I mean, it’s quite a big subject. We could talk all day just about that. So I broadly speaking from a neuroscience point of view and an emotional intelligence point of view and a sort of life goal point you luck probably about a third of everything that happens to you. Now you talk about the harder I work, the more luck I have, the harder you work is a choice. So choices you make are another third. So we have natural abilities and things like that and our emotional intelligence, but then you have choices and you have love and you’re lucky to be born. For example, if you’re born in the UK, you’re incredibly lucky. If you’re born in the UK with good health and with parents who demonstrate that you are loved. If you look at the longest running scientific study in the history of humanity is the Harvard Happiness Study, which is now, coming up for its centenary. It’s just unbelievably important study that started in the States and cross matched different groups of guys and follow them up for years and years and watch what happened to them. And for them, the, one of the biggest rate determining steps was that they believed they were loved by their parents. So if you were born with parents who demonstrate they love you. It’s unbelievably lucky. That’s unbelievably good news for you. And so I had that, you know, I had a wonderful childhood. We also know now that you and I sitting here, maybe we’ll squeeze into each other’s frame here, but you’re the sum total of the five people who influence you the most and you spend the most time with. And when I was coming to the latter part of my undergraduate career, had some people around me, two or three people in particular who I hadn’t anticipated. would be so inspirational, but they were. And these are dentists who are now GDPs. They’re still friends of mine. But no one’s ever heard of them, but they have got it going on and they’re just super smart and were courageous enough to say, Rich, look, you’ve got some abilities here. Why the hell are you doing that? Correct my flaws. Hopefully I could do the same back to them. And I was lucky. And I look back at that and I think that’s just luck. You know, they weren’t there. They’d be born two months later in a different year or something. I wouldn’t have come across them. Who knows? So I think that that’s a big part of it. And I’m grateful. [Jaz] Yeah, and I love these sort of stories and I’m very much subscribed and I agree with you that I did a webinar for for the deanery in, I forget which, it was a Wessex deanery and I called it the butterfly effect because I do believe when you were born and to whom you’re born with and then the small decisions you make early on and how it can have vast changes in your career trajectory later on, but none more so and none as big as the whole theme of emotional intelligence. [Richard] Yeah. Well but that does start before you’re four years old, so a lot of your social networking as an adult is influenced by years not to fall. And so parents have a lot of responsibility on their shoulders. But you’re right in emotional intelligence is, it’s a relatively new area of science. I guess we’d call it science with a rapidly evolving body of work. It really is huge. It’s, you almost get a bit of FOMO cause it’s almost impossible to keep up with stuff as it comes out. But nevertheless, it’s fascinating. We introduced that into our syllabus, just because as you already know, I believe it is as important as anything else in dentistry. And I think dentists are frontline. [Jaz] Brilliant. Well, before we just touch on, I’m going to ask you very straight up, what is emotional intelligence? Before I do that, you just touched on something that’s, again, very interesting about how between age four and how it is so important in our development to have emotional intelligence. And we can see evidence of that from an early age. I don’t know. I can’t quote which study it was, but from a lot, a lot of stuff that I read in this sort of flavor, your personality at age three, and then your personality, it was either age 18 or 21. Like, it’s amazing. The correlation that you, that those two have. [Richard] Well, particularly, particularly I mean, this will make a lot more sense when we get into talk about EI, but it’s particularly your social network. So, my area of interest now, and probably will be the rest of my career is, is the neuroscience, like which bits of your brain give you what, and how can we influence our own brains and what can we do with it? And we know we can do that. But if you think of a a two year old, the terrible twos is called the terrible twos for a reason. Two year olds behave almost psychotically, my two year old kids would hit their mum without fear of consequence. And they’re just testing everything because they haven’t learned, they haven’t had any neuroplasticity, but at four they hopefully don’t because they’ve had that nurturing experience and learn where their barriers are. And that will often, that really does translate through your teenage years. And we’re really still neuroplastic at that stage. That said, when you get to adulthood, you can develop, you can develop your personality. And it’s really important. And if we’re going to mention that at this stage, that we’re clear that this isn’t a threat. It is not a threat to who you are. It’s not a threat to your sense of being or your sense of identity. It is just you upgrading the version of you that you are. And I guess when you’re an adult, it becomes the responsibility of you because your parents probably can’t help you anymore. Maybe they can, but it’s certainly the crown is on your shoulder, the weight is on your shoulders. [Jaz] Brilliant. Well, I couldn’t help just mentioned some of the studies I had read about that. So if you just dive in now, what is emotional intelligence, Richard, and why is it so important? [Richard] I don’t want to go on all day and bore you too much, Jaz, on what it is. But there’s, so, you know, there’s a scientific way of describing it. And then there is probably a more nuanced and almost dental way of describing it. So, if you were to look at what the scientists say, it starts with self awareness. So I’m feeling perhaps slightly anxious and coming onto a podcast, having a chat with someone. I don’t know how many people are watching me, but I experienced those emotions and I’m aware of it. And I’m aware of kind of what I’m like, and I think about that. And then I have self regulation. So let’s say you would say something that upsets me, I can experience those emotions. So that’s absolutely fine, but it’s then what I do with those emotions. So that’s self regulation. And the third part to it is social awareness. So that means if I upset you, have I recognized that? Am I aware of it? And then the fourth part, the final part is social relationships. So those are the four sort of scientific bits to it. I tend to think of it in dental terms, and perhaps more social terms in that we now know there’s a great researcher in this area, a guy called Daniel Goldman who wrote one of the first books on this. It’s quite heavy reading, but the bottom line is when two people, even like right now, buddy, when two people interact, so you and your patient, you and your nurse, you with a group of 10, your teaching, whatever, when you interact, there is an exchange of energy and that exchange of energy. you could call one Jaz. So you’re teaching 10 people and you give them one unit of Jaz and that to them, depending on your emotional intelligence would feel, let’s say I’m one of those delegates, like one and a half Richard Porter. So I’ve walked in with plateau Richard Porter sitting at baseline zero. And now, because of the way you taught me, because of the way you interact with me, I’ve got one and a half. You could have been teaching me about potatoes. I love you for that energy. I have more energy than I have. And if you have high emotional intelligence, which you do by the way, then you will find it easy to deploy. that energy into me. Now, if you change that situation, so let’s say you wanted to take my energy, you’d also have that agency, you’d have enough utility to do that as well. And so whenever you have that situation, if two people have a high energy exchange rate, so let’s say I talk to you. And when I talk with one Richard Porter, you’re going to love me because we give net positive. And for the people out there listening, when you look forward to seeing someone, when you think, Oh, I’m seeing Jaz at the weekend, I can’t wait because you’re just going to be yourself authentically and give each other energy. So when you leave and you just like each other and you try and reschedule appointments, when you and I go through our day list, I hope we’re allowed to be unprofessional slightly. And you look at that name of that patient and you think, Oh my God, it’s really about the dentistry. It is normally that you think I have to put so much emotional energy into this patient. They give me nothing back. So they leave positive. They just suck it all out. And your exchange rate might be awful. Like you give them a hundred And they act like you’ve given them one and a half and they give you nothing back and you’re exhausted. So emotional energy is a real thing. It’s like physical energy or mental energy. It’s a real thing. And we exchange it all the time with people we meet and having high emotional intelligence gives you power to give a tiny bit if you need to, but it feels like a lot to other people. And that’s what’s important for dentists. That’s what we train them to do is that they can have, see a really difficult patient and you have to give energy because as dentists, we have to give energy to every single patient. But when we do that, it doesn’t cost us too much and they leave feeling positive. [Jaz] I’ve never heard of it in terms of this numbers exchange and I can really, it’s a great analogy. It’s a great way to explain it. I think it’s fantastic. The other way I like to think of it, this area of emotional intelligence is knowing, and maybe I’m wrong. Maybe I’ve crossed my wires here and you can tell me, I think, I feel like you are definitely more read up on this than I am, but it’s knowing what to say, when to say it, to whom to say it, how to say it and making sure it comes all out effectively. Is that a suitable definition? [Richard] Yeah, you’re a long way down the line there. But you’re 100 percent correct. That’s definitely part of the process. So if you can develop enough emotional intelligence, that means that almost no matter what comes at you, because we do face hostility and the dental environment is a crucible. It’s a real crucible for emotional intelligence. but that means that if you have high emotional intelligence, when positives or negatives come at you, you can contextually, contextually respond authentically. And that means that you do know what to say in the right tone of voice. And you almost know what to say before the patient’s even said anything. So emotional intelligence is a spectrum and there is a condition for people who have almost absolutely none. And I will try and pronounce it, it’s Alexia and those people have have almost none. So they are unaware of other people’s emotions. And you know, I have colleagues who I work with and they say, how did you know to say that? This isn’t trying to be irritating. It might sound irritating, but I expect you’ll get where I come from. If you have a great deal of social awareness, you can feel other people’s emotions, like I can feel the sun on my skin. It’s just there. And that means you can contextualize your response and you know how to respond. So that’s one end of the spectrum, right at the very end of the spectrum is, well, we don’t know, we don’t know where it ends because that path of self development is never ending, but we know the guy that took it furthest. And it’s again, if people ever want to look this guy up, a guy called Milton Erickson, who was bedridden with polio as a teenager and expected to not survive, many, many years ago. And he was essentially, cast into unbidden seven years of bedridden study. And his family had a big family, a loving mom and dad and seven sisters. And they just socially interacted with every magical, beautiful facet of their lives in front of him as if he wasn’t there. And all he did was watch and study and watch and study. And he never fully recovered from his polio. But when he did recover enough to become a teacher and was, he always walked with an aid, but what his emotional intelligence was like, no one, no stories about what he was capable of. Which you can look up there that scientifically published are staggering. And I don’t think any of us to get there because we can’t do seven year study in a bed. [Jaz] Yeah, I definitely will look that up. Absolutely. That’s great. And so why is emotional intelligence more important than so emotional intelligence, if you were to give it a measure to an individual, a bit like IQ, I believe they call it EQ, emotional quotient. So, how important is IQ to you and how important is EQ? [Richard] So I mean IQ, IQ is obviously vitally important and you don’t get into to you know STEM fields and and the type of studies that we all have to do without a reasonable working IQ. And IQ has been shown again, typically to be one of the biggest mobilizing factors if you come from any disadvantaged background, your IQ is a huge feather in your boat, you definitely want high IQ. EQ goes almost hand in hand with it, so I’m not convinced it’s more important. I think we probably all know anecdotally, particularly dentists who are really, really good at talking with patients. Patients adore them and they get away with doing, if I’m allowed to say it, if they wish, poor quality dentistry. And certainly I know many situations like that. Obviously the nirvana is you have high EQ and you can use your hands and you can use your brain, your cognitive part of your brain, and you can deploy all three. And that really is like the triple threat weapon of a truly successful dentist. The converse of it is I know dentists who super, super bright, PhD level bright, can think through any problem, analyze problems absolutely beautifully, but just really struggle with face to face relationships. If you don’t mind me expanding Jaz, just for a second, just because there’s a great example in that, in the middle of COVID, I was looking at one of the Royal college webinars and they had a hero of mine, Henry Marsh, who’s a St. George’s hospital, like me, a St. George’s hospital, retired neurosurgeon, very famous guy and a couple of great books. And he was talking about consent and he said, how can I consent someone to on the nuance of neurosurgically resecting a glioblastoma from a part of their brain. He said, you can’t, you need to have his knowledge. He said. So it took him perhaps 30 or 40 years, but consent came down to the person sitting opposite him, saying, do I trust this guy? Do I trust him? And trust comes from your emotional intelligence. Particularly for dentists. We now know that you are judged within the first 15 seconds. And actually those first impressions of how you behave there are two things we know patients are looking for. Warmth and competence. It’s just those two. Those are the two things. Warmth and competence, and that comes from great research in Harvard. And as dentists, that, you know, the warmth side of it, certainly your competence might be your certificates on the wall, or it might be pictures of your stained composites all over social media or whatever it is, or your Instagram feed, but your warmth is your emotional intelligence. And so it’s at least 50 percent is at least 50% and it gives you ability to succeed with people and by succeeding with people. I don’t mean coercing them or influencing them into anything that you want, not following your own desires. But if you think of how people interact as a relationship, so you and I a few weeks ago were relative strangers, and there’s no doubt that relationship has upgraded, and perhaps it will even more. And then you get into the point where I would describe the Nirvana of that as a relationship. Now, ideally, that takes a little while to do, and you spend more time with people. Dentists, you’ve got to get that trust on board sharp and the patient’s already anxious when they walk in, and they’re already judging you. So getting that across, we know for dentists, higher emotional intelligence equals higher income. Less stress, less litigation, that’s overwhelmingly demonstrable. Patients don’t sue dentists they like, they just don’t do it. Even if you muck things up, they don’t sue dentists they like. They sue dentists they feel emotionally betrayed by or emotionally let down by. So I can’t give it enough emphasis. [Jaz] Well, then leading on from that, the people who are listening and watching right now, they’re thinking, okay, so emotional intelligence is incredibly important in what we do day in, day out. Can we, so for example, to improve one’s IQ, there’s theories about that, but let’s talk about the EQ or the emotional intelligence. Are you, is this something that you’re born with and that’s it? Or can you actually work to improve it? And if so, if I’m a dentist listening to this right now, and I’ve, and I’m listening, I think actually, you know what, I could probably be a better communicator. I could probably come across as showing more warmth to my patients. How do I improve my emotional intelligence? [Richard] Yeah. It’s such a good question. I love that question. I don’t have a simple answer, but I will try and get into as much facet of that as I possibly can. So you are born the way you’re born, but then we have the nature versus nurture argument, and you become the person you become and you are then set with your personality, and that’s who you are. And your personality may well lend itself, let’s say you have very no emotional intelligence, then sitting and working in a silent library might be perfectly good for you. And there’s nothing wrong with that, if you’re allowed to not interact with people. And if you feel comfortable doing that you can, if you’re required, or you’ve been silly enough to go into dentistry, you are almost required for your own well being to enhance your emotional intelligence. So to get it better, first of all, everyone can get it better. And no matter how good people think you are or not, there’s room for improvement on everyone. So we’re all on that, that pathway, and we can all have joint humility with that. The difficulty with it that I’ve experienced which is pretty well documented by other people involved in the area, is it is just like physical training. So if you sitting there now said, right, I have to put on 20 kilos of lean muscle mass, you’re going to feel some pain. And with emotional intelligence, you’re going to feel pain as well. The difference is, well, it’s not a difference, I suppose it’s the same. You choose to go to the gym and inflict the pain on yourself. You choose to do the reps with emotion intelligence, you have to invite it in as well. It can’t be taught to you unbidden. So this is the thing that blows my mind every time I say it. So it’s going to blow my mind again there. But if you can choose to stress yourself with something emotional intelligence, so let’s use an example. Let’s say we have someone who says, I really don’t like public speaking, even to the point that practice meetings, I’m not getting my message across and I’m scared of speaking. And I have a quiet word with a principal when there are no witnesses or anyone around you’re less effective. So to choose to stress yourself, if you choose to do it, you have to make that choice and you go into it because you chose to stress yourself. It actually codes for new DNA in your brain, and it codes for new proteins, and you grow new synapses in your brain. So this has, again, been proven with loads of different functional MRI studies. But literally, if you choose to stress yourself with emotional intelligence, training, you grow new dormant, but they’re there in everyone dormant synaptic connections in your brain. Those circuits grow and they get better and better and better and better. So you can enhance genuinely the anatomy in your brain. You grow new protein structures in your brain and you can then just deploy them because they stay. If you don’t use them, they atrophy. So if people are too scared of the pain or too unwilling to embrace that, that self induced stress, then they don’t get that opportunity. So we can run courses on emotional intelligence, but that doesn’t mean someone is inviting the stress. And we have occasionally, or when we’ve done training like this said to people. Perhaps people can’t even hold eye contact, particularly holding eye contact if I lean in and shake your hand and we have a two minute conversation with no looking away. People can’t do it. But if they choose to keep going, keep going, keep going, literally you watch these structures grow as it’s happening. Sweat’s pouring. And then it grows. And then an hour later they come to do the same and they can look me in the eye and say, hi, Rich, how are you? And you know, I love that. I love that. [Jaz] That’s amazing. [Richard] Because there’s your warmth. It is. The neuroplasticity is fast. I mean, your brain is so adaptive. I love it. [Jaz] I really like the way that you liken everything to actually what’s happening inside the biology, inside the anatomy of the brain. I once read a book called Quiet. It’s about introverts. Have you read Quiet? [Richard] Yeah. [Jaz] So the introverts have a larger amygdala and that’s why they’re so good at sensing everything. And I believe it was that book, maybe another book where it talked about how we all have these synaptic connections, obviously, but then if we liken, for example, your public speaking synapse to be a narrow country lane versus a large motorway, it depends on how much you nourish. Nourish it, how much you practice, you have how much, like, just like you said, how much you open and welcome yourself to it. So what are the, I mean, you’ve given a great idea of how one can go about improving their emotional intelligence, but before one can do that, they actually need to have a act of self discovery to know, okay, someone may not know exactly where they might lie. So I believe there are some helpful aids out there to maybe, a questionnaire or something more complex than that to find out exactly where you lie in the scale of motion intelligence. What can we do for that? [Richard] Do you know that I’ve been thinking about that a lot recently, actually, it’s almost like we scripted this interview just, but we haven’t, tell the speakers we haven’t, but that is, you really are hitting the questions on point. So what we’re talking about there is like an immediate personality assessment of where I am. So if we started with the first scientific bit that’s my self awareness, who are we? And there’s lots of personality tests. So if you look in business, you’ve got to go home and say, they’re all doing DISC. People may have heard of DISC, D I S C, for their personality assesments. Those Myers Briggs, this type assessments, they tend to come with a little bit of a label. So they are a label can then stick with you and limit your growth. So we don’t really use those in a scientific way. They’re good and they’re popular because it gives you a sense of self identity. So on my Myers Briggs, I’m an ENTJ, but the flaws with that are the E is extrovert. That’s not a dichotomous situation. No one is 100 percent extrovert. In fact, if you are, you’re probably in prison. And if you’re 100 percent introvert, then so everybody is an ambivert, but you might just lean one way or the other. So the more scientific tests that I encourage our delegates to do is it’s something called the big five, the big five ocean assessment. And that is the one that all scientific psychological literature is based on. So you have five big components to it, to your openness, conscientiousness, extroversion, agreeableness and neuroticism. And then there are subsets within those. And it’s very interesting when people do that with us because they will come back and do a scientific test. But then say I agree with this bit, but I don’t agree with that bit and you think, well, you inside you don’t get to agree with that bit and then you just don’t like that. So for example, on my ocean score, my neuroticism is 9%. So I’m hyper low neurotic, which isn’t a bad thing. It’s just a thing, but it means that if I got to run a business, I really need to work with someone who’s really highly neurotic because I’ll just turn up and wing it. And they will be much more structured to it. And actually, it’s not a weakness in me. It’s just the thing of me. You can work out where you are. So we encourage people, if you’re going to start to do your ocean assessment. The best ocean assessment online, I’m not advertising this. This is not, it’s nothing that I have any financial interest in, but the best one I use is something called understand myself, understand myself. com. And you pay a few dollars and you get a full report and be ready because the stress is coming. None of us are perfect and I’m happy to list all my scores. I did it on a webinar not long ago, it makes for interesting reading. [Jaz] It’s great. And I like how you mentioned about the your 9 percent neuroticism. And you mentioned about running a business there, which I want to just lead on to the next question quite nicely, actually. So running a business and you want to team up with someone who maybe has a higher score to get reach some sort of balance, but dentists and dental practices. They work with people, they work with teams. So one of the things I’ve learned through attending these dental sales type courses, you know, that sort of stuff. And what they say is, the most important thing is the person who answers your phone, the reception team are the sort of gateway for revenue into your practice. And so I think the most important thing to do is that if you’re going to train yourself and you’re going to improve as part of having a more successful business is that it will be silly to just focus on your own emotion intelligence. It would be a great thing to introduce the team to this concept and get your receptionist, your practice manager, the decision makers in your practice to also learn about and improve their motion intelligence. Cause surely that will mean so much more for a business, for a practice. Is that something that you talk about? [Richard] Yeah, absolutely. And you’re quite right. You’re quite right. So we know that when someone walks into any sort of business, any sort of a hotel lobby or a dental practice or wherever it may be, when they meet you and they meet the first person there, it really is the first 15 seconds. And that study has been taken to the point where they taken medics. And medics interacting with patients on video with video and audio, and then they’ve been watched by a group of lay people judging the medic and then subtracting the time so they have less chance to observe this interaction. And what they’re doing is making a judgment call on whether this dentist, this doctor is going to be sued, going to be successful, going to be liked. And audiences are incredibly perceptive over this. They just feel it. That’s all emotional intelligence. We have no idea about this guy’s IQ. It’s just his warmth and competence. And then they cut the sound down, and the time down, and it ended up with silent 15 minute videos, and the audience still got it always right. So that moment now in your receptionist answering the phone, they haven’t got body language, they haven’t got eye to eye contact, they haven’t got that boom. So everything then comes to the phone. But interestingly, if you look at lectures delivered through an audio device. If the speaker is standing up and moving around as they do it, and when they say hello to the audience, actually put the hand out. They can’t be seen, but they do it. The audience rates that performance much, much higher. So even though your reception staff are limited by audio, I’m not saying they need to walk around the practice and shake hands with people, but having them skilled up in just presenting a warm, kind, immediate point of contact is important. We know what patients want from that. Patients want to feel wanted. They want to feel liked and they want to feel known. Now they’re probably not going to go through the known bit, until they meet you or your nurse and get into the clinical environment. But certainly when they come to your reception staff they need to feel wanted and they wanted to feel like they need to feel those two things. So it’s wanted, liked, and known. Those are the big ones. [Jaz] So how can we get our teams to also, because it’s one of those things where if you’re, if you own a practice and then you tell your team, we need to be hot on emotional intelligence. Let’s all improve our emotional intelligence. Then they might listen. They might not. But if someone external sometimes comes, then they’re, even though they’re saying the same message. They might resonate with them more. It’s one of those things. So do we need to be getting some emotional intelligent consultants to the practice to help improve, or is this something that we can start to introduce to our practices? [Richard] Yeah, I mean, I think the training can come from anywhere and I don’t mind if it comes to external sources or internal, and if you’ve got enough structure to do it for people yourself. But I mean, I think that’s a great thing as well. Learning is learning and it’s valid, wherever it comes from. So I have no issue with who does that, but definitely skilling up your team. One of the key things through anecdote and science is that our patients judge your relationship with you and your nurse massively. How you interact with people is something their subconscious mind observes. If you think of all humans have a conscious and a subconscious mind and communication like you and I are doing now, we’re just giving each other access to our minds. That’s all we’re doing. You’re giving me access to your mind. I’ll give you access to mine and in your listeners will be doing the same. And all we’re doing is judging each other’s minds. But it’s your mind and how it relates with other people. So if you have a good, friendly, enjoyable, positive, mutually positive relationship with your nurse, patients feel that energy and they like it and judge you positively because of it as well. Same with your reception staff, it’s a whole team training, I think is a vital part of it. You know, if I have a delegate in trouble and or not in trouble, but just saying I’m finding work difficult, we will always say to them, what’s your relationship like with your nurse. Like, oh, you know, it’s really difficult. They don’t want to be there and they’re bitter and twisted or it’s very, very hard. And that means you’re walking into the room every single day, having to pour positive energy, not just into your patient, but into the staff around you as well. Very, very difficult to do. [Jaz] Extremely draining. [Richard] Yeah. It really is. [Jaz] So the last question I had was, I know we sort of, picked off from where you’re talking and some tangents to get where we are. One question I sort of missed out was, can you just make the emotional intelligence for anyone who hasn’t quite got it yet? Extremely tangible in the sense that let’s say dentists listening to this, and we have an unhappy patient, someone who complains, how might someone demonstrate or someone who has low emotional intelligence behave and what might they feel versus someone who has high EQ. Can you just explain maybe how that scenario may be handled and why the role of emotional intelligence may actually have a bearing on the outcome or how it’s actually perceived and the emotions? [Richard] I think it’s a really good question. Again, Jaz, one that warrants quite sort of expansive, explanation. So if you were to look at like dental protection society, and they say, this is how you handle complaints. If you have low EI, you will just naturally look at that and think, well, I’ve got the formula to follow. I just follow the recipe. All I have to do is ABC. It’s a very linear process. If you have high EI, one, you probably haven’t had the complaint in the first place, but two, when it comes in or you feel it, you would have felt it coming on before it’s even coming on. So we all have difficult patients, but firstly, you can spot them. If you have low EI, you can high EI, you can anticipate where they’re coming from. Because difficult people are often full of explanations over why they’re difficult. They don’t know they’re difficult. They might tell you that a lot about themselves if you ask and you just have the ability to unpack their mind and understand their mind, and then empathize with their mind. Give their mind somewhere to land and make them feel wanted, even if they’re not, make them feel wanted and certainly make them feel known. And if that happens, then you really do just reduce the risk of a complaint massively. So in terms of a tangible example. I spent a lot of my time in the hospital and we have a patient, this is a real life example, who’s somebody who came in and checked in and the computer system tells us that they’re here and for whatever reason it didn’t work. So this patient arrives and sees another patient arrive and going before them and another one going before them and another one going before them. And they go up to reception desk after an hour of waiting there very patiently. And I’ve now finished my clinic and I’ve got to go to a meeting and the receptionist says, well, you didn’t turn up for your appointment on time. New reception staff, different one now, says you didn’t turn up for your appointment on time and, and Dr. Porter’s gone and you’ll be discharged. So the patient is now really, really angry. I get wind of it and then I see the patient. And so before you see the patient, if you are able, which even look at you, Jaz, I think you’ll be naturally just able to do it. You’ve got to be able to put yourself in that person’s shoes, but not put their shoes in 60 minutes waiting, saw three patients, put your shoes into how they are feeling. And as they walk in the room, act appropriately, contextually, to someone that is feeling anger, but has justified anger, is probably feeling a little let down, is probably feeling they had some concerns they needed to discuss with a consultant. And now has been told they can’t have it. Maybe feeling betrayed by the system. Maybe they had a bad day yesterday as well. They might be feeling sad and they might be, and if you could do all of that when they come in and you hit them with your warmth and your competence and you look them in the eye and say, I found out what happened to you. I’m just so sorry that happened to you. And we can talk about that. But once we’ve talked about that, now or later, I can do everything I can to make it right for you and help you as much as I can with a problem you want to talk to me about. Immediately, the situation is improved. Now, we have delegates who say that. How did you know how to say that? And I say, because if you don’t know, if it’s not given to you, you’re going to practice. So say it back to me now. I’m not asking you just now, but we will say, I say, say it back to me now and we role play and people say, I can’t role play. I can’t, I’m not going to role play. I say, well, you are, I’m your angry patient. The rest of you 20, you’re watching. I’m the angry patient role play with me. And they get really uncomfortable. And then they do it and then it comes along and the feedback we get is, is from people who go through that process is the one that this changed my career. You literally neuroplasticize people then and there or through a more structured program and then they can handle those complaints better. I hope that answers the question. [Jaz] It does fantastic. It really, it really does. So I love these real life examples that we face, you know, very similar sort of circumstances day in day in our role. So I really appreciate that. So those are the main questions I wanted to cover today. ’cause obviously we can talk about this for days and days and days. So to give those listening a flavor, those who may be unfamiliar with ei, now they know what it is and how they can improve it. The fact that, it’s something that you can work on, but it requires you to come out your comfort zone. We touched on a few interesting things about your personality and luck at the beginning, which I quite enjoyed. And actually one thing I was going to save to now, should we have enough time? And we just got a couple of minutes there is, have you heard of the, I’m probably saying this name wrong in New Zealand, Dunedin? Dunedin? [Richard] Yeah. [Jaz] Have you heard of the Dunedin studies? [Richard] I don’t know them. No. [Jaz] Oh, okay. I’m going to send you something. I’m going to send you an email, so I’m going to send you a very special email that you give you some access, some exclusive content, but it’s sort of like the study that you mentioned. I believe you said it was in London where they follow people up from birth to- [Richard] Harvard happiness, Harvard happiness study. [Jaz] Right. Okay. So Harvard. Okay. Well, from what I’ve read and what I’ve seen, the Dunedin study is the world leader of all those types. So when, as soon as a child is born in the hospital in Dunedin, then they are followed up every so months and they look at every facet of their development. Every part of what makes them who they are, the relationship with their mother, their temperature when they’re born, like various different things. Then they measure them and they measure them and they measure them. And then they see who turns up in the prison, who becomes successful, quote unquote, who has a thriving relationships. And I just. I just, one of my favorite studies and things to learn about is that, and I think it was just sort of touched on that. So for those, every episode, I like to put some resources for people to look onto. So I’m going to send that to you, but I’m also open up to everyone. I’ll find something and put it on about the Harvard study that you said as well. [Richard] Yeah. And I can say plenty more to you to put up. Well, we’re now quality of life and lifespan based on personalities. And there’s a difference. [Jaz] That’d be great. Any last points you want to leave us with, Richard, at all? [Richard] Just in terms of everyone’s going back to work now. This is a time to rebuild. This is the best, this is a transitional time. This is the time to build on this. And one of the things we help people do or willing to help anyone do not just aspire delegates, anyone at all is become that version of themselves in the future. So to do that, we know how to do that about setting goals about enjoying the process along those goals and how you actually structure that into place. That’s something we would encourage anyone to do. Don’t just become a dentist who follows a label. Goes in, fix his teeth, goes home, does a different role at home, next day, same. That routine cycle is, for many of us, a dead end. We know dentists are struggling with stress, burnout, anxiety, and depression. This is the way, it’s future authoring. You author who you want to be. And go along that process. And ei is the fundamental engine of that. [Jaz] Brilliant. Well, thank you so much, Richard. Please do send me some links, resources. I want to know about anything that you guys are putting on for this as well as the ocean sort of everything on, I want to put it on a link so people can find out more about this ’cause it’s such an important topic. [Richard] Yeah. Well, that’s great. I’ll do all that. Thank you. Jaz’s Outro: Thank you so much, Richard. Cheers. So I hope you enjoyed listening to that as much as I enjoyed chatting to Richard Porter. Thank you so much, everyone, for voting for this episode. So I sort of presented, I wanted you to have the choice, which episode you want to listen to next. So the choices between emotional intelligence or case acceptance and smile design. So the next episode will be case acceptance in smile design. And I’m not going to tell you who the guest is, but I’ve got someone who literally does the most big cases, smile design cases that I know, like personally, I know them, and the amount of cases, the volume of smart design cases they do. They can obviously speak to patients about this kind of dentistry and so many amazing gems you pick up. So really excited for the next episode. Join us in around about a couple of weeks time. A lot of you have forgotten that a lot of the content that is here on audio to listen to is actually available by video as well on the YouTube channel. Or eventually on Dental Tubules if you want it enhanced CPD. So thanks so much for sticking all the way to the end. I really appreciate it. I’ll catch you in the next episode guys. Goodbye.

At Dental School I was taught that we have 2 opportunities as clinicians to save a patient’s life. One was mouth cancer diagnosis (obviously) and the other was a patient with GORD who may develop Barrett’s Oesophagus. However, as I look back now, I do believe dental school missed something out….and that is Sleep Disordered Breathing (SDB). There is no formal acknowledgement of Airway in the dental curriculum. https://youtu.be/TKiX-J046JA Full Episode on the YouTube channel and soon to be on Dentinal Tubules for 1 hour of Enhanced CPD/CE Need to Read it? Check out the Full Episode Transcript below! What you will learn from this episode with a leader in this field Prof Ama Johal is that a team approach is needed. If the Sleep Physician is Team Leader, we as Dentists are SECOND in the pecking order, above ENT! That signifies the massive role we have to play in treating SDB. We discuss: How and why did Prof Ama Johal get in to this micro-niche of Airway within Dentistry Brief overview of anatomy with the ‘party balloon’ analogy What is Dental sleep medicine? What is sleep disordered breathing and sleep apnoea What is the contribution we can make in the dental profession? Is it just mandibular advancement splints? What is a CPAP What is the effectiveness or oral appliances vs CPAP? Why is the training at undergraduate level in both MEDICINE and DENTISTRY lacking? What are the barriers to Dentists who want to help patients with Sleep disordered breathing? How can we significantly improve the lives of some of our patients? What is the association between parafunction and sleep disordered breathing Should YOU get involved in treating the airway for your dental patients? Does premolar extraction orthodontics adversely affect the airway? What about children with massive tonsils/adenoids causing airway obstruction? Prof Ama Johal is highly regarded within Orthodontics and dentistry, for the standard of his clinical work and published research. He is the Vice President of the British Society of Dental Sleep Medicine (BSDSM) and Professor at Bart’s and The London School of Medicine and Dentistry. Resources and Downloads: British Society of Dental Sleep Medicine S4S Course Snoring & Obstructive Sleep Apnoea – a Role for the GDP – listeners of the podcast can get 50% until the end of August 2020 – use coupon code ME50 (this is not an affiliate link and I do not get commission from this – I am thankful to S4S for offering this to the community) Click below for full episode transcript: Opening Snippet: Hey guys, it's Jaz here and welcome to Episode 33 of the Protrusive Dental podcast. We're talking about airway. Jaz’s Introduction: Now airway for me what I think is that in dentistry, it really is the elephant in the room like we qualify from dental school, and this mammoth topic of airway and how relevant it is to dentistry. I mean, come on, we’re looking down the mouth, we’ve got a huge view of the airway. And it’s something that’s completely neglected in dental education. But the more I sort of delve deeper into this, it’s actually neglected in medical education as well. But it was taught turning that around slowly. So that me and Prof Ama Johal, who’s the guest today. We’re thinking that perhaps in 10 years time, it’s going to have its rightful place near towards the top of what we learned at Dental and medical school for that fact. So we’re talking about what is the elephant in the room and it’s airway. The way that I got into airway in my journey is something I discussed with Prof Ama Johal was when I was a DCT1 at Guy’s Hospital, I’d have like this one clinic like every two weeks, where I’d be making these mandibular repositioning appliances, and they were like, it’s like a soft splint for a top, a soft splint for the bottom and this sort of glue together with a mandible in a slightly protruded position or what Prof Ama Johal describes a very much as a first generation appliance. So that was my first real exposure into treating the airway or creating sleep disordered breathing flat back. And when I learned some years later, that there is an association between sleep apnea and parafunction. You know, that got me excited, which hardly surprised any of you. I know that for a fact. So I’m really stoked to have Prof Ama Johal, we recorded this episode in about April. We’re now in July. So the sort of vibes you’ll be getting is like, Oh, my God, it’s lockdown kind of thing. But it’s full of a lot of useful information. This this episode here is really to wet your appetite, about airway and the role that dentists and the dental team can play in spotting sleep disordered breathing, obstructive sleep apnea, and obviously treating snoring as well actually, which goes hand in hand and you’ll learn about the sort of definitions what role we have, what works and what doesn’t work the different oral appliances. So really cool episode, I hope you like it. Very niche, very different, something that really needs to get out there some more. The Protrusive Dental Pearl I have for you was donated by my good colleague, Tristan. Tristan has been listening to podcast some time. It’s been great to connect with him on Instagram. And like many of you that listen to podcasts, and I’ve made so many friends to this. So thanks so much Tristan for reaching out. And Tristan reached out to me and said like Jaz, I’ve got like the next pearl for you. It’s basically when you’re doing rubberdam instead of using floss, use the little flossettes. And you know me, I was like Tristan, kind of been doing this for three years. But then Tristan threw in this absolute knowledge bomb, that is definitely going to change the way I now place rubberdam and I think it’s gonna it’s a really helpful tip. So what I usually do in my workflow for rubberdam is I hold it in place. I try and stretch it into a contacts if I can, but a lot of the contacts are tight and they need flossing, right? So I train my nurses and how to floss effectively. Sometimes people get their nurses to hold the rubberdam and the dentist flosses, whatever, so the nurses flossing, but when I switch to using the flossettes, it became so much easier the nurse found it so much easier, especially to reach like between the first and second molar, it’s so much easier. But what Tristan shared with me which is the real Protrusive Dental pearl for today is to buy the floss sets, which had a double floss so they had like one higher up and then one lower down. because quite often when you’re flossing the rubber dam through the contact, it actually misses or it doesn’t quite drag the rubber dam past the contact area sufficiently. So having that second floss in the flossettes gives you a second bite at the cherry. So then you don’t have to keep flossing. So thank you Tristan for donating that Protrusive Dental pearl today. We’ll dive right into the episode with Prof Ama Johal And join me back in the outro Main Interview:[Jaz]Prof Ama Johal, it’s great to have you on the Protrusive Dental podcast. How are you? [Prof Ama]Very good. Thank you. Yeah, interesting times we’re living it but yeah, really good. Thanks. [Jaz]Absolutely. So to put some context in for those watching or listening, we are in the middle or it’s end of April now 2020 and we’re in the middle of the sort of COVID-19 lockdown period. So how are you keeping busy at the moment and maybe it’s a good point for you to tell? Because I usually like to do a little introduction for someone. But before I give my little introduction of you, can you please tell the listeners what you’ve been up to and what you’re usually up to when you’re not in a lockdown period? [Prof Ama]Okay, so, so my if you like daytime job is professor of orthodontics, training undergraduates, postgraduates and specialist orthodontic treatment. In addition to that, I work as a consultant for Bart’s charity, Funds, I should say not charity, although it is like a charity.Treating patients with you know, multiple complex needs. And then I suppose proportion of my week is spent in private practice. So treating sleep disordered breathing, which I also treated at the Hospital and as a specialist orthodontist, so yeah, my week is really quite busy. Actually, it’s pretty full on. Lockdown has actually meant for us just really getting on with an awful lot more academic work, so I’m doing a lot of academia, we have noticed you probably are aware of the challenges of presenting their assessments for them during this lockdown period. And from the NHS side I’ve been redeployed and I’m working in a&e which is very very interesting place to be right now. So we’re very much at the front line. And that’s been quite interesting but again I’ve managed to kind of relate a little bit of my respiratory understanding. And so as you’re probably aware, one of the treatments for some of these patients is one of the treatments we’re going to talk about this afternoon so it’s been yeah I’ve quite enjoyed it but a little bit out of the comfort zone, let’s say! [Jaz]Well, sounds like you’ve been very busy indeed not only with the academia, but with the this great role that you’re doing as working on the front lines so I think a thank you for the hard work to people like you and my wife is also an assistant swabber for COVID-19 and everyone who’s, you know, being redeployed is great stuff, so my version of your introduction is, you are quite famous in my orthodontic diploma that I did, because every time we’d see like, oh, “what’s the reference for that one” we don’t know when we’re revising for exams, and we all had an in-joke that if you just reference Johal et al you’re probably gonna get the mark! So that was that was why you’re famous. [Prof Ama]Thank you. [Jaz]Tell us so we’re gonna talk about airway and obstructive sleep apnea, and sleep disordered breathing. How did you get into this sort of micro niche within dentistry. [Prof Ama]Yeah, I mean I suppose it’s very unique because when I was training as an orthodontist who was a senior lecturer at Bart’s developed this initial interest in sleep medicine, and because of the MSC that was doing at the time she sort of roped me into it with her. And so it’s been almost 25 months just over 25 years actually I’ve been involved in research and clinical work so yeah it’s kind of escalated from there and now we’ve run a sort of a PhD programme I took on a PhD in dental Sleep Medicine, which was, you know, interesting and fairly novel at the time actually. So, yeah, that’s where my interest really was born out of academia, and then I started to manage and treat these patients. And I, you know as a profession I think it’s incredibly exciting I mean, the opportunities for us to shine are amazing. [Jaz]I think it’s a it’s one of those. I mean At dental school I was always taught that there are two chances you can save someone’s life. One is oral cancer if you diagnose it, and two is actually a gastric esophageal reflux disease because you know Barrett’s oesophagus, but then no one ever mentioned the third one, which was obstructive sleep apnea and the role of dentistry so I think that leads us nicely onto what my main question is can you firstly give us an overview to all the dentists watching lots of gdps listening into this. What is obstructive sleep apnea, or sleep disordered breathing. And what is the role of the dentist in the diagnosis management at the moment and perhaps what you think it could be in the future. [Prof Ama] Okay. Really good question really. So, the sort of global term that’s often applied is is referred to as sleep related breathing disorders or sleep disordered breathing, and that covers a panacea of challenges so I suppose if we go back, very briefly to the anatomy of the area of interest, we’re talking about the back of the throat so the really the point from where you see on dangling soft palate, to the base of the tongue. And this is a very small piece of anatomy and the analogy I often give dental colleagues and common courses and so forth is to think of a, like a party balloon long and thin. And if you’ve inflated it stays inflated otherwise it’s it’s just kind of completely collapsible, and that is your upper airway. So what makes it quite unique is it’s devoid of any sort of skeletal framework. And it relies almost entirely on muscle action to keep it paid. So, sleep disorders is essentially dealing with either a partial or a complete collapse of that airway, that small tissue area. And so one extreme we talked about snoring. And snoring is obviously quite a people laugh and smile about what snoring but for those who suffer it’s an incredibly anti-social condition and it has some serious impact from a health perspective and quality of life perspective. In these individuals, what happens is the area doesn’t collapse it just partially closes momentarily as the tissues, touch, and it’s that vibratory action of the soft tissues hitting each other that gives rise is allowed, or not. And, at the other end of the spectrum you’ve got obstructive sleep apnea, which is significantly associated with a lot of comorbidity. So in this condition what makes it very very unique is that airway doesn’t partially collapse it completely closes. So the individual suffers this mini episode of suffocation. And we talk about sort of apneas which are complete cessation of breathing and they have to last for at least 10 seconds for them to count a lesser form of respiratory disturbances something called a hypopnea, which is a milder respiratory obstruction but nevertheless is associated with a drop in arterial oxygen. So whether you have apnea or hypopnea is we tend to talk about obstructive sleep apnea in terms of its severity, as a condition called the apnea hypopnea index. And that’s a summation of the number apneas and hypopneas in any one hour of sleep. And this can range from five upwards to what an endless number almost but we classify it between five and 30 has cut offs between mild and severe amongst that plethora of conditions there are milder respiratory disturbances but that’s for fundamentally that that’s really what we’re dealing with we’re dealing with an airway that’s collapsing andnkind of our Dental Sleep Medicine which has really evolved. So, in terms of your question, you know, how did I get involved or what contribution Can we make well the contribution is significant now, and it’s probably taken me the best part of 25 years to really get that to the forefront of not only our medical colleagues, but the dental profession itself, because as you quite rightly recognised that this isn’t something that’s routinely trained or taught, and there was a lot of inertia towards this initially, primarily because the evidence base wasn’t supportive, but now we’ve got an immensely strong evidence base, and it’s probably safe for me to say that the government in 2018, set up a nice committee, National Institute of Clinical Excellence, the set of guidelines for sleep related breathing disorders. And I was quite privileged to be interviewed and appointed as the dental expert on that panel, and the report would have been published in May of this, this year. But because of it’s because of COVID-19, we’ve had to push that date back so I was really optimistic that by the end of this year, people will be reading an awful lot more and we’ve tried to embrace the multidisciplinary nature of this condition. So as a dental professional, if you think back to what I was saying about the collapse of this airway. The one predominant tissue that features in all of this is the tongue, and nobody has better control of the tongue than the dentist. So, you know, we’re in a very very unique position because we are the only qualified professional to get involved in this. Insofar as the simple mechanism of action really is that if you advance your mandible you advance your tongue. And by doing so, you stop these obstruction episodes, or these intermittent collapsing. So, at least you resolve the snoring at very best we start resolves up there. And there are some now very established international guidelines which accredit this work. So we tend to follow the American Academy of sleep medicine, and they’ve been updated largely to reflect the amount of research, this has been undertaken this field. So we’re in quite a privileged position. And you know, my role has been probably the last 10 years to really push dentists to get involved in this because it’s by far the easiest level of dentistry we actually undertake, we can talk about what it involves. [Jaz]Well, I actually came across, you and I learned about the role that you’re playing in a political and international and dental level within sleep disordered breathing when I came across your coupon, I think DVD series that you did with S4S, and my that’s where in that lecture was a real eye opener for me when I when I watched it. And what I want to know is, why is it that the American Academy of dental Sleep Medicine, had produced all these guidelines all these years ago and they’ve been, I mean seems to be when I speak to my American colleagues on, I actually worked in Singapore for a while, and I met some American dentists and their understanding, and they’re sort of perception about the role of dentistry in sleep was completely different to my background. Why do you think that in the US, they’re the way and Is it because of the way insurance pays or is there something else going on? [Prof Ama]And again a really good question. I mean, I suppose at the cutting edge really of sleep medicine in general has been the Australians. They take credit for an awful lot of the innovative technology that’s taken place. And the Americans as you quite rightly identify have have gone on to this. Probably a lot more quicker and much sooner than we did. I just think it’s probably scales of economy to one extent. The second is, I think, the element of funding that comes into play. Also is an issue because in the States as you know it’s almost, I would get funded health care. And one of the big things that takes place that differentiates the UK from America and other parts of the world is that insurance companies pay for an immense amount of the investigative work that takes place. So sleep physicians are often then confronted with this plethora of patients as well as conditions, which I often can’t managed and, and they were often restricted because the gold standard for treating obstructive sleep apnea so if we just park for one minute snoring to one side and focus on the coma because obstructive sleep apnea tracks, you know, most of the attention because of its profound effect on people. So, the treatment of choices, is called CPAP (Continuous positive airway pressure) which has been popularised during the covid, and because it is basically a machine which takes normal air filters it humidifiers it, and then forces it under pressure into the back of the throat so if you go back to that party balloons scenario. Everyone gets why it works so efficiently. It’s basically a pneumatic splint it has no other feature other than a pure anatomical role it just literally blows the Airway up. The biggest challenge they have with that treatment is compliance so it’s incredibly effective, but patient compliance is, is quite poor, to say the least. And so consequently these sleep physicians are either confronted with patients who are really severely ill unwell symptomatic, with no treatment of choice, or the patient simply looks at the device and thinks well, there’s no way I’m going to comply with that, Even if the monitoring has a spectrum. And I think it made the Americans, perhaps, and certainly the Australian citizen think when actually, you know where where are we going with it so when I completed my PhD back in 2004, the Australians completed the biggest international research trial, which was funded by multi million pounds. We’re looking at the effectiveness of oral appliances versus CPAP so they were really ahead of the game. And that’s a kind of a pinnacle paper that you know we really regularly recommend people to read. So I think partly that has evolved and then naturally, because of the availability of that treatment in the US and because it was funded treatment. They, I suspect have always remained ahead of the game I wouldn’t say they’re particularly ahead of the game at the moment. It’s just that from a regulatory point of view, the UK has been behind so once the nice guidelines come out. We will probably have the most up to date guidance on the management to speak to and breathing. So we will respond, a little bit slower than that. [Jaz]Well it’s good that we’re finally getting there. And for a lot of people who are listening. A lot of dentists young dentists, they probably have never seen what a CPAP looks like. Now, from the research that I be doing in a run up to this episode so I wanted to make sure I had some some knowledge in front of you is that it’s not a very sexy device to wear and that may have something to do with the poor compliance? Is that right? [Prof Ama]Yeah I mean there’s a couple of elements to it that certainly it’s not the most attractive. It used to be a little bit noisy because it’s like going to bed with an air conditioning unit home but they’ve made that better. Its primary problem from a patient point of view is travelling with the wretched thing because it is space consuming and in these in these days of heightened airport security or former days of high airport security. And these patients used to put this in the hole, and it would have to justify this treatment so one of the sort of almost, I suppose proactive elements for patients that come to me and say look I need something I can travel with, or that doesn’t need an electricity supply, because that’s the other thing it’s bound to. Beyond that, actually the mask itself is incredibly uncomfortable that’s where all the issues arise for patients it’s, it’s got certainly multiple side effects that it tends to be constructive. Despite the millions that are invested. [Jaz]Brilliant, well then what this does nicely to next question, why has the dental Sleep Medicine, do you think become, I think it’s like the elephant in the room in our profession, especially at undergraduate level I don’t remember a single lecture about the role of airway at the time. Is that changing now because I know you’re involved in education, are you now starting to teach undergraduates? [Prof Ama]Well it’s interesting you say that because there’s, there’s not just a change needed in undergraduate dental, but undergraduate medical as well, has changed. Consequently, because. Sadly the knowledge, amongst GPS of the training available to them, has been rather limited as well so I used to work a lot with Primus sleep groups are trying to raise the knowledge base so not only within dentistry but medicine. Within dentistry there’s no formal acknowledgement in the curriculum that this would be a key component, let’s say, however, a Queen Mary we I’ve integrated it. So we have students that moment to do a selective study model module a choice module is sort of a, an elective if you like. And they kind of really enjoy it. I’ve had a few of them in fact one of them wrote something for the dental mouthpiece because you know just raise dental awareness and again within postgraduate training we’ve obviously got it going now and introduced it basic orthodontic training and but it’s not just orthodontics elite effects clearly, it affects any dental professional. [Jaz]Brilliant well then fast forward from students which hopefully will, you know, it will get embedded both in the medical and the dental sort of curriculum and in looking at the dental profession as a whole at the moment. How can we help our patients who we suspect may have an airway issue. Obviously, the first thing that we need to do as oppression is learn. So for me, my initial learning was not only watching your lectures, which was an eye opener for me but also during my DCT position at Guy’s hospital. I used to. I used to give some mandibular advancement splint. These were like the to describe it to those it’s like an upper, lower soft spint, where the mandible is advanced and they’re just sort of stuck together. And that’s what that was my initial sort of introduction to it, and then went on to treat snoring. Following the S4S framework so we had the patient fill out the Epworth scale, and I liked the sort of letter that was attached so you can send to the GP, but I never once had a GP write back to me and to fact even the patients, once they got their device to help them snoring. They, they didn’t pursue it with the, with the GP. As you know as strongly as perhaps I would want them want them to. So I guess the question I’m asking is, is it just these mandibular advancement splint that we ought to eventually hopefully get involved with, or is there much more to it than that and how can we take it further as a profession. [Prof Ama]Okay, so I mean these are really crucial questions really because. So before I could open this. Let’s say treatment modality to to dentists within the UK, what I did was I engaged with the sleep societies, the British Thoracic Society the British sleep society. And I kind of wrote to the mall and I said, Look, if I was to train dentists, would you support them in clinical practice because ultimately this is a, an MDT approach, it’s not something that as a dead fish we can get in on our own or neither we want to my second port of call was the defence organisations because many of them would not support, or even recognise this as being treatment under the umbrella of dentistry. So, there was kind of a huge basic educational training needed so I managed to then demonstrate to the defence organisations that this is mainstream treatment, this is not peripheral care that we’re offering. And so they were bought they bought into it but on the premise that if dentist came into this industry of dental Sleep Medicine, they did so on the formal understanding that it was part of a team approach, and they need to require acquire the necessary sort of skill set, hand in hand with that, what I was trying to develop with the sleep physicians themselves was something that as a dental professional, we can instigate and do because one of the luxury positions where we have a humongous patient base. We know that sleep disorder breathing is actually far far more prevalent in the population than it is recognised. So, in developing a, if you like, pre questionnaire screening tool is what is what we all agreed that they thought it was an excellent idea and overwhelmingly supported this initiative. Once I demonstrated that to the defence organisations that the pathway that we were setting up for dental professionals coming into this would be the Firstly, you would gain an understanding of sleep disordered breathing because clearly we need to understand the condition. The analogy I sometimes give is if you diagnose someone as having a name yeah yes you might give them some iron supplement tablets or bitten. You know B or whatever you felt was they were short on But fundamentally, our cause is to know why they got the anaemia what is the underlying cause of that. And same in this scenario we can treat snoring and sleep apnea, but we need to have a better understanding that the diagnosis is established, and as a dental professional we’re not capable, or indeed trained to diagnose we’re not medical professionals and we don’t need to pretend to be either. What we can do, though, is without patient base existing, we can apply some very simple screening questionnaires, one of which you refer to the Epworth sleepiness scale. And for those who are unfamiliar This is a again an Australian developed initiative. It’s eight basic questions which ask a patient their probability of falling asleep during daytime, and they range from zero to three so you get a maximum score of 24. This gives us an indication of how sleepy this patient is because sleepiness if you like is a sort of a direct clinical outcome but it’s an indirect measure of what happens at night so these patients have to wake up completely fatigued. In addition, we developed one or two other questionnaires which will be pertinent to our care, so we put together this package and part of the you refer to very carefully ago that there’s a tear off which you sent to the GP. So in negotiating with the defence organisations what they wanted dentist to be trained in is one understanding of the condition. And secondly, a better understanding of what these devices do how they work and how you provide them. And finally the other feature you just touched on is the sort of appropriate level of follow up care that we instigate. So, all of this is well well well within our capabilities, but requires us to interface, a little bit. The analogy I often give is that as an orthodontist you might refer me a patient to the hospital for treatment, and my role is to provide care for that patient under your umbrella of general dental care, it would be highly inappropriate for me to take that patient and then to do a filling in them as an orthodontist not wish to. And what I would do then is I write back to you say just thank you very much your patients had their own treatment, and, over to you for their continued dental care. The same happens in the sleep world, the sleep physicians are, if you like the team leaders within that team is dentistry, an absolute second in the pecking order. It used to be ENT – ENT have progressively withdrawn, the levels of care that they’re prepared to provide because surgery out surgical outcomes aren’t particularly beneficial long term. Sadly, there’s no evidence to support the long term benefits to patients despite the optimism of the procedure, so you know you’re looking at CPAP appliances. So what why I instigators that as dental patients we provide the treatment. This is really easy treatment for us to undertake. But then we give the patient and we refer the patient back to their sleep physicians accordingly, or in some instances of snoring. We may liaise with the GP, because the GP, whether or not they have more training than you do after you’ve been on these courses. Nevertheless is medically qualified, and therefore has the indemnity to protect the patient’s care overall. That’s a long winded answer but I hope that makes sense [Jaz]I know but yeah I think I like the way that you ended that question about the medical professional yes they are the medical freshmen so they need to be taking a role, a role that unfortunate dentist we cannot fulfil what. To give you an example, I had one patient who I helped with a mandibular advancement after following the correct protocols of getting their stock bang for steepness scale and following up the patient for occlusal changes all the locks, but my stumbling point was the lack of knowledge and training of the medical threshold GP because my patient said to me, when I went to a GP. She looked really puzzled and views. So in some ways, do you think they’ll ever come a time where as dentists, you know, hopefully 10 years from now where our general sort of involvement in this is further advanced that we will be able to refer our patients directly to the sleep position for a sleep test because the more I read the more I’m thinking that hang on a minute these patients should be getting a sleep test. [Prof Ama]Okay, that’s a really good question because that now comes down to where we suspect the remit of the impending nice guidelines will sit. The challenge we have at the moment is that the NHS does not fund in the UK, the provision of these appliances per se, hence why we’ve probably not been at the forefront, back to a question about the states of pushing the guidelines, where this could all change profusely is that if there is NHS funding available. Now, it’s very much like you negotiating or contracting or patient back to me for orthodontic services. You become in primary care the provider of the care. And you could have passage, and liaison with the sleep physicians, so often I say to patients on the dentist on the course that if you get a patient for example who comes to you with a clear diagnosis of obstructive sleep apnea and for example is managing being managed on CPAP or not managed on CPAP. They somehow gain knowledge because the other thing that’s, there’s a disjointed is the patients do not associate dentists, at all with the condition of snoring or sleep apnea. Never in a month of Sundays would they think that their dentist is personally would help them. So that’s another educational cycle with we’re engaging with. But let’s assume that a patient came into your surgery and said to you know Jaz Listen, I understand. I saw a brochure or something that you’ve advertised that you managed snoring and sleep apnea. And I’ve been treated by a sleep physician I’ve been using this CPAP machine but I don’t tolerate it. And at the moment I haven’t got any treatment. Now, this is a fantastic opportunity for us as a dental profession to then engage with sleep physicians because as a sleep physician they have a responsibility to that patient’s care and they know it’s unfortunately being left in limbo if you like. So there’s an immediate have in your report that you start to establish and what I try to encourage you to embrace. It’s very interesting just because when I talk to sleep physicians and I’ve taught them a lot and presented conferences to them. You know that. They used to be all of what we could achieve now they know what we can achieve the principal questions we almost always is, where is, where are the dentists that we can provide, we can provide this care and we try and create an app available to the list of trained dentists that’s the key word. So, we don’t want for our own professionals and standards we clearly don’t want to get involved in this field if you haven’t had that basic training and it’s acquirable within an introductory course which is usually a day. And these courses, you’re going to find either aren’t commercially available to companies that sponsor these events and you know I’m on and others do the same. Alternatively, and equally We do that through the British society of dental Sleep Medicine. We do these introductory courses again to get you the sort of startup skill set and equally we work with you to try and keep you engaged and actually provide you additional training so we have follow members days and so forth, where we bring in invited speakers so it most certainly is something that we’re working hard towards because, and the feedback of much like you know you’re a living example of this that the feedback I get from patients or dental professionals and got involved in this is wow, you know, it’s quite humbling. When you get this gratitude bestowed upon you, because you think well actually, all I fundamentally did was a basic examination to impressions, and possibly a bite registration. And in respect in return for that. You know I’ve changed someone’s quality of life, to really quite an effectual level. [Jaz]Brilliant. Well, the reason I took it further and further is my interest lies in occlusion parafunction, managing my bruxism patients and then I came across some research that actually when you treat the airway with example a mandibular advancement splint that actually do reduce the parafunctional events. Now I know you are very evidence based orthodontists, have you. You think there is good enough evidence to support the correlation between sleep disordered breathing and parafunction. [Prof Ama]Yeah, I mean that’s a very very good point yes and I think. But I think one thing I do like to try and dispel is that practising evidence based dentistry is that you know there are three pillars upon what it sits. One of them is the research what does the research tell us and that is obviously pivotally an important a good resource for us. The other second sort of pillar if you like of this tripod is that it depends very much on your clinical experience as well because clinical experience has an awful lot to offer not everything is susceptible or amenable to, you know, crucial microscopic level research. And the third factor in all of this is the patient’s concerns of wishes. So, if you think of that tripod and you put a patient in the middle of that you say okay where’s the evidence for this. So, the first thing to say the reassuring thing is there is an association a strong association between parafunctional habit and sleep disordered breathing. There was some very good research published in the Journal of Applied physiology which demonstrates that essentially what happens to these patients will go back to their physiology just for a moment, because their airway is obstructed, the oxygen levels are beginning to diminish the co2 levels are beginning to write this rise in co2, can cause increased parafunctional activity, for example a massive has been shown to increase and hyper hyperflex and hypertense. So, then, you know, I never quite made that correlation for quite a while actually because anecdotally when I started to treat up the numbers of these patients and when I was doing my PhD patients would frequently come back to me and say one of the observations that that Dentists have noticed, noted is that they’re no longer fracturing their restoration so if you imagine the population we’re treating, they’ve got these large amalgam MODS which were put in, you know, back in the back in the day sort of four decades ago almost, very little customer support and they were fracturing these restorations that compromise the fit of the device, but all equally made more work for the, for the profession, and I hadn’t really quite thought about it in those lights until I started to read this literature, and I thought well actually, we are having a beneficial effect, not only are we, by putting a splint between the teeth stopping the fact that the teeth are contacting the teeth. But equally if we’re reducing the co2 levels which we clearly do, then the activity of those muscles is most definitely reduced as well. So, You know, I think. Your, your clinical experience is well supported by evidence as well, and it has a lot of the patient feedback you’re getting if you put three together. You have a good evidence based practice. [Jaz]Brilliant so it’s good to know that I haven’t been brainwashed by by the wrong type of evidence, if you like, but you know what I one thing I do do is when I whenever I prescribe such an appliance, the one that as far as do I believe is called asleep. Well, it’s got the metal portion and then they come back with all these scratches in the in the metal too which is obviously them in a lateral sort of a left to right so ParaFunctions I, I like to take a photo I’m a geek like I like take a photo of those crunches I show the patient and, and also stuff but it’s a it’s very interesting and that so I mean for those listening and watching right now I’m thinking you realise already that there’s so much more to this that this episode should really be like something to whet your appetite. And I think I am certainly waiting for these guidelines to come out I think wow what a great thing that’ll be from refreshing UK to take things forward. [Prof Ama]The other thing, Jaz, I think is often people ask me you know as a dentist Should I get involved in this. And one of the things I can say with absolute confidence that I don’t say a lot of things with absolute confidence but this I can say to you is that when you go into any innovation in dentistry you know there’s always a learning curve where you never want to get into something but we’re on the on the climbing good of that learning curve because no one wants to be a guinea pig and no one’s patient when they’re paying for treatment wants to be at that end of the spectrum, we’ve we’ve got a very much of a plateau environment at the moment, because when I first started this field. I was inundated from dentists technologists around the world with devices that were being designed, literally month by month, they’d say to me, would you would you like to travel this device. I can safely say that’s all stopped, and it stopped because we’ve reached relatively a happy medium where at this point what I termed as, third generation devices. The device that you referred to earlier is almost a first generation device. So what makes us so powerful and so effective at the moment is that we can offer a device to a patient, which if you imagine if you put anything into someone’s mouth, it’s foreign it’s uncomfortable retreating huddles them, particularly warm to it, add to that, a protrusion of their mandible now you’ve got the ability to cause a muscle discomfort toothache and all the other added symptoms, and if you’re treating a snore you’ve just given him enough motivation to not use your device, where we’ve arrived at now is that we fit these devices in relatively neutral position. There’s no protrusion added to that there’s no necessary need for it. And this was taken really from C pap because what we realised in C pap is that no patient arrives gets a diagnosis sleep apnea and has a pressure of let’s say 10 centimetres of water whacked on them because that would be immensely high and literally intolerable. So what they do is they build up the pressure because the patient adapts to it. And that’s exactly what we’ve created so we have what’s called titratable mandibular devices. And there’s a really good, solid evidence base for this now, and patient acceptance is phenomenal. It really is good because we’ve, we’ve almost minimised the unwanted effects by one. But the majority are not increasing or experiencing that level of discomfort that was, was was, hand in hand with initial treatment. So from that point of view I would say to you know dentists getting involved, definitely good time, and you’ll be amazed at the kind of outcomes you get. [Jaz] I’ve been, I’ve been very happy with my patients are happy so I’m happy but it’s a, I think it’s an area I do want to learn more about and how I can take it further. So I am cautious when I can’t, you know, when I prescribes appliance I know that still is an area, developing within our profession. And like you said, sometimes being an early adopter, and that now is reaching a plateau which is which is which is good to know but I had just a few more questions now because I think people realise. Okay, this is gonna be like a something to whet their appetite, but some people may have come across this term. I came across it from USA orthodontists marketing themselves as airway friendly, Orthodontist. And when I, when I looked in further into this, these are orthodontists which are the type of treatment they’re doing is very much a MARPE or S.A.R.P.E so there’s this thing that’s micro implant assisted rapidly platelet expansion or surgically assisted. Is that overkill or is that strong is that good evidence that that is the way to be more, you know, comprehensive treating the patient as a whole, rather than just the standard orthodontics with you if you’d like. [Prof Ama]Yeah, I think this is good, this. There is a degree of controversy about this topic. So the first thing I would say is that we need to distinguish two patient populations here. What we’ve been primarily talking about his adult population so we’re talking about individuals over the age of 18. Otherwise we’re talking about young patients, and when the young patients were going from children up to 18 Let’s see. The reason we have the distinguishing features is primarily a reflection of growth and growth potential. So, in the world of the adult therapy, which is where we primarily trained the dental professions and the dentist is because there’s very little variability in that field it’s a safe environment because you’re not dealing with an adult who’s growing likely to encompass different changes and responses to treatment is pretty fairly predictable. Generally I would always recommend that as a dentist you don’t go into the field of young. people’s treatment because especially with any sort of sleep disorder, primarily because you’ve really got to have a very very very good grasp of the underlying tissues, and the response of these tissues to age change, alone, let alone the treatment modality. So I recently was invited to speak at an international meeting where my remit was pre-, let’s say adolescent and pre adolescent and the goal I was given is address the question you just asked me, can S.A.R.P.E, should S.A.R.P.E be undertaken surgically assisted surgically assisted expansion is largely reserved for the adult population so now you’re expanding palates in adults, but surgically. And the thing I would say to any clinician and just be orthodontist be dead be under the whole umbrella of dentistry is, you know, if you want to take something, then you know nothing is free for life. If you’re going to expand some of these tools, quite considerably as what you have to do. Yes, there may be change, and it’s been shown that there is an improvement in the airway passage through the nasal passages. And that’s a distinguishing feature we need to make. If you improve the passage of air through the nasal passages that does not by definition guarantee that the back of the throat the airway tube that we were referring to gets the benefit. So yes, you’ll deliver more oxygen to that site of obstruction versus if you go back to the child patient if you start to treat, we do this treatment modalities, you probably know this is why you’ve got orthodontic friendly ones is that all they’ve done is they’ve. If you like expanded their role, inverted commas. So this rapid mixing or expansion therapy or playful expansion or splitting of a palette is largely reserved for children who have bilateral crossbites. So what you have to picture now is if you’ve got a child or an adult sitting there with a normal occlusion, and you split their palate, and we’re talking about a centimetre to affect the change. You’re having to leave them with bilateral scissor bites. So functionally they’re going to be in a very very bad place, and potentially go on to develop other symptoms and signs which are not going to be very helpful. So, I would hand on heart ear people towards caution in that respect. There are markets within America within Europe, other parts of the world where they do this fairly, what I would call was gung ho approach where they they’re they’re quite convinced by their evidence that this is effective, and yes, as I said, there is some good evidence to support short term benefits, but always there are some complication risk factors which can be quite considerable and and growing patient that you’ve got to bear in mind. And secondly, you’ve got to think long term for this patient population group because you know they are growing. So, initially I thought you were going to pose me that there are orthodontists who say their airway for me and then provided this treatment I was gonna say well, Orthodontist you know feel comfortable with this because we provide functional appliances for children so this is an extension of a functional pioneer in an adult, if you like. Yeah but, yeah, I think, and also, you know, the GDC are very very focused on us advertising within our capabilities and competencies so I think you’ve got to be very cautious promoting yourself but certainly if you train in dental Sleep Medicine, you know, that is bonafide recognised training. So, I think for anyone coming into this profession I would always err on the side of caution say stay safe initially get some experience behind you. And then the world is a more mega exciting place, treating snores for example is far, far less challenging than treating sleep apnea patients, and can be incredibly, just as rewarding. In that respect. I don’t know whether that answers that? [Jaz]No, it does. And that makes sense. But related to that, when I went, when I was looking more into some lectures here. Some theories by very eminent orthodontist in USA, they showed case reports or cases are treated of adults who had pre molar extractions, when they were younger as a first round of orthodontics. And then now, they were opening up these spaces again to place implants in to improve the airway. Yeah. Now, what that, what, what question that leads to for me is, is there any strong evidence to suggest that premolar extractions adversely affects the airway? [Prof Ama]In a simple word, NO. What we have to always be conscious of…And this goes back to these three pillars of evidence based practice. You can always look for literature that might support or impart support your practice, and you have to be slightly careful interpretation there. So, this whole, the challenge they’ve got in the states is that the whole provision of Orthodontic Care is in the private sector. And there are many many competing interests. Aside of the dental professionals getting involved in orthodontics so there’s the orthodontist and there’s a paediatric dentist who do this and every other profession is doing a version of. So somehow they’re trying to reinvent themselves. And, you know, it makes a lot of sense if you had to say to a patient well if I take teeth out in your mouth I’m going to make your jaw small make you feel smaller I’m going to impinge on your tone. What I can safely say to you is that even in patients in the opposite extreme where we try and open up the airway quite considerably let’s talk about the RME we said we’re expanding those patients a centimetre across the palate. Now an extraction is going to achieve. Best millimetres small millimetres two to three millimetres of expansion at very best. So where we expand them a centimetre 10 millimetres. We’re only affecting a small change in the nasal passage of air measured very objectively and very reliably scientifically. So then to extrapolate that and say well actually, if you extract teeth by definition closing the door, jaw like transverse dimension, you’re going to exacerbate snoring problems. It kinda doesn’t really add up. And if I went one further than that and said to you really tested this theory by actually taking patients with a class three jaw, breaking their jaw doing an osteotomy for them because as you know we treat class threes. One of the things we were interested to know is if you treated a class three patient group, it was a move the jaw back naturally you’re impinging on the tongue space, quite considerably. Do we create these patients snoring and sleep apnea, and then short and midterm results were No, we didn’t. So, where are we physically moving the jaws backward we don’t impinge on it. The thing about the airway and its collapse, is that no one true one treat modality addresses all patients and this is the complexity of it. It’s multifactorial it’s anatomical, so see puppets that theory or appliances have their effect on the anatomy. But there’s also a strong underlying physiological tendency back to the muscles again. And this is where there are emerging schools of thought at the moment about using muscle stimulation exercises or electrical stimulation so there’s a number of multicenter studies going on around the world looking at this. And these have shown some exciting results in selected populations. In other words, there are those patients who have the physiological problem, but not necessarily the anatomical problem. And this is why the results tend to be slightly varied when you look at outcomes, all appliances. Generally speaking, we do incredibly, incredibly well because we’ve shown that their role is not just anatomical there is a physiological reaction to that we do stimulate a [ ? ] with every muscle activity. And so we kind of hit a number of spheres and vectors. But yeah, I think it’s in that space is definitely evolving [Jaz]Brilliant and so the last question, Prof, I have for you is just based on my own observations and something that you know I spoke to some of my listeners I said look I’m getting Prof Johal on, any questions for him? and one question I got was, I sometimes see children with large tonsils and signs of mouth breathing. Should I be concerned and what can I do about that? [Prof Ama]And that is a very good question because. So this is where the nasal passage does have potentially can have an impact on mouth breathing, and possibly obstructive sleep apnea as well. So this is what I was saying to you that there are snippets of research which are very relevant to this field as well. So if you have a child with enlarged tonsils or adenoids. Typically, that will cause and as you probably remember back to your BDS days there are remind you of them, but lymphoid tissue follows a very specific growth curve, away from somatic growth, General Growth and lymphoid tissue. And if you like accelerates up to puberty, and then starts to shrink away so this is why tonsils and adenoids were routinely being removed in the adolescent phase because children would obstruct or snore. Quite profusely. And, you know, teenagers, it was called tonsils and adenoids was a routine procedure. So the reality is if the back of the nasal passage’s blocked, then the child does become a mouth breather. The problem for us as a mouth breathers is that humans are obligatory nasal breathe. So if we breathe through your mouth, a jaw is lowered by definition that potentially can impinge on tongue space, which potentially that can cause Sleep Disorder breathing. So, there is this relationship most definitely that we wouldn’t deny. And so in children for example if you’re suspicious of this is certainly worth getting an ENT opinion because again it’s an invasive procedure as you probably know the government changed the guidelines in early 2019 regarding tonsils and adenoids. So most of us as a dental professional more likely now to engage and encourage or see observer should see patients with enlarged tonsils and adenoids because they’re not routinely been removed. If you do have that concern my first, the first protocol would be to refer them for an ENT and [Jaz]Via the GP right? They’ll be via the GP [Prof Ama]Via the GP. Yes of course sorry yes because the GPS are the gatekeepers of the commission of the fund if you like. Just again just to elaborate just to show you the potency of this intervention in children first line strategy for sleep disorder breathing and snoring and sleep apnea is to consider removing toxins in adults, that is how high and pivotal it is. So I think you made a really good point really, and that is something again as a dental profession, we can certainly be observant of. [Jaz]I think as a you know certainly some years ago I was not looking for this stuff as actively, it’s only through learning more and developing more interest that I’m actually observing for the signs and the role that the tongue plays in the sort of expansion of the maxilla. So it’s really quite interesting and I think we can sort of conclude that watch this space, in terms of airway and how as dentists we can get more and more involved. Prof, Are there any final things that you’d like to you know you have the microphone to general dentists in the nation and the world, anything you’d like to add? [Prof Ama]Yeah, I mean what I would say is firstly I would implore you to get involved, I think it will descend in ritual practice, add variety to your day. As a when you choose to get involved. Look for a certified course, and that will provide you that basic introduction level, and ongoing support as well. And, certainly if you’re in the UK. Yeah, let’s await the publication of this report but irrespective of what this report say is that this these patients are not going to go away, and they’re just as demanding and needing of care. And so yeah i’d implore you to get involved and I’m very very happy to hear from you know from questions and be able to get in touch with me as well but we were pushing hard to develop the Academy. And the Association, the Bridgestone Society for Dental Sleep Medicine so that would be an excellent protocol as well. [Jaz]Well, what I’d love for you prof is if you don’t mind just emailing me a few links perhaps that I could leave as the footnote to this podcast episode for dentists who I think a lot of dentists will be interested in because this is an area that generally a lot of dentists feel like they’re very uncomfortable with. They don’t know enough. So I think there’s lots of hungry dentists for knowledge. So if you can provide a few resources, whether it’s, you know, be the British Academy of Dental Sleep or private companies whatever just anyway we’ve gained some knowledge we’d appreciate that. [Prof Ama]Yeah. Absolutely. I’ll happily do that. [Jaz]Well, thank you very much. [Prof Ama]Thank you. It’s been a pleasure. Thank you. Jaz’s Outro: Well, there we are. I hope you enjoyed that episode. I’m sure it was something very different. I hope you found some useful takeaway points about the role of airway, perhaps you’re going to start introducing this to your practice. So I want to say thanks to Matt Everett, who helped me get in touch with Prof Ama Johal. And they’ve got some airway online courses. So I’m gonna put a link to that. There is a 50% discount until the end of August, I’m told from Matt. So this is the course that I did when I started to prescribe the sleep well appliances. So I’ll put that in the on the website protrusive.co.uk/airway so that if you’re interested, you can join that. And when the NICE guidelines are out, I’ll also stick it on that web page dedicated to the episode. So thanks again for joining me, I think next episode, I will let you guys decide. I have, you know, the fact that this is recording April, you get an idea that actually I have got a bit of a backlog. I’m in a sort of good position, I’ve got so much awesome content ready to go. It’s just about finding the time and actually spreading it out a little bit. So the next episode, you will get to decide what it is. So watch the Instagram that’s @jazzygulati and Protrusive Dental community. So if you’re like, you really enjoy the podcast, and you want get involved more with the people who listen to the podcast, then join the Protrusive Dental community Facebook group, because these are two places that I’m putting the polls so you can decide which episode will be next. So thanks so much for listening, and I’ll catch you in the next one.

Dental Recruitment is Changing! https://youtu.be/1WmvW9-1YWE Need to Read it? Check out the Full Episode Transcript below! Would you rather work in a lavish dental clinic with all the bells and whistles, but with a high turnover of nurses and lacking a culture or ethos…OR, work in a ‘mediocre’ clinic with happy staff and a thriving culture? What makes an awesome dental practice, and how can associates and therapists find them? Where are they hiding? Are they as rare as a ‘good associate’? What is that even about? In the latest episode I chat with Andy Saunders and Simon Tucker about how dental recruitment has evolved – it is a purpose built episode if you are looking for a new opportunity or even if you are a principal looking to hire the right team member. We discuss: Why traditional methods of hiring Dentists, Therapists and Nurses may not be effective or good value any more The three types of CVs you need The power of the Video CV Importance of the same values within the team How to find your ‘tribe’ and the practice you belong in (and why you cannot just go by what their website looks like) The features and indicators we SHOULD be looking for in a new practice If you like the new face of dental recruitment (or finally, just a face!) and want Andy and Openwide to help you, reach out to Andy! Click below for full episode transcript: Opening Snippet: Hello, Simon Tucker and Andy Saunders and welcome everyone who's listening to the Protrusive Dental podcast today... Jaz’s Introduction: This episode is all about careers as an associate and a bit of a continuation of the episode I did about finding an associate position and about your CVS. It’s a very hot, sunny day today, end of June. Main Interview: [Jaz]So Gentlemen, thank you so much for joining me if you just kindly introduce yourselves, and tell us about why I might have interfered in terms of what you think why I’ve got you on the episode today to talk about finding an associate position and start with you, Andy. [Andy]Yeah, yeah. Good afternoon. My name is Andy Saunders, as you alluded to, I am the founder of the Openwide Group. We’re a careers consultancy for the dental industry. I’ve got a bit of a different take on how I believe recruitment should be undertaken. I have over 10 years experience of running a recruitment business, we launched it, we took it from naught to 25 million in eight years, it was then sold to one of the big boys. So I feel that I’m in quite a good position to tell people how to position themselves so that they are maximizing their output for how they can best show themselves off to potential new principals. They might want to be owning their own practice how they can then recruit their own associates. But ultimately, I’m really passionate about how dentists A) how they recruit. And we’ve come up with a mythology, the three R’s of recruitment, which I’m sure will allude to a bit later on, or [Jaz]Andy, I think what you’re doing is you’re taking your experience from your recruitment of days, in these successful companies that you know, help with, and you’re bringing that into the dental industry, you really shaking it up. And the reason I wanted to bring you on is because one thing you said to me was ‘how CVS are now changing,’ because over the past few weeks, I’ve been involved with helping lots of dentists with their CVS, because then, you know, then, since that episode I released about CVS, they’ve been sending me their CVS for my opinion. And I’ve been happy to help. But one thing that you told me about how CVS may not be the best way anymore, that really say the back of my mind, and I really want to talk about that today, as well, Simon, please tell us a little about yourself. [Simon]Hello, Jaz, thanks for inviting me on. I’m a salesman. And for over 35 years of my life, I’ve been selling dental products and services, to dental practices all over the world. I’ve lived in the States, I’ve worked in Australia, worked in Europe. In the last seven years, I spent most of my time helping dentists and their teams communicate more effectively with patients. And that’s based on understanding the fact that patients have an emotional attachment to their mouth or their mouth health. And so it’s really changing the mindset of dental teams in terms of looking at the patient as a person rather than just as a set of teeth and a practical solution to their problems. And I think that whole philosophy comes from the fact that dentistry is such a personal service, now involves touching whenever a patient comes into the dentist, they’re going to get their fingers in their mouth. So it’s such a personal service. And I’ve seen over my 40 years of experience that actually the whole of dental practice relies on that personal connection. So a personal connection between the dentist, the dentist or the principal, the principal and their associates, the principal, associates and the therapists, hygienists, nurses, reception staff, there really has to be that personal connection. When I started talking to Andy about how we could shake up the dental recruitment market. The section that was missing from recruitment in general, I think, not just in dentistry, but in my experience of recruitment is totally non personal. It’s about, you know, getting CVS out there really quickly and filtering through them electronically, not even in you know, in my days, when I was recruiting, I actually read every CV that came in, now they’re scanned by a machine, so you can get rejected because you don’t have the right keywords in your CV. So what Andy’s doing is building a network, which is a true network of people, that we as a team can then say, actually, we know this practice, and we know this associate or this Hygienist, Therapist, this Nurse, he’d be a really good fit, because we know them, we’ve got to know them not just through their CV. So that’s why I’m involved. I think it’s a great personal connection. And it’s great. [Jaz]Well, it sounds exactly that a very personal thing. I mean, from my knowledge that I have in my experience was a lot of my friends are principals and every time I think maybe 5-7 years ago, the place to advertise a job vacancy for an associate would would have been BDJ jobs, which I don’t think is the place anymore. But back then, even I had applied for some associate positions, maybe you know, six years ago, via BDJ jobs and never hear anything back because then I found out that that principal had received 400 CVs or thereabout. And really, how can an associate stand out on a piece of paper and that’s where Andy, I think you come in what you told me was the role Have a video and that really, you know, you know, I’m a massive fan of video myself with all the things I do, and just blew my mind. So just keep telling me about how the CV might be dead and what, how you’re going to shake it up with the dental recruitment with videos, maybe? [Andy]So, but my big thing is I don’t I’m not so sure that the CV is dead. My big thing is, how do you get that personality across on a blank piece of a4 paper with some black and white text? It is impossible. And that also has changed from the set probably the 1950s where the first CV was written, we’re not 70 years old. Look at the world of technology, look at everything, you have to tell me that that has to change. So it has to be dead. In that sense, it has to be dead. However, I think now people need to have three CVS, if I’m really honest, I think they need to have a CV, which they will send to recruitment agencies who fill to them, like Simon said with the keywords. And they need to they need to have those keywords on them. So pretty boring. Again, it’s a boring it’s a blank, dull dull document. But it gets you through to the barriers to be able to speak to that [Jaz]the first hurdle. [Andy]Yeah, it’s dull, it’s horrible. But unfortunately, the we’re still living in a world where it has to be done. You then I believe you need your second CV, which is what you would if you were approaching a principal on a practice directly, which needs to be a little bit more colorful, it needs to have your picture on it. It needs to give a little bit more background about you as an individual and not necessarily your skill set, purely and simply because what we’ve just alluded to you both said it’s a personal, such a personal industry dentistry. And then there’s the third CV, which is what we here at Openwide are all about and that’s your video CV. And this is where you set yourself apart from everybody else. And it’s what we here at Openwide are all about. We’re all about your personality, how you communicate, and how you put yourself across. Again, we all alluded to at the beginning that dentistry is such a personal industry. There is no better way of putting out your across your personality than on video. It also moves with the times if you look over social media at the moment, everywhere, it’s video, it’s you’ve got your video, you’ve got it in your pocket, you will probably [Jaz]Can I just challenge your idea if that’s okay? To see if it’s got legs. So when you first told me that Firstly, I was really excited. I was Okay, that sounds really clever. Because how much can you actually convey through paper? And it makes sense to video. But the issue is, sometimes I’ve taught, I’ve given advice to young dentists that look if you’re, you should be proud of the service you gave and you’ve done so many courses and you’re obviously a fantastic candidate. Why don’t you go on some of these groups and say, Look, I’m so and so I’ve got I’ve got this, this and this. Here’s my portfolio. Here’s my CV. Hire me. Okay? And people are timid, shy, afraid to do that because that’s really you put your head above the parapet so people with video, they, how can you help to get the best out of someone through video, so they don’t feel shy or timid or afraid. So that’s one of the challenges I had in my head. [Andy]Definitely, definitely So on that note, we do not just dive in with a video, we will not just suddenly say you might apply for a position that we’re looking for, we might be speaking to you [inaudible] hit the record button, we are going to have, that there is a process that we go through. It’s probably three stages. We will sit down and we’ll have an initial chat with you. Let’s get to know you a little bit as a person, your morals and your values, [inaudible] with us here at Openwide, if so, great. We then have a 90 minute debrief. So we will sit down and do a video call maybe beyond a video call purely simply just because it gets you used to the camera, you used to speaking to me this way. We have that 90 minute debrief is all about you both professionally and personally. So it takes out all of the anxiety that you might have of being on camera, it takes away all of the scared element, putting your head above the parapet as you put it, it takes all that away. I’ve now probably spent two hours with your company just over two hours, I’ve got to know you really well. I will now go away or we as a team go away. And we’ll work out how we feel is best to record this scenario. We might feel that it’s best to do it on a zoom call. We might feel that it’s best for you just to go away and practice on your own with your iPhone, you might feel comfortable doing on your own on your own in your bedroom. It’s really how you prefer to do it and what gives you the confidence to do it. It is very difficult, as you said, to put your head above that parapet, we, however, will lay out everything and hold your hand the whole way through that process. We are fantastic editors as well that can edit that footage down. So that we are putting you across in the best light, we would never also put that footage out there if you weren’t happy with it. And that’s something I really want to stress with. Because you have to be happy with what is going out there in that content, there’s nothing worse than suddenly seeing a video of yourself and go, Oh my god, I don’t like that, oh my god, my hair looks like, what am I, look my teeth, look, whatever that might be. There’s nothing worse than that. And we want to empower you and make you confident. But that is the data three CVS that you have to worry about today. But the one which is going to get you the most traction by a shadow of a doubt is your video CV. It’s going to give you that personality, it’s also going to save you time in you might be relocating, unless you’re relocating from Scotland down to London, you’re not going to want to travel down to see one practice at a time. In your video, you can get out there to five or six practices in the span of 20 minutes. And you will just be a hell of a lot more confident also go forward, it will benefit you in your job on a day to day basis. [Jaz]I think on the receiving end of the video. Yeah, I think on the receiving end as a practice principal, seeing this video compared to just paper CVs, you know, in a professional light, and you get to connect and you get to know what someone’s about. And you touched on something there about values and I’m so big on the importance of values and and how they should align. Simon, you’re so well connected in dentistry. You know, loads of associates, those principals, business owners. There are often stories about how associates and principals perhaps have clashes or teams have a toxic culture. Tell us about your experience, perhaps in the past, and why it’s important to get those values to line up. [Simon]I think it’s critical, Jaz, in any business, I don’t care what business you’re in, if you don’t have people that share the same values as you, you’re going to clash. You know, I know from experience having run small businesses and big businesses, your biggest headache in any business is not money. It’s not marketing, it’s not sales, it’s people. So and in a dental practice, again, because it’s a very intense atmosphere, you know, there’s a lot of stress from the clients from the patients a lot of stress for each other, a lot of part time staff, a lot of hand over information, close working environment. So there’s a lot of pressure, it’s very busy. So if those team members don’t really gel together, you’re going to get clashes, you’re gonna get difficulties, and that just gonna spoil the day every day. So one of the exercise I go through with every client, even when I’m just doing communication skills training is to get into a values exercise, I’ve got a couple of ways of doing it. But we’ll do this with every candidate that comes in, we’re and every practice. So it’s a simple exercise, we’ll get their values nailed down. And then when the cap, so we’ve got our practice values of the owners, and maybe some of the team members, and then we get the candidates values. And we’ll put them into a matrix and see where the common ground is. So we’re never going to match an associate or a hygienist therapist or anybody else with a practice where there isn’t some common ground because that would just, so no point even connects them in the first place. Let’s get we’ll do that bit. And then through the use of video, we’ll be coaching the candidate to say, Okay, these are my values, this is who I am. And if you really nail down your personal values, they don’t change, that is who you are. And there’s no right or wrong values necessarily. It’s but when you’re, if you’re a bit of an introvert, which a lot of dentists and dental people are because it’s you know what, I’m working in this field all day. So I’m fine. I don’t need to speak to people, that’s fine. But to get that across on video, what you really are about and what you care about. If you focus on your five values, I usually get five words so that they’re their five core values if you focus on those. And as answered, go away and practice it in front of mirror with a friend or family member will coach you through it. But just get that across in the video on one of the questions I asked every audience I ever lecture to or every whatever work with is, why did you become a clinician? Why do you become a dentist or hygienists? And I’ve had some amazing answer, most of it is well because it was in the family or because I care or because I’m an artist and an engineer and I want to do something medical. The best one I’ve ever heard was a dentist. He was in Greece, he was in a big audience and he said ‘I became a dentist because my wife’s a dentist’ and I said ‘Tell me more.’ And he said ‘Well, I was on the architectural course at university and I met my now wife, you know, in the first year so I switched courses just so I could be with her.’ So he changed from architecture to dentistry just so he could be with her as well. Now that is a story isn’t it? You know if that’s on the practice video that’s on the practice corporate video if you like and I’m an associate Or a hygienist therapist that, you know likes that kind of family story, that family business, that family connection? Well, there’s an instant, I want to go meet them. So that’s what we’re really talking about. It’s looking at your core values, who you are as a person, you know, all the other stuff’s important on your qualifications and what you’ve done outside of work. But actually, we want to know you as a person. The principals want to know who you are as a person, because dentistry is no longer bring patients in and diagnose, treat to the best of your ability. It’s bring patients in, understand them as people, diagnose the clinical situation, then diagnose the warmth of the why of the patient. So, you know, every dentist, every practice does that differently. So we’ve got to try and match the right candidate with the right practice. And it’ll save as early said, it’ll save an awful lot of time. And you know, just say that in CVS, because we’ll do all that work in the background say, right, we think we found three practices, Jaz, just for you, they all aligned with your values, we think you’ll like them. And then you make the choice. [Jaz][overlapping conversation] deep and profound. Yeah. [Andy]Sorry, I think that also backs up why the CV is dead. Because if somebody was to write on there their five values, whatever they might be, I’m sorry, but most people are gonna look at that and go, Well, that’s a bs, it’s just not true. They’re not going to believe it. Whereas if they see it on a video, and they can see that emotion behind that person, and you can tell whether somebody is an outgoing spoken person, or what type of personality they are, from the video that’s created, you’re more likely to believe that than you are, with an a4 piece of paper, like you said, there’s 400 applicants, they’ve all got the same thing. And you get if you’re going to sit there and read all of those, by the time you get to the 350th one, and you read the same five values, you’re going to be go, I don’t believe this. It’s a low [touch,] where is you’re not going to do that on a video. [Jaz]That and also, one thing I really respect and resonate with is and what you said there, Simon, you mentioned about stories and values, but also about stories and everyone, whether you, you know, accept it or not, you have a story, you have a journey, you are unique because of the experiences that you’ve had. And that also feeds into your values and your belief system. And so to have a story conveyed through your video, even if it’s like a 90-second video about you saying, look, this is what I care about, this one about as a dentist, and that conveys a story that is so much more engaging and memorable. So that’s why I think your idea was genius, willing to do to help connect the right, you know, dentists with the right principals, and vice versa. So that’s great. The next thing I want to ask is to make sure that those in associates listening and principals to get the most value from this segment is how can you help associates find the right tribe, find the right culture that they belong in? So one thing I have thought about is, yes, to speak to the principal and look at they’re just, I mean, what can you do other than go on their website and try and suss out from their website, what kind of people they are, but that doesn’t really do its value. So how can you get people through their homework correctly to make sure that they’re selecting the correct partners essentially? [Andy]So what we like to take a lot of that way, from the associates going and doing a lot of that digging, as I alluded to, I’ve been in recruitment for probably about 10 years. And over the last two or three years, I’ve been working really hard on what I call the three R’s of recruitment mythology. And that is the REACH of a candidate, how to ecruit a candidate, and how to RETAIN a candidate. Okay, in this sense, let’s say it’s an associate or hygienist or nurse, not necessarily a candidate. Let’s bring them to life a bit more. And from an Associates point of view or a hygienist point of view, if that dental practice is working with us, they straight away they’re demonstrating that they invested not only in their business, but in their team and in the future. Because we’re teaching all three of those parapets, whereas 90% of recruitment agencies will only teach them, well, they won’t teach them anything. They’ll go away and tell them that we’ll do the recruitment segment for them. What do we do for our practices, not only do we teach them that, but we also go behind the video the practice. So we create a corporate video for that practice. That will be a walkthrough of the practice. There will be interviews with staff members. There’ll be sit down interviews with principals when other dentists, hygienists, people in the practice, really getting under the skin of that practice. Because as you said, you can go on their website, but a website it’s a bit like a paper CV if I want it. It’s just a blank piece of paper that we have decided, what we’re going to put on it to showcase ourself in the best light, which obviously you’re going to, but what why would you not? So what we want to do is we actually want to just get to know what the real person is, the real practices and will also [Jaz]But also via video, so the practice would also have their own sort of, [Andy]yeah, they have their own account and their own profiles, on our site, it’s a walkthrough. So we do, not only do we do a walkthrough video, where we’ll talk to a couple of members, and you’ll actually get to physically see what the practice looks like. We also then sit down with the principal and one or two others to do the video job description. Again, it’s no copy and paste, it’s a conversation on video, where you get to see the whites of the eyes of the principal, you get to really find out why they’re looking to recruit. So you so not only, so it’s the same on both sides, this is their chance to put their video CV across in a sense, although it’s the job description, it’s why they’re recruiting. So we unearth a lot of that, we go to market to unearth an awful lot of the finding out about the practice for you. Now, [Jaz]Andy, can I just interject and say that I the immediate benefit I see there in a post COVID world is, it saves you at least one visit because often, you know you think in applying let me go check out that practice, right? Because that’s the first thing I want to do. Let me go check it out. Let me see what the receptionist might. Let me see how big or small the surgery is. Let me see how ergonomic the places or whatever. So you do all that. But you know, the human sign that comes across would be amazing. And you might decide okay, that perhaps not for me. Or you might find that yet this practice really resonates for me far more than others because of whatever reason that comes across in that video. So I think it can definitely save associates a visit, especially they’re relocating to have to accept from Scotland to London, that is quite clever. [Andy]I think that’s the biggest thing I think you hit on the head there is that it saves the time. And it also eliminates, it’s the elimination, you as an associate can look at our practice and go ‘Wow, that is not the part, that is just not the principle I want to work for. That practice doesn’t share the values that I share, I think there will already be a personality clash.’ And that is absolutely, in my opinion, that’s gold dust. You’ve saved everyone time, effort, money, you name it, it’s all being saved. And I think the other great thing about it is you haven’t had to hurt anyone’s feelings along the way. So an associate hasn’t had to turn around and say, That’s not the practice for me. But vice versa. A principal doesn’t have to turn around and say, that’s not the associate for me. And we do with video, if you do, you can offend people and it can upset people’s not being chosen for something is horrible. And we eliminate all of that straightaway. Just to give you an answer, then I mean, that’s what we do at Openwide to eliminate those barriers and how you do the research. If you do see a position or a practice that you want to do, what would I be going to do to dig a little bit further? I would want to make sure that there were certain things on their website. So the About Us, I wouldn’t want it just to be about the practice, I would want there to be a section where you get to meet the team and get to find out what their values are, what each individual team member is. I would also be making sure that everything on that website is up to date, I would be going and checking out all social media profiles, not only of the practice, but of the people that work within that practice. [Jaz]stalker level expert. [Andy]Apologies. [Jaz]Has to be done. I’m going to do the day work. [Andy]Yeah, but you I think, and this is where I think a lot of people forget your career. And what you do for a living in a lot of cases it can define that person, issued, what you got to get up and go to this place every day for five, six, maybe six days a week, and you’re in there from eight in the morning and your first patients maybe eight in the morning and your last patient maybe six at night. That’s a huge chunk of your life. The responsibility on making sure that that’s the right practice for you and that the personalities fit is huge. And I think that is one thing that is one of the reasons our industry gets a bad reputation is because they do as we alluded to at the beginning just throw CVS they don’t care and it’s all about making money. Just the money is just a completely bystandard if you’re good at what you do you’ll make a shitload of money anyway. [Jaz]Absolutely. Yeah. As always, you say man, is that the Money is a you know, once you’re good at what you do that will come when you’re especially when you’re young dentist, I think worked to learn rather than to earn I think earn can compound itself later, I think to find a mentor. And I think that’s where with the video you get to learn can will this dentist principle, make a good mentor? Because that’s what associates want nowadays they want mentors as well. The next question I’m going to just have a look is Simon and Andy, there’s a perception that is very difficult to find a good associate nowadays. I don’t know if you, you know, loads of principals, both of you. Have you heard that sort of saying, from a principal maybe moaning about their associate? Why do you think that exists? And what’s that about? [Simon]I do hear a lot. Yes. And I think a huge part of it is exactly the why Andy come up with this concept is because it’s all been reliant on CVS, dentist, generally, let’s be honest, there’s only so you might be working in your practice eight till six, as a dentist, the owner, so you’re not only the owner, the head of it, head of HR, head of finance, head of, you’re also head of clinical, so you’re a busy person. And you work in a 12 by 12 room all day. So you’re not necessarily connected, you know, very frequently to go to a meeting or, you know, clinical course. So, perhaps the only way you know to recruit is to get CVS and start sifting through them. So as we’ve said, already, you can’t tell from a paper CV, what that person is like. And what we’re trying to do is make it so much easier for the practice to say Actually, we like that person, because as you said, associates and other clinicians, so I guess therapists and nurses want to know about the practice are going to join. Now I’ve looked at hundreds of, well thousands of websites for dental practice all over the world, I [mystery shot] practice is when I’m going to before I’m going to work with them as a trainer. So I’ll go in as a patient, if I can get away with it, if nobody knows me. So what you see on the website is rarely what you see when you get there. So if you’re an associate or another clinician looking for position, the website will only tell you so much. So our aim is to get behind that. So you don’t have to do all the research. But also, as Andy’s alluded to, if we can get the principal on video and the owners of the business and some of the other staff that have worked there for a while on video, explaining who they are, what the business about, you suddenly get a whole lot more communication and knowledge. So there are hundreds and hundreds of really, really talented associates, hygienists, therapists, dental nurses in the market, hundreds of them. A lot of them are unhappy in unhappy places, because there’s just not a match between their values and the practice they’re working in values. But [Jaz]I just want to pick on one thing you said there, yeah, I just want to on one very important thing you said there. And something no one ever talks about. When dentists are looking for a new position, they look at the practice. They’re looking in principle, they look at whether they’ve got rotary endo, whether it what percentage, there are all those things, right? And the nurse is someone who you meet on your first day at work, once you’ve, you know, gone through all the hurdles, you’ve shaken the hand, you sign the contract, then you meet the nurse. But I think I’m as a dentist, I’m I you know, I’d actually rather work in a practice that is not all bells and whistles, that is not everything I wanted. But the nurse is amazing. That actually speaks volumes to me as someone who’s going to work there eight to six, six days a week or whatever, than having an amazing practice with a high turnover of nurses, or nurses who just don’t allow it to just come in. And it’s just another work then and just can constantly thinking about going home and they’re not really engaged at work. So I think I just thought of it now that what you guys can sort of help to do is not only connect the dentist to the practice, but the wider team and I think they put the emphasis on the nurses I think because not so so important. [Simon]Jaz, you and I both know, so I’ve been my when I first started selling in dentistry, I was selling toothbrushes to dentists and most of the people I met were either hygienist or dental nurses. And I did a lot of talks at dental schools to nurses in training to hygienists and training because that was the time to get them in terms of getting on board with your products. But you and I both know how fundamentally important it is to a good working day to have an excellent dental system. Because, you know, if you’re just putting your hand out and they’re putting the right instrument in your hand, your day goes more smoothly, doesn’t it? You know, I know nurses have to be trained and they have to learn to work with you as a person because every dentist is different. But once they’ve done it, and I would say if I was an associate looking for a position. The first people I would want to speak to in a practice are actually the nurses to see how they are treated. Because if you’re treating the nurses well and the [dicom] nurses well, then you’re probably doing everything else well, as you said, the equipment and the practice is not as important and ultimately as an associate or as a hygienist. If you’re not happy with the instruments you’re given, buy your own. You can have, you know you can do it on their own. If you want to Yes, it’s lovely. They’ve got a CAD CAM. Yes, it’s lovely for got, you know, a panorama. Yes. It’s lovely if they got a CT scanner, but ultimately that relationship with a [CIP] biggest problem in business, people. Dentistry is a very people centric business. And if you’ve got great reception team, you’ve got great nursing team, you’ve got great DICOM team, you’ve probably got great clinicians. And you know, I would avoid like the plague of practice that is just regularly taking student nurses who are on apprenticeships at very low rate and changing them when they get another one, because that tells you a lot about the core values of that practice. And yes, we will be connecting nurses-hygienists, hygienists-therapists, into the same environment because it’s a team effort, you know, this is so important, [Jaz]I am going to be quality assuring this practice that the these are practices that have this sort of, that don’t have these sort of, you know, values that we just spoke about having respecting and treating the nurse as well, is that a part of your process in terms of which [Andy]100%, we, as I alluded to, at the beginning, we don’t just go, we won’t just do the recruitment, that if they don’t sign up to the three R’s of recruitment mythology, so how you reach them, how you recruit them, and how much we’re talking about now is retain them. They don’t share the same values as us as a business. So we know straight away, it’s not going to be a match. Yes, we can get them the candidate or the associate that they want, or the hygienists they want. But what’s the point, it’s not going to be a long lasting relationship. It’s not going to benefit us as a business, it’s not going to benefit them as a practice, because the associate or the hygienist or the nurse is just not going to be probably going to be there in six months. and dare I say, you then become a recruitment company, or recruitment agency and I don’t want that bad mouth recruiters, because there are some absolutely phenomenal ones out there. It’s just unfortunate that it’s a process. We’re just changing the process, and how we do it. And we’re going to be a bit more methodical, and a bit more hardcore in who we actually work with. We won’t just work with any practice, we won’t just work with any associate, they have, we all have to align into the same belief system. And therefore, our networks will expand organically, really, because we’re all on the same page. And that’s how we will build something brilliant. And that’s how you build a great practice. Ultimately, [Simon]I think just pick up on what Andy said earlier about, you said, Oh, professional stopping. But again, when you look at brand of any business, people think the logo is the brand, and certainly getting dental practice, even there’s a lot on their logo and the image, but the brand is everything, it’s the logo, it’s how you behave, it’s the material you give out. it’s how you treat your customers, how you treat your staff. And so if you again, if you look at the social media profile of a dental nurse, if they’re really connected to their practice, their social media feed is full of stuff about the practice what they’ve done as a team, what they’ve done to raise money for charity this week, you know, dress up days, dress down days, whatever it might be, if they’re the one on social media being your feed, it’s got nothing to do with the practice is probably an indication that it might be about the person. But it’s also a good indication that the practice is not really valuing that person. And instead, if they’re not valuing their dental assistants, and their reception team, they’re not valuing everything else. [Andy]So one of the key things that we teach business owners, principals on the retaining side of staff is Who are your best ambassadors? Who are your ambassadors? Your ambassadors are your staff members. They already work for you, they already love working for you. So you’re obviously doing something brilliant. Let them shout from the rooftops about it. What they are, they are the people that make your business, are your staff. And if you don’t believe that, from the outset, you’ve got no hope. And you will constantly have a revolving door. Your staff are your biggest ambassadors. And the minute you start to believe that you’ll start doing things a lot better. [Simon]The simple indicator I look for and practice, Jaz, when I go in, if on the reception desk, there’s all the little business cards of the clinicians with their photograph on it. That’s great. But I want to see them for all the team members, including the nurses. Now the nurses might not want their phone number on it, just the practice is fine. But again, I’m saying to them, Look, while you’re out in town, shopping while you’re in a nightclub where you’re meeting with your friends, if somebody says what do you do say I’m a dental assistant, and they say, Well, I’m looking for a new dentist, give them your business card. Now again, business cards cost pennies, you can get 50 for next to nothing. So again, if a practice invested in business cards, not just for the owners and the clinical staff, but for everybody. Again, that’s a good indicator that it’s possibly a good practice to go and look at and decide you might want to work for us. [Jaz]I love that and one of the things I could tell you about my own personal situation and I’ve now started working in Reading, brand new practice. I was supposed to start just before COVID kicked off March 30. So I’ve just started working there now. The main thing that attracted me to this practice, I mean, there’s loads of things, you know, one of my best mates as a principal, they’re good location, it’s my wife. But one thing I loved is that when I walked into the interview room, on the wall was a sort of a list of all the staff and how many years of service, you know, you wouldn’t believe it, 28 years, 24 years, 19 years, 18 years, 14 years. I just, I’ve never seen that before. And that’s why I knew that this is the place for me. Because people, once they come here, they’re happy. They they feel fulfilled, and everyone’s treated well, and I’m so far very happy, even just three days there, I can tell the culture is just magnificent. So any associate looking for a job. Find that out. And if you can’t. Ask Andy. [Andy]Again, but that just backs up what I’ve just said, doesn’t it? Your staff are your best ambassadors. And there, they have them front and center, on the wall, front and center, 19 years, 18 years, they are their ambassadors, that is the business, you’re also spending, as we alluded to, at the beginning, maybe 12 hours a day with those people, you want to lighten them, and you want to get on with them. And they’ve got to share your values and beliefs. Because if they don’t, you’re not going to be happy in your job, and you’re going to want to move on. [Jaz]I hope those listening, were able to gain a couple of insights about how we should think differently about the practice we’re approaching. Think about the wider team, think about the values, which are really hot on, think about maybe investing in a video sort of presence, and to really spice up you, as you know, to showcase yourself in a better way that actually shares your story, shares your personality, and actually improves the chance of maybe aligning with the right practice, which ultimately will hopefully stop the days where we’re hearing about, there’s no such thing as a good associate. And any closing comments, gentlemen? [Simon]I want to say exactly that, Jaz, look at your own values. And if any of your audience want the value program, I’ll send it to them, it’s very quick, I’ll analyze it for them, I’ll feed it back to them, they can just drop me an email through you or you know, whatever you put [Jaz]I’ll that on this. Yeah. [Simon]So I’ll happily do that. And I said, look at your own values. But most of all, get come to people like yourself, talk to other people, don’t try and do it alone. And if it’s just about a CV based application, start looking elsewhere, because you need to be looking at a different practice, and a different way of getting connected to that practice. Because ultimately, as you said, you and I are very happy at your new practice in Reading. But you’ve got a good feeling from that first meeting from the chart on the wall. Now, we want to show all that before you even go for that first meeting, we want to get that across in the in the video about the practice. So I said when you go when you log on to the site, and you’ve signed up and you can log in to see what practice we got, you’ll see an interview with the receptionist, you’ll see an interview with one of the dental nurses or at least one, you’ll see interviews with the principals with other associates. So you can immediately see if you connect with or not, if you don’t, as Andy said, no shame, you just say no, let’s go look at another one. So before you’ve met them, you can make that decision and really get under the skin of it. So that’s the important thing, so. [Jaz]Brilliant. Andy? [Andy]I’ll just say that it can be a stressful and it can be stressful, and people there are people out there that are willing to take that stress away from you. And that’s something that we want to do. We want to take all of that stress and that worry away from you get to know you as an individual. That’s really all I want to do is have a chat with you and get to know you as an individual because I know that with the networks I’ve got and that we have the Openwide, we can put you in touch with the people that you’ll work best with and then you will flourish. And that’s really what we want to do. Our mission is to connect like minded professionals every day. And [Jaz]Have you get someone get into what’s the best way for someone to as an entry point in terms of ‘Okay, I want to find out more.. How can? [Andy]You can drop me an email, you can drop me an email at andy@openwide.group. The website is openwide.group. I’m on LinkedIn. I’m on Instagram, I’m on Facebook, there are hundreds of ways to get hold of me. Jaz, if you would, you can probably put a link to one or two of those in the notes. People read my phone number if people want it. I’ll sit down and talk to anyone all day. I love talking to people. [Jaz]So we can vouch for that. [Andy]Apologies. [Simon] It’s a pleasure, Jaz. It’s a pleasure. [Simon]Jaz, I’ve enjoyed listening to you, Andy. [Andy]Thanks to speak what the other people do. [Simon]Jaz, It’s been a pleasure. Thanks for the invite. [Jaz]Thank you so much as well. [Jaz]Thank you [Andy] Thank you.

I left you on a bit of a cliffhanger last episode – but now you can finish off Andy’s ‘origin story’ of Posterior Guided Occlusion (PGO) and understand how this is practically implemented on patients. If you missed Part 1 and the ebook by Dr Andy Toy, check it out. https://youtu.be/WJxr1JPpDO0 Need to Read it? Check out the Full Episode Transcript below! The Protrusive Dental Pearl for this episode is continuing on the theme of Dental Photography I have been posting about on my Instagram. When taking portrait photos for your patients with a ring flash, point the ring flash at the ceiling, rather than at the patient’s face. This creates a softer, nicer image! If you missed out on my Butterfly Effect webinar, you can now check it out on www.protrusive.co.uk/butterfly – it’s about how seemingly small events in your career can compound and change the entire trajectory of your dental career. I added a new book to the book list – the Danish Way of Parenting! In this episode we discuss: Structural school of thought vs Functional school of thought The relationship between the condylar movement and the teeth The mathematical equation that is evidence for PGO I ask Andy questions to test PGO What does he mean by functional contacts? What is the healthy clench? We debate anterior guides vs posterior guides How does this apply to the patient with large masseter muscles who keeps breaking cusps? How many ‘centrums’ are enough? What Andy is prescribing in Clinchecks for the posterior occlusion How to finish the occlusion on an orthodontic case – and how Andy makes this ‘patient driven’ How Andy finishes 60% of his Invisalign cases with a ‘Dahl appliance’ Is Centric relation important to achieve? Andy tells us the birth of Canine Guidance Click below for full episode transcript: Opening Snippet: The occlusion becomes more simple. You have to work less hard because all you got to do is make sure there's good posterior guides. And all that work you do not the front of the mouth. As long as you don't get too much of a clash there, okay? Then life becomes much, much more simple and you can, canine guidance isn't a bad thing. But it's not essential to a healthy functional bite. Okay?... Jaz’s Introduction: Hey, guys, and welcome to Episode 32. This is posterior guided occlusion part two, with Dr. Andy Toy. I know I left you on a massive, massive cliffhanger last time. And I hope you can join us again, to get the complete story of how to actually apply the PGO concepts. Now something like I told you guys, it was me learning a bit about this concept for the first time like many of you, so it might take me some time to implement this, if I do end up fully going that way. But it’s just great to hear other points of views and other theories out there. So I’m so glad that Andy, Dr Andy Toy was able to share that all with us. Before we join Dr Andy on the show, again, with part two, I’m gonna give you the Protrusive Dental pearl. And this is a photography one, which has been quite big on my Instagram story recently, I sort of gave a hint that I’ve ever invested in some new sort of photography, flashes and lighting. And I’m gonna go into a lot of detail about that, because loads of people inquired about how to get that nice softer lighting. So I’m going to do a whole segment on that, I think it’d be cool for everyone, and also how I can do it for way cheaper than buying it from some other places. So I’m going to show you the sort of the DIY method of how to make the softer lighting and save you lots of money at the same time. A dental photography tip for the Protrusive Dental pearl for today, which is when you’re taking your portrait photo, which is important to do. And I think with more experience, you realize the importance of it as you go on. And if anyone’s doing orthodontics, you’re probably used to taking portrait photos anyway. So when taking portrait photo, especially with a ring flash, which is the most common flash that people have for dental photography, the lighting can be quite harsh. So if you can just very simply unclip the ring flash from the lens and pointed up towards the ceiling. Now most people have like a white ceiling pointed up to the ceiling. And this will really enhance your portrait photograph, it will make it much more softer lighting enhanced the features. So that will be my Protrusive Dental pearl point the flush to the ceiling, not directly at your patient. The other two things I want to tell you is that I’ve added one more book to my book list, which is protrusive.co.uk/books. And this is the Danish way of parenting. Again, if you already follow me on Instagram, you heard me on my story, talking about the lessons I learned from this book as a father and how Danish people are the happiest in the world. I think it’s because they have a really happy upbringing. So what lessons can we learn so I recommend that as a book on my book list, and the last thing I’m gonna talk about before we jump straight to the podcast is for those of you who missed my butterfly effect webinar that I did for the deanery. That’s now online, and you can catch it on protrusive.co.uk/butterfly. And this is about a little bit of my story about how I always wanted to be a restorative consultant, how that was my real focus. But then, you know, life happens, life comes in the way and how I’ve navigated my career path, and how I do believe that little things small influences, compounded over time can change the trajectory of your career. So it’s all about the butterfly effect that little changes and how they may result in big changes in your future. So check out that free webinar online on protrusive.co.uk/butterfly, and let’s jump straight to Andy Toy’s Part Two with PGO. Hope you enjoy. Main Interview: [Jaz]Angles and [ ? ] and go continues on from there. Yeah [Andy]Yeah, it’s part of the structural School of orthodontics. Okay, what I would say, and so when I try and make a difference for people, I say, well, you either, you know, this is a structural way of looking at it, we have a functional way of looking at it. Okay? [Jaz]But Andy, most specialist would call that if you say to a specialist, well, in this case, we can accept the degree of class two in this case, they would then say okay, so you’re going for a compromise treatment plan. And that term then makes you almost undermined your entire thought process and what you’re trying to do for the patient. [Andy]Right. And so, we have the evidence to show that the compromise, so called is actually the best way of treating this patient. Because I’m going to give you know, probably because we’ve been going on a bit but I’m going to give you what I think is the killer piece of evidence. Okay. So, Ron Presswood is busy Working through all this stuff, I tell you part of the story here that really got him onto this was he’s at a party. And a patient of his comes up to him and says to him, Ron, my son has just been to the LVI, Las Vegas Institute. He’s had his mouth restored, he’s in terrible, terrible pain. Okay? And can you do something? So Ron basically goes to see, takes the guy to his practice that evening. And in the LVI, on what they do now, to be honest, because I don’t really look at them. But what they used to do in though in those days was they would fit all these muscle monitors on there, they’d get used as a so called point of neutrality or whatever, [Jaz]They still do that I’ve seen that firsthand in practice, [Andy]Okay. And they invariably, then you had to open up the bite by six or seven millimeters, and you needed 28 units of crown or bridge, okay? [Jaz]34 [Andy]And what they done with this guy opened him up, and they locked him into this position. He was in terrible pain. So what Ron had to do was basically grind away all these, this poor sling and free him up, okay. And Ron is like, incandescent, at this point, because he knew this lad he’d been a patient of his, he’s part of the family, and his mouth has been wrecked. Because people are following this model of occlusion that the LVI were proposed at the time with so called evidence that we never see. But he says, Well, I got this other idea, but I don’t got the evidence. How can I go out there and say, you’re wrong? Well, I’m, it’s just my opinion. So that really what set him on the road to really, really work on the evidence. So you, you went over to Australia to work with anthropologists over there went there three or four times, the anthropologist in Australia got masses of evidence, but they’re not their academics. They’re not clinicians. So it doesn’t really flip over into how we translate their evidence into practice. Okay? Anyway, he’s talking about this with his son, Ron Jr. Ron Jr. is an engineer. In fact, he’s a space engineer, because he worked for NASA. Ron’s from Texas, he lives in Houston. So he’s saying to Ron Sr. saying to Ron Jr. He says, Well, you know, what, there’s this relationship between the way the condyle works and moves, and the way the teeth glide over each other. Okay. And Ron, Jr. says, Well, if that’s true, then we should be able to find the mass that describes that. So and Ron Jr, had been working on actually at that point, the docking mechanism for the space station modules, okay, which is a bit like a cusp going into a fossa, if you’ve been and through space, these two bodies are moving, okay? And they got to understand how they’re going to join up together. And there’s a mathematical relationship for that. So they go off to the University of Texas, they get 12 skulls from the anthropological department. And if Ron supposition is correct, then the occlusal surfaces of the second molars and the functional surface of the joint, okay, which is called as tubercle. And actually, they looked at the canine on the opposite side. If they are have a relationship, then you should be able to find the mathematical relationship, mathematical equation that describes that, because Ron’s idea was that as the condyle moves, you know, when you tried when you’re chewing and everything, all that is in contact as well, and you may well have a contact over on the canine as well. Everything is in harmony, okay? So they take 12 skulls, they have to build an extra powerful computer [M] days, and they did a digital scanning of those three points. They gave it to a friend of Ron Jr, who was [Ed Hankel.] He is another NASA Space engineer. And he basically did the scans. And they found the equation that links the functional surfaces of the joint to the functional surfaces of the teeth. Now, I don’t care about what your sciences but when you put an equation in there, that it to me is proof that you should have a posterior guide that it matches the condyle motion of the in the joint. So we have the equation that proves this. One of the frustrations for me is I can’t but we have gone to the articulator manufacturers, okay, especially the digital guys. I would say you know what, guys, if you gave us a cbct and we find two of the points, we can match all the other points because we have the occasion the Regional data, and it’s nonlinear maths. And the guys [at ankle] said done it, he did it all different skill sizes, he said, 12 is enough. This, you know, there’s enough synchronicity here that everything comes together. So we talked about evidence, I’ve not seeing any other model of occlusion come up with significant evidence over nevermind our own clinical experience that we get just as you’re describing. So, you know, going for a, the patient’s present occlusion, okay? The occlusion, they walk in with providing that the joint is healthy, and they can chew everything and they’re not in discomfort, I think we’re obliged to keep to that occlusion whenever we can. So it’s not a compromise. [Jaz]That’s really fascinating. I mean, when you told me that story the first time. And then when I read your ebook, and I looked into it, and I saw the skulls. And I learned what a Centrum was because I have to admit, it’s not so much the spoons and stuff. So it is certainly very, very interesting. And the fact that you have, you know, your comparison of the evidence that you present against what the occlusion world presents the moment, I totally get it, because one thing that I was always taught, but my mentor and principal Hap Gil, who you know, a fellow a Hanky Pankey yourself. And he was telling me Look, Jaz, all this occlusion stuff, there’s actually you have to reverse the respect, there’s no evidence for this stuff. So that’s why I was also very open to what you had to say, because I know that the evidence for a lot of what we apply, doesn’t exist. [Andy]Yeah. So always, as good clinicians, right? I know Hap’s like this as well, you have to take all this in, just like I did as well, and you’re gonna try it out on your own patient. And when you try it out with splints, then it’s an irreversible manner. And I know Hap, and you know, you were seeing that how actually, what you see is, suddenly occlusion becomes more simple. You have to work less hard, because all you got to do is make sure there’s good posterior guides. And all that work, you do not the front of the mouth. As long as you don’t get too much of a clash there. Okay? Then, life becomes much, much more simple. And you can, canine guidance isn’t a bad thing. But it’s not essential to a healthy functional bite. So that makes life a lot simpler. So good. occlusion is really very simple. Which is bad for me in one way, because if I made it really complicated, you could pay me a lot of money to come in give you five days [Jaz]your tax bill would be would be one page, because literally the last minute of what you said there is essentially the crux of it. So I think my opening snippet to the podcast episode will be exactly that 45 second, what you said there? So is this a good time to now for me to then ask you some questions, which a lot of people might be thinking at the moment out there listening to this people who’ve never come across PGO I mean, I think I will try it out on splints, and go from there. But it’s interesting, we, you know, we mentioned about Hap Gil and one of my first experiences is when he gave me the job offer to work with him. And I went to shadow him a few times. So he was just finishing up an Invisalign case. And he, you know, removed the attachment, and now he’s checking the bite. And okay, right. Okay, I know what he’s gonna be doing here, watch. So checking the bite. And it’s a young female, and she’s now excusing left and right. And you’re a very long way away from canine guidance. There is no canine going saw. And I saw him do his thing. But of adjustments, check. Okay, everything feel smooth, good. Okay, fine. We’ll talks about retention and the patient goes away. And me, you know, I respect Hap very much even now, of course, more than ever, as our relationship has grown over the years. But I said to him very sheepishly like, ‘Hap, what about canine guidance? Aren’t you worried there was no canine guidance? And he said to me, ‘Whoever taught you all that rubbish, just forget it, you know. There’s no evidence for that stuff.’ And that’s what really got me thinking, no, I was already very much into occlusion. And I’ve been more and more and I love respecting and listening to all the schools of thought. So thank you so much for sharing the origins of PGO the origins of the structural viewpoint of occlusion which is important to know that actually, it may have started from a dream in 1884. So very fascinating to learn that. So now let’s talk about real world and how to apply it and some of the questions we have. So the first question I have is do about definitions, right? Function for me is in my map of the world, at the moment is a function is or masticatory oral function is speech, swallowing and chewing. That to me is function. So in speech, speech to chewing and swallowing. [Andy]Yeah, of course. [Jaz]So in swallowing Yes, that we need, we need a contact like MIP or whatever. So to build a solid says contact during swallowing, there is no contact during speech. Unless you’re, there’s some degree of parafunction going on that sense, and chewing. There are some fleeting contacts. But for my understand that there shouldn’t be any hard or significant contacts while we’re chewing. Otherwise, it’s a lot like when you’re walking up the stairs and you miss a step and suddenly feel a thud, you’d feel like that. So when I was reading your ebook, and I was reading the slide you very kindly sent me over while I was doing the last couple days. There’s a lot of and the way you mentioned it was about, okay, are the functional movements but you see in my map of world that doesn’t fit into the functional movements, because it doesn’t fit into what I just said, there. So what do you mean by these functional movements, and when you go into the, in a high force, and you grind back to the middle, that shouldn’t happen in normal function in chewing is what my belief is. [Andy]Yes, so the, there’s two aspects of that, firstly, you do get these fleeting moments, fleeting contacts, okay? And so you want to make sure that there’s not a tooth that’s in the way. So that’s where the freedom thing comes in. But there’s an important thing, and that is something called the healthy clench. The body needs a chance to fire those muscles, without the teeth being in the way and the condyle seated properly. So the pipe, the purpose of the splint is to enable those muscles to fire and to have the healthy clench. So there is a time and I don’t know, I’ll be honest with you, I don’t know how much it is people might have done research on it is but there is so many times in the day when you do need to clench and be able to move around a little bit. Now I got an interest experienced in myself, this is a research study of one, okay, because I had my Invisalign done, I wear my vivera retainers. And I can tell you and this wasn’t a name of treatment, but I went from about 35 millimeters opening with a deviation to one side. By the time nowadays I got 40-45 millimeters opening, no deviation, no clicks, get out like one here. When I take my viveras out in the morning, I can’t feel my back teeth touching. Okay. Now then, I was just waiting for, you know, my mouth and my head to explode. Because I didn’t get my back teeth touching, they generally come back during the day. One of the things I realized is actually your, your bite changes throughout the day. And I go back to my osteopathic and chiropractic friends and I say what it’s all about, where’s your jaw, jaw posture and muscles change and fluid balance change and things like that. So one of the things about a functional approach is you don’t get too hung up about the actual contact, but you do want good function. And what I think happens is when my viveras are in during the night, I’m doing a bit of clenching. It’s really time that the muscles here the functions really improved. And the fact that I can chew without my back teeth actually touching because I could chew everything all day, no problem. And so it’s that it must be that at night, I’m just going to the gym a little bit. And I’ve got a nice posterior guided occlusion, good contact in the centrums. And everything’s fine. So I think that there is a certain amount of time during the day or night during during the 24 hour period when the patient should be able to get into that centrum, that little spoon thing there and just grind around a little bit. So we call it the healthy clench. And this is one of the other things that you know your average approach occlusion says you must stop clenching, and grinding is bad and stuff like that. So can I tell you just one little bit about bruxism then [Jaz]Please, this is gonna stimulate debate about bruxism and parafunction because because you were hitting all the right points, you know, I’ve come from a background where parafunction is bad. The teeth shouldn’t touch is essentially the background coming and then what you’re telling me now and it makes sense, because to be fair I spoke about the episode Barry Oulton, Barry Glassman is that we’re all complaining nowadays that so many of our patients are parafunctioning. And sometimes I think Hang on a minute, maybe that should be the norm because if patients are parafunctioning, maybe it’s the 10% who on that the abnormal. [Andy]Yeah. So for instance, or Okay, so a certain amount of wear is normal. That’s one of the things no, we don’t get this in the UK so much but In the US, you know, if you had, I don’t know, you’d lost like a millimeter enamel or something that’s a reason to restore the tooth because it’s not looking like a virginal tooth. Right? And if they can crown it, they’ll do it. That well, that’s the way they are. And [Jaz]I’m sorry guys who listen this in the States, but it’s kind of true. [Andy]You know, well, I’m talking about the 80s 90s you know, go to pankisi some fantastic dentists and doing brilliant preps. And this is the way we thought you know, every tooth must have that cusp to fossa relationship and all that sort of stuff. If you look at the anthropological evidence, you will see that teeth are designed to wear so some wear is normal. And if you think about what is a equilibration it’s really just advancing the wear a little bit that we should have had if we were on a proper natural diet. Okay. So there are a little bit of freedom to move around that a little bit of wear is a good thing. So that’s part of it. Where was I going to? [Jaz]Bruxism. You mentioned bruxism? [Andy]Bruxism. Yeah, right. Okay. Now then. Ron, I assumed that bruxism was something to do with up here. Right? I think in it’s not really anything to do with occlusion people brux is someone who some has gone on, you know, a mentally, emotionally or whatever it is. And I start talking to Ron, he says, I actually, you know, I find that when we give them the posterior guided splint, the bruxism stops. Okay? And I think it’s because what they’re bruxism because there’s something that’s in the way, and they’re trying to get rid of it. And as soon as we get rid of that noxious contact, and if you think about the way they adjust occlusions they’ll say, is there anything doesn’t feel quite right feels like it’s in the way just here so they adjust it? Yes, please. That feels better what you’re doing with equilibration, just giving them some bit of freedom. Okay? So anyway, we decided to do a study on this at [ ? ] University. And we couldn’t this is interesting, we couldn’t recruit a single student to this study, because what we want to do is give them a canine guided splint, right? With sort of moderate steepness. They’re going to wear that for 28 nights, then they’d have a rest for 28 nights. And then we give them a posterior guided splint, so no anterior rump. And just to mix it up a bit, they may start with the posterior guidance plan and finish with canine guidance splint. Anyway, [step four] is to go through a lot of students, not one single student was willing to have any dental procedure done, even though it was a split. So I had to recruit 12 FTS, right. [Jaz]Is it because it’s not sexy to wear a splint? Is that what it is? [Andy]They were happy to have stuff put on their muscles and different things. But they were not happy to go and have impressions and stuff like that. So I had to recruit 12 FTS. And Fortunately, we got them in. And we went through the study. We tried to show, we tried to do sort of laser imaging of this splints to show the different wear patterns. It was a failure. Okay? We couldn’t get decent data out of that. They did show like we expected that in the canine guided splint, you know, when he moved off to one side and the other the muscles switched off. So we could show that. But the other thing that we did is we took photographs of the splints. So we then compared the wear patterns on the acrylic of the canine guided splints, and the posterior guide splints, okay, because you can tell you know, once they want to spend for 28 days, if they grind in, you can see the effect of the occlusal contacts on the anatomy. And we also asked them, we gave the subjects then a questionnaire to fill in about comfort and stuff like that. So there was no evidence of bruxism on the posterior guided splint. And on every canine guided splint, they’d been grinded up and down the ramp, because you can see the acrylic had been worn in because we compared the photographs of when we fitted it to when we looked at after 28 days. And 11 of the 12 subjects reported better comfort with the posterior guided splint, and the other one was neutral. So to me, it was strong evidence for Ron’s assertion that if you will grind your teeth if you don’t have good centrums, good posterior guides, and you could well be grinding because you’re trying to get rid of something. Yeah, now I know that invariably now when I get sent a patient from a dentist to deal with their a TMD quite often they’ve had some anterior dentistry done in some way. And they’ve restricted the path of motion. And so they’re not got that contact at the backs that they used to have. And they’re starting to get problems. Okay? So it’s usually the dentistry looks too good. And it’s too anatomical and is not functional enough. So that’s one of the reasons you know, we talk about in the diploma, you know, overjet’s your friend basically, building two or three millimeters overjet, give them some freedom in centric as sort of a [Pankey.] So, there you go. So, I know I wouldn’t say hand on heart that every parafunctional situation every bruxism is due to an occlusion issue. But it’s certainly significant. And I and Ron being a Pankey dentist, he takes photographs of his patient’s splint year after year after year, and he’s got photographs of people, you know, came in with massive parafunction. 20 years later, their splint looks just the same, no grinding. [Jaz]I respect that a lot as someone who takes photos while splints. You know, as many of my listeners know, I get a Sharpie pen, I color my splint in and I can see the patterns. And to fair 80-90% of the splints I’m doing is anterior only whether it’s b-splint, FOS, NTI. So this is why I’m excited to be exposed to this type of learning. But what you said there about how one might want to grind away that canine guidance because isn’t the way and I simply I completely see that. But it’s funny how in those lectures by the “occlusion gurus”, you see, we all seen that case where they say, Oh, this patient, we need to restore them because they’ve now lost canine guidance. And now they’re parafunctional on their posterior teeth. This is really bad, the forces are high. And the very crux of occlusion is let’s rebuild, let’s anterior rise, this occlusion, and it’s just so why is it, Why do you think that we dentist yourself even when used to do Tanners and Michigans, how can you attribute the success that we can get from doing anterior dentistry? [Andy]Okay, so what does the tanner applaince do? And we I’m talking about a flat plane appliance, pretty flat here. That’s the way that we were taught at Pankey. I mean, it basically opens them up. And allows them to move around a little bit. And when they clench that posterior guide comes in. I’m not checking for that. Because when I was doing the side to side, it was just gliding movements. So it’s just back to be Ron’s work in 64. So the point is, 100% of people have posterior guides. That’s what we found on those dentists, even the ones that have been equilibrated. Okay, so, the reason that the splint has worked is because we open them up, and we allow them a bit of freedom, and it’s flattened it all the whole thing off. And I don’t, I’m not going to get into this right now. But there’s been a bit of work done with the denture system that’s come out of this. And this is where [John Bill] comes in the denture technician. When you open up, you know, with dentures, you can open up the vertical. Okay? I’ll tell you a little bit about it. You know, I don’t know if you make full dentures anymore. I made when [Jaz]I make about two or three a year. [Andy]Okay. So, you know, a good full denture On what basis is it made? Curves of spee and wilson? [Jaz]Yeah. That’s what we tend to follow. [Andy]That’s right. Now, what is the radius of the curves of Spee and Wilson? [Jaz]Radius. I’m gonna say it’s based on the work of four inches Bonwill’s triangle, right? [Andy]It’s four inches, right? So they set up a denture occlusion based on Bonwill’s work. And the denture occlusion is symmetrical. And it’s a linear movements, and you’ll put an end to a nonlinear system. So John Bill’s a denture technician in Leicester. He’s my denture technician. He’s always trying to solve problems. And one day he comes to me, because he’s working with a dentist and he was setting these dentures up in the most perfect occlusion. You could even set up he put them in the mouth at a slide from side to side, and they’re flipping all over the place. So we grind them down, grind them, we grind them down until they stopped moving. Okay? And he found it was steeper, the occlusal plane was steeper on one side and flat on the other. It was asymmetrical. He comes to me. He says, “You know about occlusion. I’m grinding them down like this from the perfect curves. And I find it steep on one side flat on the other. Is that right?” I said you got to meet Ron, because Ron had found the same things on the dentate patients. And as a result of that with Ron Jr. They developed a whole new denture system called CQR, okay? And the occlusal planes of the dentures match the patient’s own asymmetric condylar movements. And when you get that, you get absolutely stable dentures. And did I direct you to the site which showed the videos on that? We’ve got videos to show you can [Jaz]Are you happy to, for the viewers, listeners and viewers of this podcast to I’m sure we’d be happy to share the ebook. But my listeners love downloads. So if you’ve got any videos, that sort of stuff, they will loyally watch it because I’m sure they’re you know, people listen to it are generally interested in parafunction, occlusion, different composites denistry and all [Andy]I get that because we’re the same. And the thing about showing it on a denture is you can immediately see instability, right? And the thing to get your head around is the occlusion on a denture, functional occlusion in denture is the same as functional occlusion in the mouth, on a dentate patient. And when it’s unstable on a denture, when the occlusal planes are not in the right place, the denture moves, you can see it straight away. When it’s in the mouth, you don’t see the teeth moving is what’s happening up here that you don’t see is unstable. Or maybe there’s some fracture and forces on the teeth. Or maybe the periodontium is getting stressed, we can’t see it. But you can’t see it in a denture. That’s why I often show the denture videos to help you understand what’s happening in a dentate patient. Anyway, what John Bill understood, then when you start, we start to build these dentures with functional planes that match the patient. As you open up the vertical, the steepness of those curves changes. Because actually, you’re on a different part of the condylar surface. So what happens if so in his average sort of facial height, he said, it’s steeper on the right than the left, and we haven’t found anybody yet it was the other way around, okay. But as you open up the vertical, it becomes much flatter both sides. So what do we do when we put a splint in and put a flat plane splint in we’re basically creating that we’re allowing them to move around, and they can really then free up the muscle start working. And when they really clench that little posterior guide comes in. That way, I think the splints work. [Jaz]I know that was a good answer. That was not like a politician at all. I asked the question, why are they successful, I think you’ve answered that in a different way. And is back to what we said earlier about a different way to explain the reason why we see success in what we do. And I appreciate that. How are we doing for time? And because I’ve got some more questions I’ll be doing okay? All right. So you mentioned about the muscles having a the correct amount of function the correct I mean, the How is it that you worded it in terms of the muscles being able to contract in a coordinated manner? And with enough volume, would you say, or, how do you? [Andy]Volume of contraction, maximum contraction, that’s what the sEMG measures? [Jaz]Sure. What I what I do is, as part of every new patient examination, myself is I always palpate the muscles of examination, and I make a note of the degree of hypertrophy. And I had to have either quote, say, their normal what they feel to me, or if I feel a bit of a bulge, then I said, Okay, they’re mildly hypertrophic. And if I feel a bulge of the masseter, that’s, let’s say, more than three or four millimeters now I’m being like, you know, subjective here. And you know, those patients very square Jaws, really severely hypertrophic masseter. Well, are they all normal? Or is there at what point do you say okay, this patient is, you know, some you get this very thin, slender ladies in and they bite together. Are you biting together? Yes, I am. But you can’t feel any contraction, whereas others you feel a massive buldge. So what is normal? [Andy]Well, let’s take it away from dentistry. And look at the people walking down the street. Okay? They’re all walking perfectly happy, healthy, can do whatever they want. Some of them got tiny little muscles, some of the got big muscles. To me, that’s a structural point of view. Things from a structural viewpoint. Okay. I’m more about the function. So one of the things that I do, and generally this is with TMD patients, you know, when I’m one of the reasons we’ve not done research on patients in pain, because pain is complex. Let’s remember that pain is actually felt up here. So whilst they may feel it’s their joint, their tooth, their neck, or whatever it is, they may actually be nothing wrong with those it’s all up here could be that. So I need to sort of determine is there an occlusal element to this patient’s head or neck pain. So all I do is I get them to clench. And I do my own sEMG just like we did then, and I feel any movement. I do it up here as well. Okay. I then put some cotton rolls in and I see if the volume changes Because I’m more interested in the volume of movement, and the coordination, rather than the size of the muscle. So that’s a functional point of view, rather than a structural point of view. [Jaz]Sure. Well, the reason why I’m so hung up on the size is because I do believe in something I feel I do observe is that for those who have larger muscles and are parafunctioning, they are destroying their teeth more, they’re able to generate more loads, I’m getting more fractures of crowns. And I’m using Zirconia instead of Emaxs or gold in those patients. So it informs my dentistry in my approach, these patients come back. And they’re the ones who are breaking the splints, for example, because they’re the strong muscles. So that’s why I can sort of relate it to maybe not function, but the power function. [Andy]Yeah. Okay. So but what I would say was, I’m more interested in the volume of movement, rather than the size of the muscle. And it’s an it’s a useful tool as well, actually, because one of the things that we have to do particularly with a pain patient is we, we have to build trust with them. Okay. And I’m sure that the more they trust you, the more the pain goes away, frankly, that’s part of it. But I say to them, I need to try and work out whether your bite makes a difference to your to the muscles. And if it does, it’s possible, but it’s part of the problem that you have is problems with the muscles here and the joint not being stable. Okay. You tend to get pain from muscles that don’t work rather than muscles that do work. Right? So just be aware of that as well. [Jaz]I do. I think I’ve observed that because people who’ve got these hypertrophic muscles, their muscles are not tender, you know, I do palpate them and then right, then sell them tender. [Andy]Right. So I mean, I broke my arm in the past. And I can tell you, you have to hold it still for like, three or four weeks, I’m desperate to move those muscles and the muscles that hurt the ones that you can’t get working. And there’s good evidence to show, you know, a healthy muscle has good blood flow through it. And the painful muscle doesn’t. So that’s all another thing. We want movement, we want function, okay? So I get the patient and I say, okay, you test, let’s test, you know, you’re now getting to put their hands on the temples, because it’s usually the temporalis that doesn’t react, and I get them to bite together. And they can feel maybe it goes big, big like this, okay, or is fluttering on one side, okay. And then I put the cotton rolls in. And we see if it makes a difference that often is going to work. And they go, Oh, that made a difference. And my assumption is, when the muscles do this, then they’re going to be healthier, less pain, better function, then when it’s doing this. [Jaz]That makes sense. Someone who respects what physios do, and like you said, osteopath, and stuff, you know, that’s very much the functional matrix. I can see that viewpoint. [Andy]So so that’s what I’m testing all muscles. I do test with trigger points as well. One of the things I would say to I don’t know, I’ve never seen you test a muscle or work with a muscle. But one thing I’ve learned from the physical medicine people, particularly cranial osteopaths is that, you know, we need to develop a real sense of a real light sense of touching our fingers. We tend to use metal instruments. And I’ve seen dentists really squidging around here. But typically, that’s particularly rough on a TMD patient. I just go in, I’m feeling the quality of the muscle in that and you’re sort of tuning in. And if you touch them, and they feel pain, it’s pain, it doesn’t matter that it’s all up in here. It’s still pain so. And I’ve learned I’ve learned a lot from Ron Presswood here, you know, Ron is in his mid 70s now. They’ve got locked down in Houston. Do you know what he’s still working? He’s still working, because he gets two or three referrals every week from local psychiatrists, and MDs, and people are allied with people in pain. And he’s worked out I can see these people on my own. And but you watch how he and his team handle somebody with an extreme chronic facial pain. And you recognize there’s a lot around the people management, as well as what he’s actually physically doing with them with any sort of splint. So, you know, this is why we now research people in pain, because that is so complex. But, and you have to understand the nature of pain. But there are, there is a connection between the occlusion and the function of the joint. And there is a connection between the occlusion and the functional muscles, we know that we proven that we’ve got the equation, and we’ve got the data to show that so that can affect people in terms of their pain as well. And remember, I’m coming from the 80s when you know, good research has shown there’s no connection between occlusion and headaches. Right? That was the best research that was out there. Well, they’re wrong. There is. It shows inadequacy in that research. How do we get onto that? I can’t remember. Well, you’re talking about muscles and parafunction. [Jaz]Yeah, I was talking about how strong is strong, or I know these patients I’ve got with really large masseter that worried me. They worried me because of Oh, gosh, they’ve already broken this cusp. They’ve already got a virgin premolar that’s now, a lot of photos on my drive of virgin premolars and molars that get vertical root fractures. And all these patients have one thing in common with a couple things common, they’re parafunctional patients, and they’ve got significantly hypertrophicmasseter, in particular, sometimes quite often temporalis as well. So sort of mean to that I want to switch these muscles off is what I’m trying to say to Andy like I did to let them go in it did the thought of them running free and wild on those large muscles, it to me is going to result in another vertical roof fracture with the view point [Andy]Let’s think about it, right? First thing I’d say is, is it both sides? Or is it one side? Because if it’s one side, there’s I would say there’s some sort of contact there that they’re really working that muscle. Remember with these, okay? That the masseter work, even when there’s just anterior tooth contact. It’s actually this anti temporalis that’s not working. And if they’re fracturing teeth, I wonder whether that contact, you know, the occlusal contact is on a steep angle, and there’s no freedom to move around there. They’re trying to get that freedom. If you open them up and gain more of a Centrum to work on at the back. I wonder if that would be different. I wonder if they’d stopped bruxing, I wonder if they stopped working on you know, one side of the mouth. So they get this massive muscle on one side, that things would start to balance it. In fact, I’ve had probably I’ve got 8 to 9 Invisalign patients, I’ve had four with any sort of TMD issue, bearing in mind that I don’t treat them if they’ve got TMD, as a general rule. I had one patient come in once it was in my early on in my Invisalign days. And she said, I’ve got this terrible swelling on one side, okay. And I looked at it and there was nothing wrong in the mouth. And she’s basically got this huge masseter. And she’d been wearing aligners for about six or eight weeks. So I was looking, I thought, wow, why is that happening on that, and I saw her, flew right over to one side and really clench on it. And she had a bit of a habit. I said, Oh, okay, she was a gym bunny type as well. And she was playing on one side. So it was a time I was working with a number of people. So I showed him pictures and stuff like that. I said, Oh, what am I going to do? You know, I built this muscle up. And he said, Are you simply stop them working on it, it’ll go back to normal. So she learned not to do that. And she was fine. So they’re working that muscle, but I work. So I wonder if it’s both sides, number one, and it immediately tells me they haven’t got freedom in centric, you’ve got contact on steep occlusal planes to create that the force has to do fractures. Now, when we talk about putting the contact to the back, if I’ve got a tooth that’s heavily restored, okay? I’m not going to stick it all on a weak tooth, I’m going to bring it on other teeth as well, you got to apply a little bit of sense here. But as a general rule, if you can get two or three good contacts on the posterior teeth with a centrum, right? That spoon and they’re got freedom to slide up and down on that guide. And that is genuinely a guide is not too steep, in which case it becomes an interference, but you’re taking either, okay, then I find that they say yeah, I’m happy. That’s what I do with my splints. And also, I finished an Invisalign case. [Jaz]How many Centrums do we want? [Andy]I’m happy with, you know, if I can get it on two molars. So that’s four contacts on each side, basically. Okay, all four contacts so that will be enough. If the patient tells me they’re happy, I’m happy. [Jaz]So I’m just retry that tangible. So if you talk teeth me, so for example, if we have upper left seven and lower left seven, and as the patients are going into sort of a heavy sort of clenching and in an excursive movement, and they’re now going to have a nonworking side guidance or a Centrum on the contralateral, let’s say they could have it in the first molar because it’s so the second molar may be heavily restored. So now you’ve got four teeth touching, and potentially two centrums being formed. Is that enough? [Andy]Yeah. [Jaz]Okay. See, I’m trying to think of the practical aspects of when I’m potentially gonna be working with splints and stuff. And then a lot of people might be thinking, Okay, I want to look for the Centrums in my own patients, where can I start looking from? [Andy]Because I don’t feel a need to go in and alter the patient’s teeth too much. I certainly don’t want to be building up premolars to big contacts or grinding them down. Unless there’s a good need to do it because of the weakness of the teeth, or the periodontal ligament or something like that. And I come back to what we said at the beginning, you patient driven in your equilibration. Just keep going, until a patient says that feels comfortable. And you don’t need to look too hard. And frankly, Jaz, 98% of our colleagues don’t look at all, do they? Let’s face it. And if you don’t look, you haven’t got a problem, right? [Jaz]It’s true. [Andy]And the patients are okay. Because another thing that comes out of the anthropological evidence is the joint adopts to function. Right? So as long as you get them fairly comfortable, the joint will adapt, they’ll come back. In the old days, you know, you fit a crown on the NHS, you really short of the time is really high, you take the patient come back in three months, if it’s still a problem, they never come back. It all adjusts find God. And that’s what gets us out of trouble. But that makes me less anxious as well, because I’ve just got to make sure they’re comfortable when they leave. And I do. Personally, I do take care with them at the end of Invisalign, because I’m known for occlusion in my area, and I’ve got to do it right. The other thing is, I work in a practice in Melton Mowbray, there’s nine other dentists there. And most of my patients come from there are their patients. So anything I do is checked every six months. And if there’s ever a problem, they’re straight back to me, obviously. And I’ve been there for 10 years now. And I finished everyone with a posterior guided occlusion. And I can think of two patients have ever come back. I see their kids, I see their family, I treat them, they are happy with the occlusion I’m finishing the one. It really is simple. You don’t really have to sweat about it. [Jaz]Well, the reason I say I respect that coming from you is because because of your diverse background in the different schools of thoughts that you’ve gone to listen to, and you’ve done probably hundreds, maybe even 1000s of let’s say Michigans, Tanners in the sort of structural school of thought, I’m sure you’ve done all that. And now you’ve made a switch some years ago to the PGO model. Are there still times where you would say Actually, I’m going to, for whatever reason, treat this patient in a structural way and give them canine guidance. Is that something that happens? [Andy]Right, so I, you know, there are times what happens when they come away from the Centrum? They then go into canine guidance or group function. That’s okay. So, do you know Subir Banerji? [Jaz] Yeah [Andy] I mean, lovely guy. And he teaches on our diploma course. And he teaches a functional approach to occlusion while that’s why he’s there. And, you know, he’s talking about accepting what the patient’s got. And it was working with him, I suddenly realized I thought, Ah, what people aren’t understanding is that the centrum isn’t necessarily all of it, but it’s the first part of it, it’s the essential part of it. Where do they go after that? Well, I wouldn’t want them to go on to a heavy contact on a Periodont involved Central, I’d want to protect that central by them going on the canine, okay. Or if they’ve got heavily restored premolars or pre molars with fractures in, I don’t want them going onto that I’ll take them on to the canine. So there is then the next stage from that but usually then it’s only think of that stage they don’t realize there’s this initial thing all together and that is the essential. That’s the bit that’s present in nature. Right? We’re only trying to reflect what we know is present in nature. And nature does not give everybody dot dot dot stripe dot dot all. They doesn’t. [Jaz]We know that from all our AOB patients that are breathing normally and surviving just fine I’ve got a great collection of AOB photos looks weird and wonderful ones and I do a lot I do load testing, I do the Rocabado Pain Map on them and they got nothing about his patients and and all that sort. [Andy]What happened when they got though? [Jaz]They probably have a PGO, they definitely have a PGO for sure. But yeah, they have these simple elements like the centrums but here’s the thing, Andy, I’ve not been looking for the Centrum. So I’m looking forward to lock down finishing and just you know, with a fresh viewpoint now might it look like it took you Andy some goes at it to you know, you followed Ron and listened to him multiple times before he said, Okay, I’m gonna give this a go. It might take me that sort of set. I might start with this video first. But I mean, I’ve always never chased canine guidance always. I’ve always said okay, for me, it was important for it to be smooth, everything should be smooth, less resistance in the muscle should be able to because the more resistance you have, if someone is locked in, that’s when the muscles really going to overdrive and I know that’s my sort of background, if you’d like as well. It’s not too far away from what you’re saying at all. Next question is you obviously a very eminent speaker in orthodontics, especially clear aligners as you talk in the diploma. So orthodontics is a full mouth in enamel, let’s say, when you’re now setting up your clincheck. I think you’ve already given a flavor that actually no, we don’t need to chase a class one and what these other orthodontist may call as a compromise, you can now accept as you’re going for a functional occlusion. Is there any tips that you could give to people setting up their clinchecks to get the right occlusal setup and occlusion at the end? [Andy]So the first thing you do is you make sure they got a happy, healthy joint before you do anything. This is exactly what we teach. Now, you know, I teach Rahman a like, you know, he came from his school of orthodontics, which was over in Denmark. And you know, they were so wedded to class one. And we meet up together. And, you know, he talks about functional occlusion, I can remember actually, the first time I sat with him to teach occlusion, I was really worried because I come up with all this stuff. And you know, he couldn’t accept it all straight away, but it sort of made sense. And same as Subir. But one of the things that was so important to me about working with Rahman is, he think joint first. Okay? So everybody should think joint first. So the, my first touch with a patient, after I’ve listened to them on what they’re interested in giving them a mirror, and got it built a better relationship with them said, “Right, can I just check your jaw joint? Because my job to make sure that we give you a healthy functional bite at the end? It’s no good having a nice smile If you can’t chew properly.” And they go yes, you know what it is, the more times they say yes, the more they’re likely to take up their treatment. It’s the lightest touch, and I check their joint function. So that’s the first thing I do. So invariably, thank god 99% of patients have enough opening to chew, they might have a click, they might have a slight deviation, but it’s not really a problem. I mean, check in the mouth. And I’m not seeing any significant problems with occlusal wear, mobility, recession, fracture or anything like that, so that patient’s occlusion works for them. So I’m now going to try and maintain that posterior occlusion as much as I can. Because I’m unhappy with their occlusion. So I, as a general rule, I do not move second and third molars. I locked them on the clincheck. Okay? I will move first molar as if I want the width to get rid of the deficient buccal corridors, I need the width for space. And as another sort of general rule in terms of how I plan in the case, how much expansion do I want? Well, I go back to the second molars, they come in, there in [jam] where there’s a zygomatic arch comes in, and I want a smile at built that fits the face. Okay? So if they got really high cheekbones, wide, and they’re wide at the back, then I feel well, we’re gonna make it wider at the front as well. So I use the second molar as gently as my reference point for expansion. Anybody’s familiar with the four centers prescription that Rahman and I developed for Invisalign? Well, no, this is just absolutely comes in there. So I generally not move the second and third molars. And so you’re going to maintain your posterior occlusion, you can get intrusion, you know, with the molar of the aligners, [Jaz]which is why it’s so good for AOB cases. [Andy]There you go. What happens in at the end of my alignment, when I’m happy with a patient’s happy with their appearance, and then saying, right, we’re going to check make sure you bites okay. And I’ll ask them does anything feel like it’s in the way and it’s patient driven equilibration. Now, the one thing you got to check with orthodontic patients is their teeth immobile. So they’ll say, Yeah, I can bite okay, but what might be happening is they’re biting and the anterior teeth are moving. So they’re forcing those posterior teeth together. So I put my fingers on the front, or I get them to put the fingers on the front, and they can feel any of those front teeth moving, I don’t want that. So it tells me there’s a slight posterior open bite, even if I can’t see it. The other thing is I’ll do is I’ll put a little bit of 80 micron paper in there and get into clench. And if it catches, then that tells me That’s okay, as well. I finish about 60% of my Invisalign cases with a Dahl Appliance, because I’m not prepared for them to have any movement of the front teeth. And if I’m honest, I’m not that bothered about having any anterior tooth contact at all. And so if there’s any movement, or they don’t really feel like they can bite really well on their back teeth, or that paper comes through, I’ll get the last lower aligner, trim it distal to the canines and send them away using the upper aligner as a retainer. And usually I say it might take six to eight weeks, but over two or three weeks, those posterior teeth come together. Now, I don’t know if the anteriors have intruded, the posteriors super erupted, or whether the condyles changed, I don’t know. But they get the back teeth together and then I’m happy. Constantly asking the patient, Is it comfortable for you? That’s enough. I don’t really worry too much about what the actual contacts are. Because in function, they’ll be telling me if they’re in the way basically. And if they’re not in the way they can chew what they like. So [Jaz]I really like that answer. So the answer is very well. So how Andy approaches the occlusion, so not moving the second molars and third molars and at the end, using the aligners as a dahl appliance, fantastic. And just a couple as well, [Andy]One other point there is crossbite, I bit worried about crossbites as well. If I’ve got like molars in crossbite. And there’s no [hit and slide], there’s no functional issues, I’ll often leave a cross bite, there’s nothing to say, you know, you can get good occlusal function when the teeth are in crossbite. Because it’s that initial movement, that’s important, not the fact that it’s inside or outside class one, two, or three. It’s that centrum is important. So I will often leave a cross bite as well. [Jaz]I tell you, Andy, I wish that I can think of a couple of patients where I wish I left a cross bit. [Andy]Why make it complicated, right? [Jaz]So true. Takes an awful while sometimes. Well, one thing I forgot to ask you is how important is for your patients to be in “centric relation” when all this is happening, how important is for the condyle to be the definition of the anteromedial port the condyle to be on the posterior part of the sort of articular eminence, do you, does it matter? [Andy]What the hell is centric relation, right? So in our world, centric relation is a border position. It’s not a functional but necessarily the functional position, they actually function further forward than that in various positions. So the way if you watch, you know, I learned bimanipulation technique at the [Pankey Institute], they got this fantastic bit of kit, which, you know, shows you exactly where the condyle is and how much force you’re supposed to put on and stuff like that. And with some patients that works really well, other patients, they’re all over the place. So when you watch Ron do it, he’s almost, he’s talking him into it actually. And you will get, you’ll just put a little bit of pressure on their chin, and just get into open and close gently. And what you’re looking for is actually a muscle defined position where they want to function. Okay? And if it’s a patient with TMD, you might not find that straight away, because they’re all over the place. But you know, average, you know, Invisalign patient, for instance, and you check in if there’s a hidden slide, you just get nice and quiet, you try and get him to stop thinking about their teeth. And you put a little bit of pressure down, sometimes I get them to lift the tongue up. And that will just put the condyles in roughly the right place with the teeth not interfering. And then you get them to close together. And if their function defines the condylar position, that’s the point. It’s not you pushing them into a position. Now that people like centric relation, because it you can get back to it all the time. So but you lose the point of it. That’s not a bad thing to know. But it’s not their function. It’s a just the reference point. And it’s the back end of that functional area, if you like. [Jaz]So what you’re trying to say is that, although you’re not too hung up on it, you’re still sort of when you’re maybe equilibrating for someone to achieve PGO you are trying to approximately get to Centric relation? [Andy]Well, I’m aware of it, but I’m certainly not pushing them back. Again, I’m letting them drive me. So generally, if they’ve had a splint, the muscles balancer, okay, started work properly, the joint gets to where it wants to be. And then they take the splint out, you find the teeth are in not in the right place. So you’re basically then getting them to just remember where it was without the splint, and then show me where it touches and then they’ll tell you, basically, oh, yeah, that feels like it’s in the way. Because you’ve done that reprogramming, you know, of the whole neuromuscular job with the splint. [Jaz]Fantastic. I’m just now checking if I got any more questions left. Let’s see. Okay, so the last question then and then I’ll offer it to you to put any final points if you’d like to. It’s very educational episode. I really enjoy listening to you, Andy. So the question is some schools of thought suggest that MIP is a pathological position. So that actually we shouldn’t, you know, our teeth shouldn’t really be touching. So if you look at the end, of course, you might argue that the quality of evidence not good. And that’s a very valid point. But the, I believe, is 1964. The Graf paper, which showed using the latest technology that had at the time was that our teeth should only touch for 17 and a half minutes per day. And even then, not much force and psychological like we said, as those fleeting contacts, whereas you offered a theory of actually, we need to have a healthy clench, which wasn’t mentioned in a paper such as that, for example. So some people say that MIP is a pathological position. And, frankly, the what contacts there are in MIP is not important in the non parafunctional patient. Can you explain your views and then also, freedom from centric or freedom in centric, at maximum force, but that is something that maybe only happens in parafunction, but I think you’ve answered that actually, that healthy, the healthy clench is part of health. So I think you may have already answered that. But what do you think about that view that MIP is a parafunction or sorry, is a parafunctional position itself? [Andy]So I, to me, it’s what’s the quality of the contacts when they are in MIP. And if you’ve got contacts that are on steep inclines, and they’re locked in, then that’s going to create, we certainly know it’s going to create problems with the teeth. Okay, we know that those sort of contacts will switch muscles off. And remember, I wonder if that’s such an old paper, whether it’s coming from the old Tripodization philosophy. It’s actually a commentary on the old Tripodization philosophy. It was when, you know, dentist got so into their engineering that they believed that a good occlusion was three contacts for every cusp. Right? It will lock the patient in. And here’s another story. I wasn’t there. Ron wasn’t there. But Ron knew somebody was there. And this is the birth of canine guidance. Right? So this is high powered study club. And I can’t remember whether it was East Coast or west coast, but through the 50s. And 60s, there was like two battling schools of thought, east coast and west coast of the states. And one was about Tripodization. And the story goes that this dentist wife and the mouth restored by this top level occlusionist, okay? And she had gold on all our occlusal surfaces, ultimate, most jewelry, Tripodized contacts. And within a few days, she’s in terrible pain. So what they did was the ground all the contact zone, and the left with canine guidance, and she got better. And so Oh, she got better because of canine guidance. [Jaz]Mm hmm. [Andy]Whereas, if you took a functional point of view, no, she got better, because you gave her some freedom. You got rid of those tight contact. So I don’t know, Jaz, about that. But I wonder whether that part is the reason for that paper? Was to say you should not be locking people in. [Jaz]Okay, that’s it. Yeah. I mean, you will never know. I mean, I’ve got the paper I can send to you. But essentially, is that you know, you must have heard that, you know, they’re 17 and a half minute chewers is that really, the teeth should only retouch when swallowing. So it’s a difficult, you know, it’s a lot of the background stuff that I come from. I mean, the other thing I want you to answer [Andy]how do they measure that? [Jaz]It’s a technique where they use some sort of laser or something, I forgot what it was now. It’s a term I’ll send you the paper. It’s interesting. This is widely cited this paper even is it you know, and I say, how often should our teeth touch together. And something I say to my patients, actually, you know, if you’re, so one thing I think we can both accept is that at rest, it should be lips together, teeth apart. So that’s essentially what I teach my patients, you know, that you shouldn’t actually be grinding clenching. That’s parafunction. I mean, I think it stems from that as well. What do you think about PGO? And does it have any similarity to the, you know, 60s and 70s, the balanced occlusion, is that different to PGO? [Andy]Well, from what I understand, with a balanced occlusion, it was actually was a denture occlusion, and they’re saying that you should be and that’s why you had the curves of Spee and Wilson, [Jaz]but they were applying it to a dentate [Andy]A dentate patient. So I’m not aware, I couldn’t give you a decent answer on that. Because I don’t exactly know what they mean by balanced occlusion. I mean, I don’t think Ron and Henry came up with these ideas themselves, necessarily. They were part of, if you Ron’s written a book about Henry Tanner, and if you read about Henry Tanner, you know, he started dentistry 1946. And he was given the job of a equilibration in 1946. So, you know, they were all these competing theories all the time. So it may well be that this idea of balanced occlusion was around. But it hasn’t been described as fully as Ron and Henry have gone on to do it. And Ron has gone and got the evidence for it as well. And remember, you can’t get some of this evidence because the mass didn’t exist in the face. So you can see how these whole ideas have changed. And what we accept today as being obvious, isn’t obvious then. And we come back, if there’s one closing thing that we want to come back to New mentioned, if you say it’s your worldview, for instance, well, we are Oh, we’re talking about theory. Okay? Now, the purpose of theory, if you want to get back to scientific science, philosophy, the purpose of theory is to explain as succinctly as possible, all these different facts that are out there. There are facts out there that are not explained by a particular theory. And as the science develops, a new theory comes along, but not explains these facts, but can explain those things as well. And that’s the way that science develops. And I think now with PGO, we have a theory is not necessarily a perfect description. But it’s a better description of the real world than the theory of the structural theory, which explain that, you know, when you put people in canine guidance, they get better. All right? So that’s where we’re at. And this whole process is replicated throughout science. But as scientists, science students, we’re not taught about all those competing theories. It’s all about the one that becomes the truth. If you’re in social science, it’s all about the competing theories. And as I was teaching this social science education course, I recognize that actually, this whole thing around occlusion is just the same. And one day, possibly, everybody will see Actually, yeah, this theory, and maybe PGO explains more things to me and allows me to get on with my life, than the old theory does. And then as we develop more and more conversations like this PGO will develop as well and will develop into something else. But I think personally, we’re at a point where we not only have clinical experience, lots of our friends and colleagues not bothered with occlusion and patients aren’t queuing up in terrible pain. We have experiences like we have in terms of what you’ve done with splints. We have the evidence, like Ron’s audit, I did audit on his pain patients, for instance, how quickly they got better. We’ve got all his pictures of his splints, we’ve got our experiences that we do with, for instance, me finishing off these Invisalign patients over 10 years in this practice, where all my patients are being checked every six months by general dentists, just like you and me. And we have the dentures that show the effect on how changing the occlusal planes to match the functional surfaces of the joint makes an absolutely stable denture without implants. And then finally, we have the equation. And all those different bits of data facts can be explained by this theory. It explains all of those things, not one of those bits of evidence is enough to convince anybody that this is the truth. But you put them all together. And to me, it explains the truth in a much more complete and simple way than anything else I’ve come across. And that’s basically it. [Jaz]Fantastic. Well, I really appreciate your time to share about the origins of PGO. And also look at the structural view, you’ve answered a whole lot of questions that people out there might be thinking, and if anyone wants to, you know, comment right in, and I can always send these questions to Andy. And if there’s any resources, please Andy email it to me. And I’ll put them on as part of the downloads of this episode. I think you’ve summed up very beautifully at the end, they’re almost poetic, but is there anything that you’d like to, you’ve got the microphone now. [Andy]Well, only mainly to thank you, Jaz, for this opportunity, and to be questioned by you and challenged by you is a joy. And all of your listeners and people watching out there, come back with the questions. Okay? Because it makes it, the model needs testing, and it needs development as well. And but what I would ask everybody to do now is to understand that the way they’ve seen the world can be seen in a different ways, like a different set of glasses, and start to look at the back of the mouth as well as at the front and start to think about function rather than structure. And let’s keep talking. And let’s help develop these ideas. It really is should be simple, and hopefully will be. I really, really appreciate what you’re doing here, Jaz. Thank you. [Jaz]No, no. Thanks for coming on, Andy, and as I said, in one, every episode, I start with something called Protrusive Dental Pearl, like a little tip, it could be dentistry, could be something else. And one of the pearls I shared maybe five or six episodes ago, was a quote from Malcolm Gladwell. And it was “There’s something very unattractive about someone who refuses to change their mind.” So I think I’m always open to, you know, I completely accept but my hands up that what I believe now may be different to I will believe in five years, and I’ve got no problem to change on mine as long as evidence where the evidence, like he says many arms, it’s a whole clinical practice arm of evidence as well. So I think everyone should keep an open mind. And I like to have discussions like this in the future. And I think this is how the profession will develop in all the ways but I think it was occlusion which lacks a lot of evidence, it’d be great to test PGO more and really look at the different models like we are social scientists as well. [Andy]Yes, exactly. Jaz’s Outro: So occlusion geeks, thank you so much for listening all the way to the end. I hope you found it really useful. For those who haven’t downloaded Dr. Andy Toy’s ebook that was available with part one in the show notes on the protrusive.co.uk website. And again, like always a really appreciate you listening all the way to the end. Loads of cool speakers coming up. I’ve got Richard Porter on emotional intelligence. Got Zak Kara back again, as well as Gurs Sehmi talking both about presenting treatment plans and a little bit about you know, the whole case acceptance kind of thing. How can we actually get our patients to understand our treatment plans and go ahead with what we think is the best thing for them. Imminently, we’re coming out what about careers and actually making yourself employable. And also Ama Johal in airway, which is gonna be a massive, massive, very much a topic that is not talked about enough. So really excited to get that content out to you very soon. It does take some hours per episode to actually produce it all and get it all edited. So stick with me and I really look forward sharing that with you. Take care.