Protrusive Dental Podcast

Do you worship canine guidance? I think I went through a phase where I placed a very high importance on the presence or absence of canine guidance. I then got thinking…how and why are my patients with AOBs doing just fine? Why is it that some studies suggest that only 5% of the population has canine guidance, and others suggest up to 60%? Is group function really the villain? This is why I am open to listening to theories that explain this. Posterior Guided Occlusion is one such theory. I am joined by Dr Andy Toy to explore PGO concepts I wanted to delve deep in to PGO – so we split this episode in to 2 parts. https://youtu.be/k6T8cbqSY1I Need to Read it? Check out the Full Episode Transcript below! What we cover in this episode: We hear Andy Toy’s stories How did he get in to ‘Posterior Guided Occlusion’, clear aligners and treating TMD? The journey that took him to Pankey The story of how Andy met Ron Presswood and the influence that he had in his views on Occlusion What is patient driven splint adjustment? Why was Andy getting good results with PGO splints, just as he did with traditional tanner appliances? Why are we trying to switch muscles off, but Andy is trying to switch them ‘on’!? The surprising origins of Bonwill’s Triangle What is a functional occlusion? Realising that the the quality of the evidence in Occlusion is poor Link to Dr Andy Toy’s eBook on PGO All the other downloads from every past episode is on the Protrusive Dental Community Click below for full episode transcript: Opening Snippet: Know what goes there's no evidence for this stuff that we're doing really, if you get down any sort of textbook like Dawson, right? Sitting up there, you go to the end of the chapter masses of references. And I had learned to look at those references in. Well, you know, they weren't nothing... Jaz’s Introduction: Hello, Ron and welcome to another episode of Protrusive Dental podcast, a very special episode, something very different. Do you believe in canine guidance? It’s the first thing that we’re taught at dental school is the only thing that you remember about the occlusion aspect of dental school. Whereas having been to many occlusion courses, and then championing the role of canine guidance, I did always think why is it that some of my AOB patients are just fine? Why is it that some of your patients in fact, most of your patients, according to some studies, do not have canine guidance? And why is that okay? I think we’ve covered it a little bit in some of the episodes with Barry Glassman before, but I want to bring something completely different to the table. So today, I’m joined by Dr. Andy Toy, who is a fantastic dentist and mentor, based in Nottingham. He is an educator for Invisalign, and he treats TMD, does orthodontics and he has a massive interest in occlusion, hence why I connected with him. The story about Andy and you’ll hear his story throughout is very fascinating how he did all the traditional routes of occlusion was also in favor of the traditional mainstream sort of knowledge about canine guidance, and then how he met some people, and how he also considered that they may be another way to think about occlusion, that might be another theory that we should consider. And that theory is the PGO, which is posterior guided occlusion. So imagine everything you know about occlusion, and turning upside down. And then thinking, whoa, I mean, this blew my mind when I first came across it. So I want that as part of the handout of this episode, I’m gonna leave Andy’s ebook about PGO for you to read, because it’s a two part episode. Part one, this one is more of the introduction how Andy had done all the other occlusion bits and bobs, and then learn about PGO, and then we talk a lot, we get a little bit deep into the PGO and I leave you in a bit of a cliffhanger. Sorry, not sorry. And next episode, we’re going to get into how to actually apply PGO concepts, not patients, and how to actually make it practical. The Protrusive Dental Pearl I have for you is a communication one, what about when you get a patient and maybe you’ve seen this patient a few times before. And their oral hygiene is just not up to scratch, they still have plaque at the ginger margins, and you’re not 100% happy? How did you communicate your patient? Sometimes it’s embarrassing to as a dentist to say to a patient, I look you know, you’re not doing a good job, especially when you know, they come in, you have a nice chat with someone you’ve been seeing for quite a while. And then to put like a negative twist on the appointment and say, Look, I’m not happy with your oral hygiene, which we have a responsibility as clinicians to do. So I think there’s a tactful way to communicate that to a patient actually, you need to do a little bit better in a you know, keeping politeness and kindness and sincerity at the core of it. So my Protrusive Dental Pearl is that if you want to tell a patient that they need to improve something about their oral hygiene, here’s what I like to do. I like to ask their permission, and it works every time. So I say to a patient, may I kindly have your permission to give you some feedback about how your cleaning is going? Or May I kindly have your permission to give you some feedback about how your brushing techniques are going? And always like Yeah, yeah, fine. Yeah, please tell me I’m really interested. And then you show them in the mirror that look, you’re here, here, here, you’re doing amazing. Please keep this up. I’m really, really happy with this. But can you see around the lower anterior as you move the lip out of the way, and then you see all that mature plaque that they were missing for probably weeks and months. And then you show them look with a probe and you lift off the plaque. And I’m just concerned that you’re missing this plaque. And you probably haven’t realized it’s probably because of the fact that it’s so low down, your toothbrush just not reaching and just want a small change in technique, we can get your gum hygiene from 7 out of 10 to 10 out of 10. And they are so so appreciative of having advice given to them in this way. And it’s much better than saying look, your general dental checkup today was fine, but you need to do better with your tooth brushing. It’s not only more specific, but the fact that before giving them criticism, you allow them to give you permission. I think that’s really powerful. So let me know what you think about that. Anyway, I’m not gonna take any more time let’s join the episode with Andy Toy on posterior guided occlusion part one. Main Interview: [Andy]Hello. [Jaz]Hello Andy. How you doing? [Andy]Very well. Thanks, Jaz. Nice to see you. [Jaz]You too. It’s great to finally meet face to face have been talking on the phone and emailing on the run up to this podcast. So it’s great to finally have you on, on the Protrusive Dental podcast. [Andy]It’s a real pleasure. I’m so looking forward to our conversation. [Jaz]I am too because one of the things that I want to do with this podcast is I want to make it a voice for all I mean, I don’t want this podcast to be is a reflection of just my beliefs and mainstream beliefs because what I want to do is listen to other alternative options because I think that’s how we can expose ourselves to new treatments, advancements in the long run. So I first heard about you when my friend, the [Mitlani] brothers, were doing a study day a couple hours evening session, and it was posterior guided occlusion and that’s when you came my radar. We’ll talk about that today by also understand you you teach on the clear aligner diploma? [Andy]I do. Yeah. Yeah, that’s most of my work nowadays. [Jaz]Brilliant. And so tell us how you’re sort of career has evolved into this, you know, occlusion, clear aligners, orthodontics, and just tell the listeners where you work and a bit about yourself. [Andy]So I qualified way back in 1980, in Bristol, when the world was black and white, and felt a lot simpler. And I was very lucky because I had three years of undergraduate training in orthodontics, so we saw patients all the way through. And so as soon as I got into general practice, orthodontics was part of my life, and it was all removables, functionals and stuff like that. I was really, really lucky with my first job, because I effectively had vocational training before it existed. And my boss [Bob Barrow] was always interested in extending his knowledge and applying it in practice, he was a really strong general practitioner, and willing to go out on a limb. So it was a friend of his actually was a perio consultant in Sheffield. He has me sort of hanging onto the tables of [Bob Barrow] at 22. And you can see I was really into my dentistry and just like you, and he said, You ought to find out about occlusion because we’re starting to think about occlusion and restorative dentistry and stuff. I said, Yeah, that sounds good. He says you need to go to the Pankey Institute. Right? So there I am, 1981 is mentioned this thing called [Pankey Institute]. Now there’s no internet in those days. But he says [Jaz][inausdible] in this world. [Andy]Right. Well, exactly. So anyway, I write to the Pankey Institute, and I met a couple of dentists who are in his sort of friendship groups as well. And they were very encouraging, just like you would be with a young dentist. So I stole up there in 1982 in November, going there to learn about occlusion. Okay? I sit there. And the first morning, you sit in a big sort of circle. And you tell people while you’re there, and I’m the youngest by far. So over half the dentists were ancient as far as I was concerned, which meant that over 35, right? I’m here to pick up on Dr. Pankey’s philosophy and all that sort of stuff. I wonder what the hell is all about. Anyway, Pankey is alive at the time. So he comes in about 11 o’clock in the morning on a Monday and he starts to talk about, you know, why the institute is there and he is put some of his personal stories. And by the Wednesday, the penny drops, you know, this is there’s more to dentistry than just occlusion. You’ve got to look at the patient as a whole in a comprehensive way. Not just teeth and gums and jaws, but you know, the emotions, this personality types, but also then it’s all about your life in dentistry. So this really, really helped me at the time and I got me very, very excited. So I’m really getting into occlusion and I go on all of the occlusion courses I can go on. So I don’t know if you ever heard of Roy Hickson. [Jaz]Yes, of course. [Andy]Yes. So Roy set at the British society of cultural studies. And I went on Roy’s very first course that he set up and it was actually he set one up. And he brought Jim Moore over from the Pankey Institute because Roy had done all the Pankey stuff. And I went on that I went on [Harold Gal, Brendan Stack]. I started to do courses with osteopaths and chiropractors, cranial osteopathy, you know, I learned how to tune into the cranial OCR, cranial sacral system. I mean, the world we got into nutrition, you know, the world just opened up and you’re willing to have a look at anything and try it. So I made TMD part of my practice in life as well. I mean, you need a certain approach to TMD to be a certain type of practitioner but because I’ve done a lot on the sort of personality and people side of dentistry it really tuned in with that. And that carried on and I can I was part of the BSOS and you know, we went on courses with them. I remember very well still actually, Henry Tanner coming to Warwick that the early 90s and we had three days with Henry Tanner, for instance, we were going into trigger points and all that stuff. Anyway, that’s party life, occlusions party life. And in terms of orthodontics, I started the straight wire ortho in the 90s. I did the University of Sheffield course up there, and started doing more and more also. And so that was part of my general practice life as well enjoyed it. I’m pretty useless with my hands to be honest. So, I don’t know if you know [name]. But [Milesh] became a part with me in Loughborough where my practice is. And he’s so good with dentistry, you know, I pass all the blood stuff to him. And he was doing all the crown preps and stuff like that, but I was more the ortho and the TMD. And [Jaz]It’s interesting, Andy, you say that because I always am. I did have this once upon a time a belief that if you don’t like dentistry do ortho. [Andy]Okay. Well, [Jaz]I’ve since moved on from that I definitely. [Andy]In a way. So, I mean, you learn to do the things you love. Right? And you know, and if you can manage your practice that way, and that’s one of the benefits of I’m doing right. Anyway. So another thing that was in my life was I got heavily involved with the faculty. And I was doing a lot of teaching a with foundation dentists and things like that. And in the 90s, about the mid to late 90s, this thing about evidence based dentistry comes into the world, right? So I’m what I was a really, really strongly in favor of really good general practitioners, especially so great, you know, and the academics are great, we’ve all got our part to play. But I feel very, very strongly that the general dental practitioner is really the top of the tree, to be honest, rather than the bottom of the barrel, like they’re often thought, by specialists and not everyone. So anyway, in part, the faculty, were getting involved with teaching and research and evidence based dentistry comes out and all these academics are producing these research. And I’m looking at the results. I’m thinking, well, that just doesn’t look right to me. That doesn’t apply to the population I’m seeing in the Loughborough. So I’m getting a bit pissed off, to be honest, [Andy]can I say that ? [Jaz]Oh, you can’t. You certainly can’t. [Andy]I just stop. So anyway, [Andy]because these academics are telling me what it should be like, and it’s not like this, right? So I decided to get into some practice based research, there was a whole sort of, you know, movement and to do research is based in practice. And I started getting involved with that. And I’m part of the local NHS network and the deanery, and all that stuff. And one of the things I do is I decided to go on the Oxford University evidence based dentistry course, that was run by [Derek Richards]. So you might know him because he was the editor until recently of evidence based dentistry as part of the [inasudible] So Derek, lovely guy, he’s from Wales, and the valleys as it happens. So we know, we started to do that. And that’s nonsense. And I was beginning to learn about what is the nature of evidence, Okay? Another thing that happened in my life is I taken a master’s in clinical education. So clinical education involves a lot of social science research, okay, and evidence. And I started teaching the social science research module on that course. So I’m now teaching clinicians and nurses and all dentists and stuff like that all about social science research. So I’m getting heavily into what do we mean by evidence? And understanding that actually, scientific evidence is just one type of evidence. And whilst you and I might have been brought up to think this is the truth is really you start to appreciate Well, actually, evidence has different levels of quality and applicability. And actually, no matter how much evidence you’ve got, nobody’s got the evidence for the patient in front of you. [Jaz]100%. [Andy]So you have to understand the limitations of the evidence as well. So all this was part of my life. And but I’m also into occlusion right? So there was a BSOS trip to the University of Florida. I think it was 2002 or 2003. And we went to the Parker E Mahan Facial Pain Center, University of Florida, Gainesville. Henry Gremillion was the lead director there. Parker Mahan was still alive. And Parker Mahan taught me TMJ in the Pankey Institute in 1983, I mean, he was a fantastic personality. He brought anatomy alive for me, you know, in a functional sense. They used to, they got me there three days so that they’d have to build you up for two days. So you’re ready to train. Right? and Parker Mahan comes in. So Parker Mahan is obviously donated a lot of money to University of Florida who set up this facial pain Center, where there was 12 of us from the UK And we go have five days at with Henry Gremillion, CM patients, do an exercise and stuff like that halfway through the week, and Henry comes up to us, he said, we’ve got a colleague of ours was visiting Parker, his mentor is a guy called Ron presswood. And he really likes the Brits. He goes off to the UK a lot. And but and he’s got a particular way of looking at occlusion. Are you interested in listening to Ron? So we all say yes to and what else to do. So it’s take us in this little lecture theatre. And there, Ron turns up at two o’clock. And Ron is this quiet, introverted Texan, who speaks very quietly almost speaks out the side of his mouth, sometimes, you know, and you have to sort of really stop and listen, he’s introverted. He’s an ultimate like biomechanical engineer. And he can go off at tangents, and stuff like that. And anyway, he starts to give us his presentation on his views on occlusion, which is the posterior guided occlusion. And I’m sitting there listening, and I’m, I can’t don’t quite understand what he’s talking about. But he had serious evidence. Because all the way through that week, I’m telling these and were talking to these dentists, I’m saying, you know, what goes, there’s no evidence for this stuff that we’re doing really, if you get down any sort of textbook like Dawson, right? Sitting up there, you go to the end of the chapter, masses of references. And I had learned to look at those references in. Well, you know, they worth nothing. So we change in the 80s, from volume quanty of evidence to in the 90s and early 2000s. It’s about the quality of the evidence, and the quality, the evidence for occlusion was very, very poor. Okay? I knew that stuff worked. But the way that I’ve been taught at Pankey, and all these other places and modified it to my own thing, but so I wasn’t wrong. occlusion was important. But the evidence was poor. So Ron is done. And he’s coming up with some serious evidence, such as anthropological studies, okay. And the other thing about Ron was that he’d been one of the original teachers at the pankey Institute. So when they set it up, I think there was 12, or 13, original teachers, and Ron had been a teacher there, right from the start. He then taught with Henry Tanner for 20 years. /-Wow./ So I didn’t know what he was getting. It was very challenging what he was telling me because it’s feel that felt like it was like 180 degrees from what I was being taught and practicing. But he had evidence and I thought, I’ve got to listen to this guy, I’ve got to get to understand it. Now, the one of the reasons is challenging, is we’re all sitting there, we spent thousands of pounds to get there. We’re all going BSOS, we’ve spent tens of thousands of pounds learning about occlusion and I will tell you, right, and I bet you’re the same. And you will get embedded in one way of thinking and you almost have to enjoy, you have to say it right? Because you, you know you’ve [Jaz]committed [Andy]if you say it’s wrong, you feel a bit stupid to go on a site. You know, we all get this is one of the things about occlusion, I think we all get entrenched. And one of the lovely things that I’ve noticed about you is you’re willing to be what I call positively skeptical, right? You just don’t accept it, but you’re not going to ignore it either. That’s so anyway. And , that’s the stance that I would like to take. So Ron tells us this stuff. And I go up to him at the end, you know, and introduce myself because the Pankey guy and things like that. And I said, it’s really fascinating. I don’t really get it, but I really want to know more. And he says, Well, I’m coming over to the UK in three months time, why don’t you come to the study club. So we off down to Bristol for a study club, and listen to him again. You know, again, I get a bit more understanding. So I invited him up to our study club in Loughborough. So three or four months later, he comes over to the UK again, one of the reasons he has to come to the UK is he because he can’t talk about this stuff in the US. He gets shoved it down. A little text and guy right engineering type. And you know, there’s people with vested interests on teaching a certain type of occlusion approach to occlusion over there. And he was saying is not like that. [Jaz]Andy, for the benefit of those listening some of the young dentists out there who may be UK graduates for example, which is the majority of my listener base. I know Adam from America and those listening in the US right now please don’t be offended by what by what I’m about to say. But in the US just as you mentioned, Andy, it these conferences, they do get very heated with the different occlusal camps and say, and I’ve heard you know, of fist fights breaking out at events and stuff. So just to give some context of what Andy’s saying here is that, you know, that’s probably a good reason why Dr. Presswood was not able to speak about his very alternative view at the time. [Andy]Yeah, absolutely. So he, and you know, he wanted to explore this model. Right? One of the things I’m going to really enjoy about our time now is you’re gonna ask me some questions about it. And every time we talk about it, we learn something about it, because it needs to be tested. It’s just a theory. But I think it’s a better theory than all the ones I’ve seen before. So Ron comes over. And I’ve seen him a few times, I’m still not 100% Sure. Because he’s telling me that is not really about canine guidance, right? And I have worshiped at the altar of canine guidance for 20 years, okay? and tried to build it in and I can imagine, I can remember building massive bits on my splints to get the canines involved. Okay? You know, I’ve spent that time. And he’s telling me, it’s not like that. So I still don’t really you’ve got to get into your own clinical experience to really, really trust something. So one of the approaches that he taught me and this is the way that he and Henry used to teach the splint courses. He said, If you start to and this is a great tip, actually, for anybody doing TMD. Okay? Is you let the patient drive the adjustment. Right? So the patient, it’s not your splint, it’s the patient’s splint. So one of the things that you do is you put a splint in tap, tap, tap, rub, rub rub, he say, what does it feel like? Is anything that feels like is in the way and they point to a spot, they take the splint out. He’d point to it said, Is that what you mean? He says, Yeah. Can I adjust it? I’m gonna say yeah, so we adjusted, okay, so the patient driven splint adjustment, [Jaz]I love that [Andy]You will have in the back of your mind, I think I know what it should look like at the end, right? But you let the patient drive it. Now, when you let the patient drive splint adjustment. They don’t want canine guidance they don’t like. Okay? So I was starting to sort of pick that up. The other thing that happened is I had a patient, she was the daughter of a local dentist. And she’d had obviously, she’s a great big class two. So you can see this. And as a teenager, she did every fours taking on everything driven back. And she had a really deep, tight two div two. And she had a horrendous TMJ, head and neck pain, horrendous. And you can just imagine that the mother, you know how bad she felt because she’s a dentist. And she ought to be able to do something about this, and nobody could do anything about it. And she was one of my first patients I put on a PGO splint, right? And I’m telling the mother, let’s try it. Let’s have a patient driven splint adjustment experience. And so the mother is then sitting in the corner there. And we basically one of the things that you want to do is to get some what we call freedom in centric. I’m sure you’re familiar with that. And I was basically building and building and building and building the vertical here and getting that release. Okay, of those that deep bite. And I basically said, Well, we kept driving it she said kept saying I don’t like this at the front. I kept taking it off. And I had the her actual teeth poking, just poking through the anterior section, [Jaz]I could all rise up, right. [Andy]And we sent her away. And it makes an incredible difference. And so I basically just put put, it felt a little bit like the old gelb splint, I don’t know, [Jaz]I was just going to say that it seems like a almost like a posterior like a pivot appliance almost appliance, you know, what you were describing there. [Andy]It does vary but it’s more because I’ve done loads of them. But actually the working part of the splint is what we call a Centrum at the back of the splint and then fill that in. So it wasn’t just a flat plane, or a gelb appliance was designed to move the condyle into this some sort of special position and stuff like there wasn’t that. And I did cover the anterior teeth. But there was some little windows there for the because I’ve grown so much away. [Jaz]Surely [Andy]Anyway, made a big difference to her head and neck facial pain. So the penny was really starting to drop here and I’m thinking Yeah, well, so all my splints then I started doing as PGO splints, and I got good results with my normal Tanner appliances to be honest, because the way they teach you the Tanner appliance at the Pankey, they teach you freedom in centric and make it very flat. And it’s just that they say you should have canine guidance and immediate posterior disclusion. So what I was doing here is was I was creating a Centrum at the back with no posterior disclusion but smooth and harmonious patient driven, because they’ll tell you if it doesn’t feel right. And I wasn’t bothered to put a ramp on the front unless the patient, you know, eventually got into it. And I was getting good results with pain, just like I was getting with my tanner appliances. But interestingly, a lot of the clicks started to clear up as well. Because I used to say to the patient, I think I can make a difference to your pain, but I’m not too sure about the clicks. But if they if you’re out of pain, would that be okay? They say, yeah. And so that I was finding with the PGO splints that the clicks were starting to go. So that was an interesting experience. So [Jaz]In my map of the world, Andy, the way I can, because it’s funny, right? When you learn something, and then you apply it, and then you figure out supposedly away something works, and when someone else offers an opinion, and sometimes you can say, okay, maybe I was still getting good results, but it was for different reasons. And when I initially thought, which is why we had that phone conversation, you mentioned that and I really respect that I really like that. So in my map of the world in the moment, when you when you said exactly what you said, I’m thinking that by having these centrums, you’re giving the temporomandibular joint a bit more support, by you know, by having a bit more posterior guidance, if you like, rather than less support, for example, the more you anteriorise, a splint, the more seating you get other condyle, and that may be compressing some of the tissues I mean, that’s me being very logical engineering type. [Andy]Okay, so you’re right in terms of support. But you get you do want a seated condyle, Right? And so the reason that you get a more stable condylar position in function is because you’re switching muscles on. Now, this is a significant difference to every other approach that I’ve heard in dentistry, that, you know, you get health, when you switch muscles off, there’s something about the overworking of the muscles. So I’ll take you back now to my work with chiropractors and osteopaths. This is one of the sort of challenges I used to get. And I learned this particularly off osteopath, they were all about function. And it wasn’t, whilst they were in a structural way, what they’re really interested in is the patient’s function. So when we were looking at a patient, you start to see whether they’re not symmetrical, you know, is that a problem? So not really, because you can be functional in an asymmetric way, because nobody’s a symmetrical, okay? And so, and they would be always, when they’re talking about joints and stuff is that we want to make these muscles strong around the joint. And then, you know, I don’t know where you’ve had a knee injury or anything like that, you know, you go and get treatment for it. What do they want to do? They want to strengthen the muscles. And yet the jaw joint, they’re trying to switch muscles off what Ron was coming back with, he says, we’re actually no, we want stronger muscles. Healthy join needs good strong muscles, okay. And you can go to Wolf’s functional matrix, okay. And there’s a basic biomechanical principles that show that the structural part of the joint is dictated by the function. The better function you have the better the joint. [Jaz]Okay, that’s like a functional matrix theory as well. Right? [Andy]Wolf’s functional matrix. Yeah. So you got so. So when eventually a part of the story is then Ron keeps coming back over and Ron gets a one of his patients offers him to a quarter of a million dollars to do some research. Right? So Ron comes back over to Loughborough He says, I’ve got a quarter million dollars, you know, and I was telling you, I’m interested in practice based research. And always when we’re trying to do a research project. The money was always the problem. This time, we’ve got some money, right? So I’m thinking, right, we got some money. Now let’s do something with it. So I write to all of the dental schools. I know in the UK, I’ve got an interest in TMJ and occlusion. And instead of me saying our GDP, can I come and do some research? Let’s, you know, they say no, we I’m getting funding. I’m saying our GDP, can I come and do some research on I’ve got a quarter million dollars, [Jaz] a better position. [Andy] So anyway, send all those emails off. And guess how many replies I got? I think I sent eight emails. [Jaz]I mean, it’s probably going to be not very much unfortunately. [Andy]Zero. absolutely zero. So Ron comes back three months later, I say to Ron, we’ve done it we’ve done a whole study club, it’s four o’clock in the afternoon. And we everybody’s gone home and I said, Ron, I can’t spend this money is and I said it, the dentist just don’t get it. We need somebody who understands muscles and joints. And then the penny drops. I mean, Loughborough. Right? Literally a mile down the road is one of the World’s Leading Sports Science universities, the best. Okay. I think, hang on a minute, forget the dentists, best foot biomechanics? Because that’s really what we’re talking about. So, next day, I write email at this point, Ron and I had written an article, we got published in the, in the faculty journal. It was a historical perspective on occlusion and stuff, right? Because, and we brought in some of this anthropological stuff that Ron got involved with it. Right to the head of the department. And two weeks goes by, no response. Okay? So, you’re in practice, right? Do you know what it’s like, you get patients you get to know and there’s a particular patient Maria. She’d been a patient of mine for probably 15 years, her and her family. Maria was from Eastern Europe before the Iron Curtain came down. She was an Olympic Rower. And she basically defected when she was over on a competition in the UK, she got a knock on somebody’s door and said, I want to leave East Germany. Okay? And she’d come to live in the UK, she’d ended up as a research assistant at Loughborough University. Okay. She comes in to see me. And your 20 minute appointment is five minutes during the dentistry and 15 minutes talking about what’s going on. And she says to me, Well, what are you up to? I said, Maria, I just written to your head of department. Oh, because I’m interested. There’s research, I’ve got a quarter million dollars. Oh, what did he say? I said he hasn’t report replied. She says send it to me. Okay? Within two days, I got a response. The next week, he sent me to see this guy called Dr. Mark Payne, who’s like leading one of the research teams. Anyway, eventually, we get to do some proper biomechanics research at Loughborough University, or because of those connections that are out the luck that we had. And we spent, [Jaz]it’s amazing how these things work out with patients, sometimes. [Andy]It’s just amazing. So then with Ron, then we did some serious research at Loughborough for surface EMG muscle testing, and the effect of occlusion on the action of the muscles. And this is peer reviewed research. And we were working with three PhDs in Loughborough. And these guys, they don’t give a damn about occlusion, and whatever model of occlusion and whether you’re a Dawson guy or a Tanner guy, or Kois guy, or whatever it is, [Jaz]for the love of science, [Andy]they are, well, their job is to do top class science, otherwise, they don’t have a job. So these guys really know their biomechanics. And [Steph Forrester], she is actually no done more sEMG measurements on massseter and temporalis anybody else in the world. And it is, you know, it’s first class basically. And it was there to test the effects of different occlusal conditions on the action of the muscles of the head and neck. And actually, they found you can only really measure masseters and anterior temporalis. You can put stuff everywhere else, but you won’t get a decent measurement, they wouldn’t allow for that. In fact, this might be the time I don’t have time in the story where we I’ve got you know, I asked you to get those lollipop sticks. [Jaz]So my wife is a at the moment. So to put context, if you’re listening to this episode in the year 2021, or something, it’s locked down period COVID-19. And my wife, conveniently is a COVID swaber at the moment. After suffering from COVID herself. She’s now a COVID swaber. So she’s doing a great work for the NHS in the frontline. And she was able to get these wooden spatulas 72 hours before so that they can hopefully be COVID free by now. So I’ve got them ready. [Andy]Okay, so we could reproduce this is one of the things I do on the courses, we can reproduce a bit of the evidence. Okay, [Jaz]Let’s do it. [Andy]Is this a good time to do this? [Jaz]Yeah, let’s do it. [Andy]Okay, so basically, we looked at, I can show you the results as well if you want, but we looked at the six different occlusal conditions on healthy subjects, which I think is significant because we’re trying to define what is a healthy jaw joint and healthy jaw joint function. And when you know what health is, then you know how far they deviated from it and you know what you’re trying to aim for. And one of the problems with [Jaz]definition of health is I’m sure you did it, very mythologically properly range of motion. I mean, the whole law absence of it, it’s not it’s not just absent of symptoms. Did you take MRIs for example to confirm health? [Andy]No, they did it on, they use USA internationally accepted definition. And you know, the patient’s reported no pain, ability to chew and a good range of motion where it comes out where it was, what exactly is and all these guys are pretty well Loughborough Universitystudents, basically, a lot of them are triathletes, actually because [Steph Forrester] run the trade club. And they’re trying to keep him with her. So they get involved with research if she said so. And so you can do it with tongue blades, we actually used for the posterior ones, we used cotton rolls, actually, but these will do anyway, and what we did six different occlusal conditions, we did a clench. Okay, we did an anterior blade, parallel to the maxilla. With an anterior blade steep. So you probably heard of Lucid jigs? [Jaz]Absolutely, yeah. [Andy]So that’s effectively what a Lucia jig is, yeah, we did one blade occlusion on one side, occlusion on the other side, and then occlusion of posterior that is and posterior occlusion on both sides. Okay, and what you find is funny enough, in these healthy patients, when they clenched, without any blades, you had pretty good contraction, the masseter pretty good contraction of the anterior temporalis. And not only that, it should be coordinated as well, they spent a lot of time in those first few minutes seconds of contraction, and see whether it was coordinated, and there was a high level of coordination. Now we all know this, when you put the blade at the front, lot austie what they found was the temporalis shut off. Okay, the masseter still did function slightly less, but the temporalis basically temporalis shuts off, [Jaz]which is how anterior mid point stop appliances, you know, the main roadblock now function. [Andy]Exactly. And one of the ways that I’ve been taught, you know, with I get a really, really challenging patients is a lot of pain locked up, you put a little Juicy J again, and just send them away. And I would still do that, consider doing that to this day. Because whilst I’m saying we should turn muscles on, we want strong muscle function, you can over work a muscle, just like you and I go to the gym, and suddenly we start working on something and you know, it’ll be painful in your arm or whatever it is. But we shouldn’t be necessarily switching muscles off in if we’re aiming for long term good or good health and function. Okay? It’s gently, that would just be a small interim stage. So anterior, but all that temporalis switched off masseter still works a bit. Now that when you put it on one side at the back, okay, you find that the opposite temporalis switch is off. I’ve been waiting to be able to feel it there. But what you want to do is when do it with nothing, I have to I think at all, and get it onto your temporalis and you should feel hopefully not only a good volume of contraction, but also quite coordinated as well. [Jaz]Yep, coordination and yet, but a decent volume. Yep. [Andy]Okay, now you put a tongue blade in on one side, just posterior. And you should feel that the opposite side is either [inaudible] [Jaz]See, I’m one of these freaks. I’m just being very honest. When they speak, I think it’s less, but it’s not as much as when I do something like this on my patients. A lot of my patients, they would switch off or be significant less, I’m a bit less. So I in principle, I can vouch for that. I’m just a freak. I’m very parafunctional patient. I’ve got quite hypertrophic muscles myself. But yes, there is a difference between the side where I’ve got the wooden spatula, which is contracting normally and the other one, or well, and the other one is not contracting as much in Yeah. [Andy]Well, one thing that might be happening is actually you’ve not got really good volume either side. Because the other thing then they did was when they found that the optimal a maximal contraction and coordination was when they put cotton rolls in between teeth, it was better than the clench. So let’s put it in both sides now. A really clench. Certainly in my mouth. I’ve got more volume. Right? So now if you compare it, I think you’ll find it. Certainly My mouth is less volume than I had on this slide. Then when I had both of them in there. [Jaz]Absolutely. [Andy]So the maximum contraction and coordination was when they had cotton rolls in there, which was mimicking food, basically. So let’s think what’s happening though, because you started to talk about, and when you have an anterior contact, that it’s affecting the ability of the condyle to really seat. Okay? So if we think about this here, what’s happening, when you’re biting down on this side, this condyle has shifted over to the left. And it’s because there’s no contact on the teeth [inaudible] And the muscles will not contract, because it’s not in a stable position. As soon as you get a contact on that side, the muscles will then contract, right? So you need the contract on the both sides before the muscles will contract. And that really allows the condyles to seat. Okay? Because So essentially, there’s condyles in space. Until you get a contract on that side. Now that we don’t eat like this, we eat like this. So you have to have contact throughout that movement, which means that you have contact on the nonworking inside. So when we shift over to this site, you still need contact on this site, you should not have immediate disclusion. [Jaz]Because that will be an unsupported joint on the other side. [Andy]Exactly. So this is I mean, it’s an inference from the data. But why does the, Why did the muscles contract maximally and in most coordinated way? It is because we think is because it allows that condyle a really seat and disorders tubercle. Okay? Now we know is always tubercle is the is the point of greatest force, because that’s where the bone is thickest. And the cartilage is thickest. Okay? Now, there’s an area here as or as tubercle is an area of contact, which also says is not one position for the condyle. Okay, it moves around. I don’t know if you ever saw that X ray movie, they could never do it today, or somebody I know a whole side extra with somebody chewing [Jaz]I’ve seen it’s like a lateral skull view of them is chewing. [Andy]What’s the condyle doing? It’s doing this. [Jaz]A lot of movement. [Andy]And the point is, this is what it does in function. And one of the problems that I had in my training is that you know, when we look at the way in which the teeth occlude together, and we slide on from side to side, and things like that, we’re looking at these gliding movements. We’re not really look at them now looking at them in function. Now that brings me on to the the other exercise I do when we do a course. Okay, and this is referencing [Bayron’s] work back from 1964. So Bayron looked at occlusal contacts and the difference between occlusal contact in function and in gliding movements. So we can do this now. You and me, okay? /-sure./ So put your teeth together and glide out on your on the side, on your preferred side, it doesn’t matter which side. Okay? I go out to the left. All the way out. And which I’m contacting on my left canine now. [Jaz]I’m very much in group function. [Andy]So you got group function. Okay. So are you going off to the left as well? [Jaz]I’m just going to the right now [Andy]To the right. And so if you’re going off to the right, and the teeth and the left coming apart? [Jaz]The amount of force I’m doing this and it’s just a normal, like you said, a glide. So just just yeah, just keep contacting, rubbing if you’d like skirting to my right. So know that my I have separation on my other side. [Andy]Right. So you’ve got group function with posterior discusion on the opposite side. Okay. Now just slide out to preferred side again, about a third of the way out. And this time, you’re going to crunch back with force. Okay? And just feel what’s happening on that opposite side, as you come back in to MIP. [Jaz]Okay, as I came in, and just when I was almost there, I felt a contact on the other side and my masseter I felt my masseter a contract on the left side, [Andy]Right. So you, you felt the end with force, there’s not immediate posterior disclusion. Okay, so when you glide, there is, but when you put force on, when you apply functional forces, the teeth come into contact. So, when I’m trying to explain the difference between what I’ve been taught as canine guided occlusion in the past, and the way what we teach in posterior guided occlusion now, I say there’s two ways of looking at it. There’s a sort of Structural way. And there’s it’s either about the structure or it’s about the function. And posterior guide occlusion is about function. Because when you look at occlusion with function, you have to factor in this there’s compression of the joint, okay? The bones compressing, the periodontal ligament’s changing and any although it’s a fraction of a millimeter it’s a significant fraction teeth come into contact. And we know through our Loughborough research that’s which is the muscles on [Jaz]which year was that Loughborough research by the way? [Andy]off the top of my head if we had the slides it’ll be on the slide show 2007? It’s the Journal of oral rehabilitation. We’ve done another couple of studies there as well. And I might we might get into that one. [Jaz]Sure. [Andy]What Ron was describing was actually confirmed then it was just confirming what was Bayron research done way back in 1964. And when you do it with Dentists we’ve done it all our study clubs, you get something I forget what it is exactly about 40 or 50 60% of canine guided about 30% are group function. And every now and again you get somebody who’s got function both sides they got contact both sides. When we ask them to bite back with force, you find about two thirds start to feel that nonworking side contact show and we then going with silk occlusal silk marking paper, okay? You find that contact on 100% of dentists. Okay, it’s just that we’re not always aware of it [Andy]So this posterior guided occlusion is coming out of what we see in nature. Right then so back to Ron Presswood Okay. One of the things that happened Ron and Henry have been working together on this thing and they’ve got this idea that this is the way that occlusion should be because it’s patient driven. And he was to do minimal adjustment to the occlusion, you know, I was taught, you know, massive amounts of equilibration and you have to dot dot dot stripe, dot, dot dot, you know, they were doing just touching here and there because it was patient driven. The patients were getting better. So Ron’s at a party [Jaz]that was on splints, or that was occlusal equilibrations or both? [Andy]I’ve done a equilibration course at Pankey, I think I may have done it twice, actually. And you know, we would aim to get that those dot dot dot stripe, dot, dot dot on every patient,Okay? [Jaz]and that was very different to what Ron was doing. [Andy]Exactly, because Ron and Henry saying, Well, actually, you don’t really need the canines, necessarily, it’s really what’s happening here. And you certainly don’t want posterior disclusion in that initial, what we call centrum thing, [Jaz]That is with force. [Andy]Well, because we’re interested in function, right? Then you should aim to build if you’re, if you are building somebody occlusion, you should aim to build in the ability for that normal side contact to come in. And actually, I’m going to bring you on to my next proo now. I hope you can see this. See this little spoon? [Jaz]Yes. [Andy]Okay. And if you look at my ebook, I tried to build this into the pictures. If you imagine that’s where the centric stop is. Okay? And if this is the lower right second molar, as you move over to the patient’s left, they should right up and down. [Jaz]And your finger there is the palatal cusp of the upper first molar or second molar. [Andy]Exactly. Doesn’t matter which could be a first or second molar. But that’s the contact that you’re looking for. Okay? There’s a little Centrum a little bowl to allow a little bit of movement. And then as soon as they start to move off to one side, it rides up, at least for the first millimeter or so that posterior guide. Now we call that a guide now, up until really understanding Ron’s work, if I saw that I’d be grinding away, again, because that shows me we’ve got haven’t got posterior disclusion. [Jaz]So yeah, and that’s what we’re classically taught as a non working side interference and interferences are bad. You know, Well, this is not why I believe in but this is obviously because for me nowadays, with the way I look at it in my map of the world is that they are not interferences, they are just non working side guidances. Now, what you’re throwing on the table is, is even you know, is making me very excited. And we got about a whole bunch of questions for you at the end just to debate this and explore this because this is really great. But one thing I just want to highlight now when you’re discussing the centrums, and the contacts is that the reason I read resonated with you and the reason I was so excited to bring you on the podcast for everyone to listen to was yes, you offer a 180 degree viewpoint. I think it should be heard by everyone. But you’re the first person who I’ve read in a book. And maybe that’s because you know, you may argue all you haven’t read all the books or whatnot, be the first person I actually read about the fact that most people who you think are in canine guidance, as soon as they put force and today go to one side, they’re no longer there actually in group function. So when I read that, hang on a minute, yes, this, I need to actually hear out what you’re trying to say. That was one on one kudos point. [Andy]Right. And so you know, that’s Bayron’s work back in 64. But, you know, if you don’t like that idea, you’re probably not gonna even look at that. Okay. But one of the things that Ron is very open minded, and he is the only person I know, who’s gone back to look at every single book on occlusion and read every single book. Right? And he went back, what happens is you get Dawson. And a Dawson then would see reference [ ? ]Yep. So you get gi Shea and gi Shea references, whoever it is, okay. And it goes all the way back to this chart called Bonwill in 1884. Now, I told you I’ve been doing social science research. Okay. So this is, what I understand is you have to understand the social history of what we how we learn and what we learn about. So I’m going to give a little bit of social history now of occlusion. Why do we think of occlusion the way we think about it? [Jaz]Is that a rhetorical question or you want to answer that? [Andy]Well, this is actually Ron’s. Ron is such a detail man. He says, I’ve got to find why we think the way we think because it’s not matching what I’m seeing in the real patients, right, and other bits of evidence. So it goes all the way back to Bonwill. Bonwill was the first person in English anyway, to write about occlusion he was a very well known dentist 1884 he writes this paper, and he says the body is designed on a set of equilateral triangles. Okay? Most clearly manifest in the mouth and jaws. And in the mouth, and jaws is based on a four inch equilateral triangle, four inches from here to here, and four inches from here to here. Okay? So where did he get this information from? In his article, right? In the article, he says, I had a dream, I was visited by God. And he described to me the way that the body is made up. Now we’re laughing but in those times, God was part of the science. Okay. And here’s some people say I said he stole part of science, fair play. But so anyway, we’re four inches from here to here and four inches from here to here. So it tells me two things. I don’t know about your God, Jaz, but Bonwill’s God was clearly English because he used Imperial measurements, okay? Right? And second thing it tells you, is it tells you the body is symmetrical. Because we’re four inches from here to here and four inches from here to here. Now, how many patients have you seen who are truly symmetrical in the physical form? [Jaz]Well, having done a diploma in orthodontics, one thing I started looking at more was faces. You know, I really went from identifying looking at teeth looking at faces, and right at the moment you go on Photoshop or keynote, and you flip transversely the patient’s photo, they look like a different person. [Andy]Yes. Symmetry does not happen in nature. It’s not natural. Okay. So who was a student of Bonwill, a certain chap called Edward Angle and he then got into detail about describing the way the teeth meet together. His angles class one, class two, or class three. And he references Bonwill, he was a student of Bonwill’s. And so suddenly Dentists have got this thing Oh, yeah, this looks right. Okay, now another part of our research team is a dental technician called John Bill okay? And John, because he really got into this as well, he looked into the history of articulators so around about the turn of the century 1800s and 1900s when Angles was coming up with his ideas, Ron and also seeing papers on a functional view of occlusion and being challenged by the structural view of occlusion so as Angle and Bonwill, the structural people, you know, you healthy when you like this, okay? And the functional people say, well, it’s don’t matter so much how you are. It’s whether you can chew or not. And there was this sort of competing ideas at the time. Now, the articulator manufacturers would go to both camps and say, Tell us what you want, we’ll build you an articulator. Now the structural people, their mass was normal standard nonlinear mass, okay, because it’s easy to describe, it’s like a hinge, it’s symmetrical. Okay? The functional people couldn’t describe exactly what they wanted, because that is based on nonlinear maths. And the condylar movement and occlusal function is nonlinear. And nonlinear mass did not exist at the turn of the century. So basically, they are to articulate the manufacturers piling with the structural guys, and then somebody’s got something to sell. So it starts to build up from that, and these functional people, you know, got, they didn’t have it couldn’t really compete with that, or whatever. And frankly, I don’t know you’re not not old. But I can tell you a lot of my friends and colleagues are qualified when I did never bother with occlusion throughout the whole career. And they just go on with life in their way. Okay, and nobody died pretty much. So basically the structural piece, that’s why the structural ideas got took hold. And then it all leads up to people like Kois, Dawson, I’m not so sure about Kois, to be honest, because I hear that, you know, he’s far more functional. But you know, the Dawson’s in this world cliches. And certainly orthodontics For God’s sake, your orthodontist used to be taught, you got to treat a class one, you know, and get the patient the class one. And that’s why that dentist’s daughter had four falls out, she had to get the class one, molar class one and all that sort of stuff. I mean, it’s it pervades everything that we think about. So I teach it on the diploma. We do look at other class one, two, or three, but I say to people, look, this is not a treatment aim, it’s just a description. And if you know, you know how far they are, from this reference point of class one doesn’t mean to say you should treat a class one, because you have to treat according to the needs of the patient. And patients are not symmetrical. And some people skeletal patterns are more two, some people more three, what you’re looking for is a functional occlusion. And you can have a functional occlusion with a six millimeter overjet, you can have it with a minus three millimeter overjet. And you can be in a terrible, terrible pain if you have class one. And you know, too many overjet anterior contacts. It doesn’t relate to whether their own pain or good functional. It’s not related. So how do I get it? So basically, I was telling you where [Jaz]You’re refreshing those you know, that’s very refreshing to hear about. Now We don’t have to treat everyone to class one, but still on as far as I can see on postgraduate degrees and degrees in orthodontics, they still teach Roth. Roth is five sort of principles, which very much echoes from Angles and Andrews and go continues on from there. [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. [Jaz]Okay, 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 compromised treatment plan. And that term then makes it 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 compromised 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? Jaz’s Outro: So that’s quite heavy stuff. I hope you enjoyed some Andy stories of the origins. Next episode, we’re going to go really deep into PGO. And we’ll also talk about how Andy applies PGO actually clinically, to his patients and what he’s looking for in his Invisalign patients towards the end of the treatment protocols. So I look forward to catching you for part two of PGO.

Yes, you have read the title correct. I DID get Chris Orr on the Podcast…the silver lining of lockdown?! I am very excited to share this episode with you – Composite vs Ceramic, Direct vs Indirect. I have placed hundreds of humongous composites in my career that in hindsight should have been indirect restorations – I share the challenges that I faced in my journey and I am sure many of you will be able to resonate with it. https://www.youtube.com/watch?v=SGWcwkZD-kk Need to Read it? Check out the Full Episode Transcript below! We discuss: An extremely insightful episode with Dr Chris Orr (whom I refer to as ‘the Rockstar Dentist’ and I share the story WHY I give him this name) Is there a place for inlays? At what point does a composite become a ceramic (or read: direct becomes indirect) Is there a place for composite onlays? Does the parafunctional status of a patient influence the choice of restoration? Is eMax acceptable for 2nd molars? Dual cure cement vs light cure cement for onlays? How do you decide which cusps to cover? What kind of join is best to the tooth? Pressed eMax vs CAD/CAM eMax? What does Chris Orr think about BOPT/Vertipreps? As promised in the episode, if you are waiting for announcements of Advanced Dental Seminar courses by Dr Chris Orr – check out their ADS Facebook page Click below for full episode transcript: Opening Snippet: Bruxism has a lot in common with periodontal disease. Because we have to have these difficult conversations with our patients that you have this problem. I can't cure this problem for you. I'm happy to help you. But it's your problem... Jaz’s Introduction: Hello, everyone, and welcome to another episode of the Protrusive Dental podcast. I have got an absolute Rockstar and I use that term purposefully because I’ve got a story associated with Chris Orr. Dr Chris Orr who’s coming on the show, say to discuss about a mammoth topic, which is basically composites versus ceramic, which is best and how do you choose? So the story with Chris Orr is when I was a student, when I was about a fourth year student, we’d have these dentists who were several years qualified, come in, and they will be learning how to place implants. And we’d be like on these clinics just floating around as students do doing nothing much. So anyway, I got talking to another dentist, and he was giving me some advice as me being a fourth year dental student, he wanted to give me some advice, just thought was very kind. And basically, he was basically blowing off some steam. He was having a rant about the state of dentistry in the UK, he wasn’t a very happy dentist in terms of how dentistry was in the UK. And he kept saying, look, if you really want to be a great dentist, if you really want to be an amazing dentist, you have to go transatlantic, you have to go to the USA and do some training there or get to a American Dental do a postgraduate degree or do some courses in USA, and basically move to USA is essentially what he was saying to me. But then he said, however, there is one dentist in the UK that I think is amazing. He said, Have you heard of Chris Orr? At the time I hadn’t heard of Chris Orr, and he said to me, Chris Orr is a rockstar dentist. And that has never, I’ve never forgotten that, that has never left me. So whenever I see the name Chris Orr I always think Rockstar dentist basically. So obviously, that dentist, I think I see where he was coming from. But I think nowadays, with the UK also producing such we already have lots of great dentists. And I think that perception that USA has better dentist and UK, I don’t think it’s 100% true at all. Whether the training is better may be a different story, but definitely the color of dentistry in the UK, something I’m proud of. And we have some huge names and one of them is Chris Orr so it’d be great to chat to Chris Orr today. The Protrusive Dental pearl I have for you is I’m going to show you how you can quickly rotate and edit your photos and crop them. So they look more presentable. So there’s a typical lower occlusal shot that you have. And when it comes out the SD card onto my Mac, there’s what looks like it’s in the wrong orientation, it’s got excess on one side that we want to get rid of. So all I do on a Mac, and it’s very similar process in a Windows is I’m gonna click on Edit, crop. What I do then is a first one define my borders. So here we are on the buccal surface at seven. I mean, this is a good occlusal shot, not perfect occlusal shot, because it would be nice to have a bit more retraction in a lower labial segment. And we get all the way to the seven, which is pretty good. And there we are, so I’m happy with that. So then I’m gonna do is I’m gonna rotate twice, once, twice. And then of course, because a mirror image, you have to flip it. And that’s it easy as that quick as that I’ve got my correctly orientated occlusal photo. And the other question I get is, how did you get those posterior quadrants, sort of quadrant photos? Well, one way to do that, which is not the way I like to do it, but one way if you want to do is again, once you go to the right orientation, you crop it. And let’s say you want the lower left side, because you’re going to show the patient that everything is not doing so brilliantly in this area. So you’re going to crop it around about like that. When I click save, there we are, that’s something you can show the patient. The problem with this is that it’s not as crisp, the quality isn’t amazing compared to let’s say, when I’m doing a quadrant of let’s say caries. Here the difference is, and again, I can still crop and edit this. The difference is that in this photo, I’ve actually zoomed in on my camera lens and got a high quality zoomed in photo. Whereas the other one, you’re taking it from further back, you’re taking a 3:1 ratio, and then you’re zooming and the photos, it doesn’t look as crisp. So depends on what you use it for the other one may be acceptable, but to see this level of detail, then you only want to put it to 1:1.5 for example, and get zoomed in shot like so. So I hope that helps as the Protrusive Dental Peal for today. So over to Chris Orr and the discussion, composites versus ceramic, which is best and how do you choose? Main Interview: [Jaz]So Chris, Dr. Chris Orr, thank you so much for coming on the show on the Protrusive Dental podcast. [Chris]Thank you for having me. [Jaz]You are someone you know you are someone that a lot of my listeners have sort of messaged me proactively say, can you please get Chris Orr on the show? And I think that’s one good thing that came out at lockdown, enough to get your free enough in your schedule to pounce on the opportunity, I guess. So I really, really, really appreciate it. And the people on the Instagram page were quite excited to learn from you today. And the topic we’ve chosen is something that as I said before, you can write a thesis, several theses on this topic. So it’s composite versus ceramic, how to choose, which is the best basically, tell us about what why you think this is a good topic to discuss. [Chris]I think it’s very pertinent for high practicing at the moment, not just returning to work post Coronavirus, locked on. But just generally, over the last probably 20 odd years, we’ve seen quite a few trends in the material science that underpins what we do on a daily basis. We’ve moved away from restorations which are retain mechanically. So a lot of the traditional Shillingburg stuff of preparation geometry, making a restoration stay on a tooth that has largely fallen by the wayside because we rely on adhesion for the vast majority of restorations that we place. And also, of course, the materials that we attach on to that adhesion have become a lot better. So composite has improved hugely away from the stuff that we had 20 years ago, which you have to be super talented, sort of Didier Dietschi, Newton Fahl kind of level brands have any kind of level of skill to achieve a good result. And their work was awesome. And it still is, but if you gave those guys, you know, playdough, they could make a tooth on a banana would look perfect. Today, we have materials that are composite materials that are really, really wonderful. They’ve been designed for a whole range of usages. So a dentist with an above average level of skill, and above average level of motivation. And a sensible amount of clinical time can do a really decent job, just great. Porcelaina also got a lot better. A lot of the thing, the materials that we had used historically, which were either very difficult for the technician to make, or didn’t look all that nice, they are sort of falling by the wayside. Not every material is dying a death. But most things do still have a place. But in how much of a place those things have. That’s something I think we’ll explore during the rest of the podcast. But essentially, it means both of these things mean that we can be very, very conservative, we can hopefully produce a restoration that’s going to be durable for the patient over whatever timescale we happen to want it to last over. So we’re in a very, very good place. And the difficulty, I think, is that the there’s always these sort of pendulums that swing back and forth, in dentistry, we’ve seen the professional regulatory pendulum swinging far too far over to the side of witch hunt, which is where we’re at. I think we’re we’re sort of starting to swing back the other way with the GDC at the moment from what I can see. But the pendulum of you know, do you prep the tooth? Do you try to do it no prep? Do you, What do you try and do? At the at both extremes, outcomes are not good. So we can prep teeth very heavily, we can get things that may look very nice. But sometimes when you think about survival, I wonder sometimes if we’re thinking about the survival of the wrong thing. So if the restoration lasts 25 years, and at the end of that 25 years, a tooth has to be removed. You know, on some level, are we really doing the patient a favor? Whereas on the other side of the pendulum, the idea to do it no prep, which is very easily achievable with a direct restoration in many cases. And there are some situations where we can do it, an indirect restoration with no prep, provided that the patient has grown a tooth that’s in the right shape, to allow us to fit the restoration on [Jaz]that’s a good way to put it. [Chris]But it is we think about it. The classic example if you can think of a peg shaped lateral incisor, that’s like an ice cream cone. [Jaz]Yeah perfect. [Chris]And the orthodontist has opened up all the space perfect, you take an impression you glue on you’re at a ceramic job done easy. You could also do it in porcelain or porcelain composite but the number of that exact presentation you’re going to see in your life, it’s going to be quite small. So it’s the reason the discussion is interesting is that some people seem to believe that every problem in dentistry can be sorted out with composite. A lot of problems can, wonderful material. But there are some there comes a point sometimes where depending on where you started from with the patient. And depending on how long you want things to last, then there may be some other things you and the patient may wish to consider, I think is the best opening statement. Other thing is, I think probably looking at some of the, and again, it’s very common when I’m talking to a group of colleagues, that a lot of the questions are along the lines of, what do you always do? Do you always do this? Do you always do that? And unfortunately, one can never be completely black and white. I wish we could. If you want to do, if you see this, and you always do that, you’re practicing probably about 50 years too late. Because if you think about the 1960s, and 70s, if you had a small hole, you did an amalgam filling, if you did medium or large hole, and amalgam, maybe an inlay, big hole crown, easy. Bigger holes not to take it out, [Jaz] way more complex [Chris] Other decision tree was very easy. Blessing and curse. Dentistry is very sophisticated these days, which means we’ve got to be really mindful of exactly what would Jesus I think the only answer that I would give to, what do you always do is look and think, lose your brain. Every one of your listeners is smart enough to make those decisions. They’ve all got good brains, we know that because they were able to get into dental school in the first place with A-level grades that are so high that I don’t know if I could get back in again, if I had to do A-levels again today. And everybody’s able to get out again at the end with a degree. So unfortunately, those require a little bit of mental effort, which can be challenging in the busy practice environment that some people have. [Jaz]Perfect. Well, with that in mind, one thing I can automatically say is in that position of someone who’s got into dental school is now qualified a couple of years, I’m just putting myself in that position again. And I think a lot of very young dentists were abusing composite. These were doing very, very big, large composites, for a couple of reasons. And one thing that no one really discusses about or certainly, I think we could discuss a bit more is because sometimes the and this is a communication thing is that the dentist, the young dentist is afraid to prep because of the lack of experience in preparations, they’re far more confident with something direct. And that might be hugely influential to why they may choose the direct composite, but also talking financially, a concert is always usually going to be, you know, several factors cheaper than or less expensive than a indirect ceramic, for example. And I think sometimes as a young dentist one year two year qualified, you’re not really confident enough to then say to a patient, okay, that’d be 1000 pounds for crown rather than 300 pounds for a composite, just made up those figures. So that also has a role to play in that I think? [Chris]It’s okay, I can understand completely where that call that sort of problem can come from. And yeah, there are a number of things that I think is thinking back to when I was in that position, a couple of years out of dental school. At that time, my world was very different. The I was I spent probably about three years working in the NHS in a variety of different environments. The diversity of the NHS I worked in, is probably closer to what you are to work in either Northern Ireland or Scotland have, where you get a fee per item without a very good fee. But you know, you get paid for unlike the current system, which is just nuts. At that time, also the if things went wrong, if you had a complication, there was often a way of it being repaired and sorted out without the patient having to pay and nothing usually, and without the NHS really noticing unless you really went crazy with your guarantee claims. These days, I understand it’s a little bit more challenging. But certainly the big talking, I think actually it I think probably for your listeners what I would say it’s an important skill to learn to look to talk to your patients to say, look, here is the problem. We can here are the choices as to what we can do, we can do this option, which has the following pros and cons. We can do this one does the following pros and cons. And we can do this one, but whatever it is. And our job is not. I don’t think our job is ever to sell any treatment to anybody. Our job is to explain and the patient makes the choice to make an informed choice. And very often the patient will say well, what would you do? And then the answer and even I get that question very often. What would you do that okay, if you were a member of my family, brother, sister, mother, whatever. Then I would choose this thing for these reasons because I think it’s the best balance A lot of patients will trust you. It’s a lot of it is building up rapport with the patient. That is not something you can manufacture, it takes time. And it takes confidence to look people in the eye and say, Okay, I really sorry, this is not a good situation, we have to take the two tides, I’m sorry. But just that sort of honesty is quite helpful. The big advantage that we have today that I didn’t have when I started off in practice, is digital photography, makes it extremely easy. Get a photograph, put it on the screen, people understand. In my day, we used to take metal film based expert hold up to the light and go to see that there. And the patient’s looking back at it retrospectively, I don’t know how anybody ever agreed to treatment on the basis of that, because they have no idea what they’re looking at, what you’re talking about, and they just go, Okay, I trust you, let’s go for it. But I think the advice would be use the humans, we are visual creatures. So use all the visual tools that you have, learned how to use a camera, so that you can show patients things so that they can understand better, and then the explanation becomes an awful lot easier. [Jaz]Well, I think just because it when I was a couple years, I mean, I’ve done hundreds of Restorations in direct composite, which really should have been indirect in my career so far. And that was because of all the things you know, lack of confidence at the time. And the lack of the right communication skills and rapport building and establishing enough trust with your patient. But that was just a little something. It’s not I don’t want to be your main focus or anything. That’s all interesting point. So when one thing [Chris]It is actually irrelevant, this is actually a relevant thing. Because we do see, and we’re all influenced by what we see on social media. And we see beautiful things. And you look at these clinical works of art. Some of them are gorgeous. And you look you think, wow, that’s fantastic. It’s much better than I can do. And you ask the person, how long did this take you to do? They go three hours. And let’s say it’s an MOD composite. That’s an unrealistic amount of time. So the next question should be, you know, how much of that time did your patient pay you for? And then the following a follow up question, but they never ever answer. How does your boss feel about that? So what I think it is an important thing that when we’re thinking about direct versus indirect, we have to be pragmatic about, can we get something that is clinically acceptable for that patient for where that varies a little bit from patient to patient, perhaps, can we get something in an acceptable amount of clinical time and amount of clinical time the patient will pay you for. And we also think about longevity. Some, there are other some situations where having something that is medium term. So that’s that let’s think about how long we mean by short, medium and long term, short term, for me, probably a is up to three years. So what’s gonna happen in the most sort of reasonably immediately foreseeable future for the patient, medium term, probably between five and seven years, and long term 10 to 15 years. And if we think about restoration, longevity over those kinds of times, and compare, time and motion. A composite restoration, we see very good data for posterior composites lasting 10 years in we’ve gone way past the time when posterior composite was pretty awful. Certainly, when I graduated, it was pretty terrible. And you had to have this conversation with the patient, saying, well, we can change those amalgams for composite, but it’s not going to last as long, not a good material. With improvements in our ability to control shrinkage stress. So the stress at the interface between the tooth on the resin and also our ability to get good tight proximal contacts, the medium larger sized coppers they perform well. And the screener will get good data to show with up to 10 years. The longevity is not different from that of amalgam. And that those are papers have been published [Jaz][Nick Optam] is a big paper by [overlapping conversation] [Chris]actually, yeah, it gets ignored by some of the UK academics because it doesn’t suit their point of view. I’m trying to think of the other one Hindson Rusan was a 2012 paper. Optam was one I think was 2014, the one you were mentioning. But yeah, those sort of papers show us that composite is no longer the peer relation of amalgam. I think probably controversial statement. One of the controversial statements that I regularly make is that what that means is that the place for inlays in today’s clinical practice is becoming much more limited. Because you look at something and you can almost gauge the age of the book you’re reading by what they suggest you do with a medium sized amalgam cavity sort of thing you inherit from an old big class two. The older books will say, shrinkage is a problem, contacts are a problem do an inlay, the newer books will tend to say composite is fine, or heaven forbid, even bulk fill composite works very nicely. So, you know, composites a wonderful material, but as long as it’s going to work for that situation for the patient. There are some situations of course, where composite is definitely better class four fractures, for example, let’s try to do an indirect restoration. I’ve seen it done. The people who are doing it have either are wonderful technicians themselves, or they have a wonderful technician. And they always say, if we tried to do a class four in ceramic, make sure you make about three of them, and you fit the one that is the most. It’s ridiculous. It doesn’t stack up against direct composite. Although, in some situations, if you think about longevity, over, let’s say, a 20 year period, if you have multiple anterior restorations, you can do it in composite. But it may need to be replaced at let’s say 5, 7, 8 years after placement, which is good longevity for composite. But ceramic will need less maintenance over 10, 15, 20 years. And if you stack it all up over 20 years, the two things may end up costing the same amount of money for the patient. [Jaz]Well, the one thing I want to focus with you, Chris, for the duration is yes, we can talk about anterior but a lot of the questions that I run sending in is actually more based on posterior. So I’d like to give a conversation more towards posture. And I think you answered one of the points ready, which is one of the first things I want to ask you is does Chris Orr believe in inlays? I want to hear your view in inlays because I’m going to give because because that’s you know, it’s something I mean, I personally I can tell you, I believe is I think it’s a robin hood dentistry. You’re stealing from the from the rich and you’re giving to yourself. And that’s something I heard a lecture saying, I love that. Do you think there’s a place for inlays? [Chris]Oh, okay, everything has its place, but I think inlays are extremely limited today. I’m thinking, I can probably count the number of inlays I do every year on one hand, and have many fingers left over. In all seriousness, the sort of situations where an inlay becomes something that I think about, if I’m treating a quadrant or group of teeth. With indirect restorations, one tooth has a large restoration that needs to be replaced. So let’s say it’s two MOD molars to right to the sort of a six with a MOD, seven with an MOD, and the five has an MO. And it’s possibly simpler, just rapid as an inlay and get the technician to make an all in one go. In those situations, I charge the patient the same fee as I would for the filling, which just about covers the lab bill, so I don’t make any money on it. Or there are some situations where in that exact situation, the plan is to do composites to replace the amalgam and you think I’m not, you know, we’re running a bit short of time here. Let’s just prep that and take an impression that will stick something in. So for those sort of situations, it can be helpful. Otherwise, no. [Jaz]I’m really glad you said that. Okay, so the next question is in a nutshell, What so really, the conversation is not it is about concept versus ceramic. But another way to think about it is direct versus indirect. Right? So at what point does something become indirect for you and no longer direct? What guidelines? Can you share with the listeners? [Chris]Okay, a few things in no particular order. The balance of longevity versus maintenance. How long is it going to last? How good is it gonna look along the way? And sometimes that stacks up in favor of indirect restorations. How long is it going to take you to get it to look good with the technique you’ve chosen at the chair side? And it’s going to take you longer with a direct technique and an indirect technique, then you have to seriously question your motives for doing it directly. Or you have to practice your direct technique a lot more. Because, unfortunately, we go on all these wonderful composite courses. And what you realize is that you’re probably not booking enough time to do the finishing and the polishing of the restoration, particularly anterior restorations, where the finishing. I’ve learned a lot from our mutual friend Joe Bansal about this, that you should spend at least 35, if not 50% of the total time doing finishing and polishing, which is much longer than many people think is correct, but certainly spend more time in the that, because that stacks up in favor of doing something indirect than in direct. Other thing of course, is the I cannot think of a scenario where the direct restoration is going to be less conservative. than the indirect. The indirect is always, not always, very often that will be some kind of preparation. And most commonly preparation is to remove any undercut relative to a path of insertion. Like we said a little while ago, if the tooth has been has grown itself in the perfect shape, unrestored peg shaped lateral incisora are rare but good example. Upper premolar is that are unrestored. Upper premolar, very often extremely suitable for no prep veneers, bond on to the enamel, like your buccal corridor works very, very nicely. And again, the other thing of course, we’re thinking about how much prep do we need to do? That’s possibly the wrong question. The question really is how much space Do you need for the material to do? So if you think about, again, some in standing upper premolar, you want to build them out let’s for the sake of argument, say the occlusion is favorable, then you don’t need to touch the teeth because the space is already there. Very easy. And I think but those are probably the major factors, probably on the other thing I think we should be mentioned is what, Where are you starting from? Are you starting from an unrestored tooth? Are you starting from a tooth where you’ve inherited some previous baggage? Baggage from previous treatments that, you know, old fillings, the results of old caries. Is the tooth significantly compromised because caries and endodontic treatment have already taken a big chunk out of the tooth. And in that situation very often where you’re trying to restore the tooth. And I don’t want to say strength cause good restorations rarely strengthen teeth, was to try and do the thing that will last the longest and do the least damage. Then again, sometimes indirect, thankfully, posteriorly can be very helpful. [Jaz]Well posteriorly is the the main thing I want to grasp about is when you’re looking at molars, and you look at the various configurations of cavities, how large they are and the remaining tooth structure, remaining once you remove the old restoration or the disease. At what point when you did the classical literature suggest that you know more than a third of the isthmus is something that you should consider cuspal coverage is that something that you follow? [Chris]If we’re thinking about isthmus, and again, in terms of giving guidelines, a lot of the time we’d like the guidelines to be a certain number of millimeters. And teeth vary in size. So rule of thumb I tend to apply I look at the intercuspal distance. And I look at the size of the isthmus of the restoration relative to that intercuspal distance. So it’s a little bit smaller for premolar, a little bit bigger for molar. Up to a third isthmus relative to intercuspal distance, direct restoration very easy to do, third to a half that’s either direct restoration or inlay. Depending on how good you’re doing direct restorations efficiently. Probably more than half would be where you start thinking about covering cusps. Plus or Minus if you’re in any doubt, and if having usually the decision as to whether you want to cover cusps or not something I learned way, way, way back more than 20 years ago from my, one of my first mentors, Swedish guy called Sverker Toreskog. Sverker always said that you make these decisions cusp by cusp, after you take out the old restoration. And then he carries. Basically same as this three choices. Option number one inlay prep, ie no cuspal coverage. Option number two onlay prep, some cuspal coverage. Option number three, what he called crown prep, finishing at the labial gingival margin. Other people call that different names. Some people talk about laminate onlays to describe that. I’ve heard veneer labeling mentioned I’ve heard people saying vonlay. Yeah, these sort of words that Americans invent to make. I like it a lot. He’s a nice guy. I’m trying to think who else but it’s at the end of it, somebody just extends up the labial surface of the tooth. So basic, and if you are working in the UK, and you’re applying that rule of thumb to the kind of cavities that you get in many of our patients coming in, who had big amalgams placed on the NHS, you’re going to be covering a lot of cusps, and that’s fine, because it’s better to cover the cusp, then have something break off and then did you can’t control where the fracture happens and sometimes fractures happen very far subjgingivally, and it’s not manageable. With all the best will in the world, you have to take the two sides, which is sad. [Jaz]Is it fair to say that if anytime a cusp replacement is necessary that your default is going to be ceramic? Unknown SpeakerYes, for a couple of reasons. One, because the likely condition to the rest of the tooth is the tooth may be in need of some further protection. Secondly, I know there are some hugely skilled people who are able to do cuspal replacements in composite. I’ll put them out there, but I am not one of them. I can do it, but it’ll take me five times as long and it will not last as long as something done indirectly. In terms of it’s not, it’s not always ceramic. Occasionally, I do get to do gold restorations, once per couple of years. Again, something we offer to patients, some people, most people say oh, yeah, thank you. But no, thank you. Even though you say okay, gold is gonna Outlast everything else that we have. People don’t seem to want it, unfortunately, even dentists who come for treatment, they don’t want gold, unless they have gold in the minds already. There you go. [Jaz]Well the next question then is: Composite Onlays – do they have a place in Restorative Dentistry? I mean… I’ll put my hands up say I placed quite a few in my NHS days, not so many now. My default is lithium disilicate. But is there a role for Composite Onlays in Restorative Dentistry? Indirect [Chris]Now, when we talked a little bit earlier on direct versus indirect, I chose my words carefully to say that the direct techniques are more conservative than indirect, not to say composite will always be more conservative and ceramic, because I’m not a big fan of composite onlays having done lots of them in 15-20 odd years ago. A couple of problems with them. Number one, they are less conservative than today’s ceramic. Typically, for composite you need minimum 2.0mm of occlusal clearance to make it durable enough to have some chance of surviving. And that’s a lot more to take off than, for example with most ceramics, lithium disilicate, you need one millimetre as a minimum – Second molars you might go to 1.5mm. On the first premolar, you might even get less, 0.7 millimetres. But let’s say 1.0mm for the sake of comparison, Gold half a millimetre. So from the point of view of conservation, NO – composite doesn’t win from the point of view of longevity. When we’re talking about onlays to patients, the conversation is along the lines of ‘this tooth, classically would need a crown’. ‘A crown involves cutting a little bit away from all the way around the teeth a little bit off the top, I’m gonna make it a little cap, called a crown that fits over the top and protects what is left of the tooth from breakage’ and so on. The usual conversation with the patient, ‘but the problem with the crown, it involves cutting away a lot of the healthy tooth is remaining. So an Onlay does the same job as a crown, only more conservatively’. We know again, from the literature that some of the survival rates that crowns versus onlays over a 15 year period… it’s pretty much the same within a couple of percentage points. So I think it’s a reasonable thing to say to the patients that are normally is ‘kind of like an extended filling – it extends over the biting parts of the tooth’ (and hopefully you’re pointing this out on the screen while you’re telling them). ‘It covers over those things, it stops them from breaking it binds what’s left of the tooth together, does the same job as crowns only more conservatively. And the other thing… I have a huge collection of pictures of composite onlays that have failed, broken, debonded etc and they’re all done by me…when I switched to ceramic, those problems went away. [Jaz]They’re done by you and they’re still failing then [Chris]Well know to be fair, they this was it was early in my career when I wasn’t as good as perhaps I ought to have those problems went away when I went to our move to doing those same things in ceramic. So for all those reasons, I don’t do them. I actively try to talk people out of doing these sort of things in composite. If you’re working in an NHS environment where your budget for the lab work is limited. And I can appreciate that’s the reality of many people. I would encourage your listeners to try and find a lab that will do a ceramic onlay within a reasonable amount of money that will fit into what you can spend on a band three, so that you get some experience of doing it. While you’re doing that, get some photographs, so that you can talk to patients through the sequence of events. Because one day you will not be doing everything on the NHS. For me, offering people private treatment. It’s not just about taking the time with the better materials, it’s not just about offering people stuff that might not be available on the NHS, it’s about you as the dentist having the experience to get the patient from A to B to C to wherever Z may happen to be. And you can anticipate problems so that the patient’s journey is as smooth as possible. And you have to have done things a few times to be able to do that. [Jaz]Perfect. I think the answer is about composite onlays. I was gonna ask about the choice of ceramic tools up I think that’s gonna be so mammoth, that I do want to get through some of the questions that some of the listeners have asked. So the one thing when asked just real quickly is there’s a parafunctional status of a patient play a role in influencing your material of choice? [Chris]Okay, if we think just about posterior teeth, we get we get an answer that question we’re thinking about ceramic selection. I guess the parafunctional status question is one about strength. And how strong does the restoration needs to be to survive in that patient? If you look at the literature, actually, interestingly, a lady in Innsbruck called Stephanie Byer has been altering a number of papers over the last 20 odd years, they placed a large number of Empress restoration, so the Leucite Reinforced Pressable. And they report at various intervals. Curiously, when they did their study population, they did not like most people do, they did not eliminate bruxers from the study population. So they kept them in. Under the study with it’s a 2012 paper where they reported on the survival of the posterior restorations. They did not notice any significantly higher rate of fracture, on people who they thought were bruxism at the time of placing the restorations. Now, to put that in context of the question about strength, it’s like a game of top Trumps. You’ve got a we’ve played it over the last about 30, 40 years. So on the bottom, we’ve got feldspathic porcelain, then the next thing that was supposedly better was the Leucite Reinforced Pressable, like Empress, which is about two to three times the strength of feldspathic. And during the years, we’ve had all sorts of other variations. We’ve had the sort of aluminous type porcelain, so the original version of Procera, which was probably about three times the strength of the Empress, Emaxs, dilithium disilicate, dilithium silicate type materials. So, Emaxs comes in probably about two, three times the strength of Empress as well. So for me, I’m not concerned about I don’t try to beat the patient’s parafunction by making my ceramic really, really strong. Because the problem with that thought process, you start talking yourself into saying, Well, I do want to do an onlays, it might be too thin. So I’m just going to crown it and you end up doing very destructive restorations. And then of course, your crown will survive beautifully but the underlying tooth fractures. So the short answer is does the parafunction status of the patient influence my ceramic choice? Not really, the patient’s willingness to own the problem, comply with whatever night guard we make for them. Because at the end of the day with bruxism has a lot in common with periodontal disease. Because we have to have these difficult conversations with our patients that you have this problem. I can’t cure this problem for you. I’m happy to help you. But it’s your problem. If the patient is expecting you to be responsible for periodontal failures and loss of teeth caused by their lack of maintenance, or the parafunctioning patient expecting you to repair everything for free forever, because they will wear the night guard or comply with whatever else you want to do. That is not a person you want in your practice. [Jaz] Absolutely. [Chris] And you need to be strict with them. Because at the end of the day, some people are very unreasonable. And you don’t want to be fixing stuff for free and taking responsibility for a problem that you cannot fix or cure. [Jaz]I like the comparison of perio and bruxism in the sense that yes, ownership has to come from the patient. [Chris]It’s not my problem, but I’m happy to help. [Jaz]Brilliant. Well, absolutely. Well, you’ve answered their parafunction, you know, how strong does something need to be. I think you’ve answer that quite well. So how about the situation and when you’re talking about, Personally, I get worried about placing lithium disilicate on second molars. That’s when I’d sometimes I mean, I do a fair amount of gold, for a young dentist, I think. And I also may be more likely to go monolithic Zirconia on a second molar. Then just my concern, am I right to be concerned with lithium disilicate okay in second molars? [Chris]Okay, it’s..And there’s another extension of that [hostile] stuff need to be questioned. Because right on the top camps game, you’ve got the zirconia type materials, the majority of which have strength over, the majority of the early versions have flexural strength over 1000 megapascals. When you’re doing monolithic Zirconia, you’re making a choice of either aesthetics or strength. The early Zirconia is that core type materials are very strong, but they’re ugly. So Lava™ is a good example of that very, very good material, but you have to put something else on top to make it work. And until it worked out hard to support the veneering ceramic, lots of tipping happen, the second generation similar crystalline structure materials like BruxZir, or that you can use for monolithic. And then the third generation, the use of Cubic Zirconia [Patana] being the main commercial example of that they much more aesthetic, much more translucent, but a massive drop in strength and the strength is at best two thirds of what the Lava™ BruxZir products are. Now and that means you’re choosing how strong Do you wanted to be versus how aesthetically wanted to be. And you get to a point where actually the, you’re not that far away from things like lithium disilicate. So I think perhaps for if you want to do something that is going to be slightly more conservative, then perhaps the monolithic Zirconia may have an advantage on the second molar where the occlusal forces are higher. If you want to do it in lithium disilicate probably that’s where 1.5 millimeters of prep would be thing. So half a millimeter more than you would do on a first molar, for example. [Jaz]By certainly something you don’t worry about as much as long as you do the correct lead to have the correct space for the material. [Chris]Yep. Unfortunately, that sometimes it’s a bit of a conflict, that, again, you see people posting cases on social media, where they say, okay, the patient’s got anterior wear, and posterior wear, let’s open them up on the front. And then we’ll place no prep onlays on the back. Yep, fantastic idea. Except that you realize that the anterior teeth have to become either a mile long or a mile thick, in order to get the space on the second molars to do that. So unfortunately, you it’s very, very rarely possible to do no prep onlays on second molars in a wear case, just because you can’t get the thickness. Sadly. [Jaz]You may not have to do as much prep. But because you still get some space from opening the vertical. But you still I respect your point there. There’ll be some prep, it can’t be no prep, a lot of the times. Now I’m going to just dive into some of the questions the listeners have sent. Before I do that any last words on No, the very pure conversation about direct versus indirect composite ceramic? Any points that you wanted to cover that perhaps we weren’t able to? [Chris]I don’t think so. I mean, it’s it’s really about the conversation, I guess, with your patient. And I think the other point that I would make about choosing, particularly if you’re thinking about choosing ceramics, talk to your technician, ask the technician what they think is best in this particular situation. If it doesn’t appear to be a run of the mill case, get on the phone, talk to the lab, the technicians fix many of the problems that we tie ourselves up in knots about they do it day in, day out. And there’s a huge Bank of experience and knowledge you can draw on. Having said that, don’t be scared to challenge them, because sometimes they will do what’s easiest for them. And you may have to be a more discerning consumer, I guess, to get the best from them. [Jaz]I like them. Something I learned only few years ago is that as a young dentist trying to develop and become better, why do sometimes you reach a point where actually you have to learn that you have to actually train your technician as well. And just because your technician maybe twice my age or whatever, they still have something I can, they can learn from me and I can learn from them as well. So have that. That’s a great point you made there. So question is from Nass, and he says, Do you prefer dual cure resin cement or heated flowable for bonding onlays or neither something else? [Chris]Right for a veneer. I prefer a light cured cement because I tend to fit them all at once on one thing to set on command. For an onlay, my preference is a dual cure adhesive resin cement, preferably a self etching one. My favorite one at the minute is Maxcem Elite™ Chroma, Kerr product, this one that goes pink when you mix it and when it’s ready for you to do the cleanup. It’s gone from pink to transparent or whatever. If I can give you your list One top tip for cementing onlays, please use it the dual cure cement. Please wait for it to set chemically and do the cleanup when it is easy. Do not do what I have wasted, probably days of my life if you added on up by trying to be clever and tack cure it with your light, always overset it always stick some things together. And it’s really really difficult to get something in between that upper six and upper seven to clear the contact, anteriorly we have those wonderful little serrated strips interproximal saws that you can go in and clear the cement with they’re fantastic. They work posteriorly but getting them in with like cutting lips and fingers and things not worth it. And the reason that I learned that when that Maxcem product came along, the color change the reaction from pink to transparent, it forced me to wait. And my nurse one day said You do realize that we’re spending on average 45 minutes less perfect appointment for multiple onlays than we used to? So even though you’ve got to wait for it initially, and I recognize that persuade dentists to wait for something is really really difficult. Because we’re all very impatient, myself included. Overall, the whole thing takes less time. So dual cure cement definitely. Now the issue about heated composite. I’m not sure why you’d want to heat flowable specifically to make it more [Jaz]Yeah, they said heated flowable, but maybe they meant heated composite, those will become flowable [overlapping conversation] [Chris]The heated composite idea, that’s a thing, again, from many, many years ago, the very early version of CEREC, where the version one basically where you had to finish the occlusal surface yourself. And the marginal fit discrepancy was typically about 400 microns. One of the workarounds at that time was you put normal restorative composite, heated restorative composite into the tooth, and you seated the on the inlay, because that was all they did at that time, you see to the inlay into that. So the margin was filled up not with cement with regular composite that would be more wear resistant. So those that technique work, yes, is a pretty good evidence base of the early CEREC literature on it. Do I do it? No. Just because sometimes particularly when we’re thinking about the other end of the spectrum with our restorations, where today we’re increasingly doing very, very minimal thickness, no prep type restorations. The big advantage of all the strength that we talked about a moment ago, the restoration is-the material sorry, is strong enough that it will survive manufacturing in the lab, heating and cooling and glazing and cooling, etc. without it breaking. It’s durable enough to survive us fitting it. The number of restorations that break on fracture during cementation is very, very low fortunately. And it’s that’s an interesting name because the all the survival studies that we have, the clock starts the moment the restoration goes on the tooth. They don’t tell you how many things they broke in the lab or the dentist broke before they fitted them up. [Jaz]It’s interesting, never thought about that way. [Chris]So the strength means that we can make super thin restorations and unfortunately if you’re rough with them, they do break and for that reason, the seating pressure, hydrostatic pressure on for seating, even the hottest, regular composite. I find it’s too much and I’ve tried it and broken restorations. So, then particularly the person who talks a lot about this technique is Pascal Magne. The material he recommends for cementing veneer with heated composite is a denting shade of HFO, the Micerium, Vanini’s material. I don’t know if you’ve ever used that one. But it’s one of the stiffest composites in the universe and heating it is obligatory to make it workable for anybody, including Vanini. So how he fits things, and I’ve asked him, you know, many, can you just run me through how you fit things without breaking them, particularly the way of thin veneer that he just been showing in his presentation. And I must be missing something. Because it doesn’t make logical sense to me. So I use resin cement all the time. [Jaz]So even for anteriorly? [Chris]Well, absolutely. I mean, you could, I guess you could use flowable. I’ve used Variolink, the lighter version of Variolink which is Ivoclar material. I’ve used that for many years. I’ve used Nexus™ which is Kerr material. Either those two to be ever done any light cured cement for veneers, any dual cure cement for onlays just wait for it to cure cement to set please. [Jaz]Excellent. Very good tip. And then the other question which Yeah, I think this will help a lot of young dentists is do you always go for some sort of preparation join circumferentially or do you sometimes leave the buccal or lingual walls with no preparation or just a small bevel? So I think sometimes let’s say you’ve got, if I’ve got a example cavity I can show you. Okay, let me see if I can get this up just a second. It’s sometimes nice to have a visual as well. So I’m going to share this photo here. So here is a, I think it was a lower molar at the time, and we can see that crack on the buccal wall. So for me, I would be taking this buccal and I’d probably the entire buccal tie down. And I probably preserve the if I said it was a lower molar, let’s say, upper molar-sorry..Upper molar, let’s preserved this palatal. I think that’s what they’re asking is, are you happy to preserve some cusp or bevel or do you always cover them over? Unknown SpeakerOkay, I think there’s a couple of answers to that question. One, what do you cover? And two, What sort of design do you do? So coverage, if there’s no doubt in my mind as to whether the cusp is going to be viable, I will cover it. In the example that you’ve shown the buccal cusps definitely they need coverage, I can see a lovely crack there. But so definitely cover the buccal cusps. The palatal cusp, I’d be tempted to leave and then use then life becomes more complicated. You think is that a functional cusp? It’s an upper tooth so it shouldn’t be functional. It was a lower lingual cusp I’d probably covered. How much overbite does the patient have? Do they have sufficient canine guidance or anterior guidance to make the posteriors disclude? So, if in any doubt, cover the cusp over. Second thing, what finished do we do? If I go back again to the days of using Empress, so, probably about a third of the strength of lithium disilicate, maybe not the material of choice today for that reason. Empress was beautifully translucent, and a flat butt joined would blend in really, really beautifully. Slightly paradoxically, sometimes you had to use a very broad color of cement to get it to do that trick, but all right. So it can be the flat butt end and even an upper premolar was okay. Emaxs is a little bit less translucent than that. So for a visible surface, I will place a small bevel, that small bevel will be probably two to three millimeters long, the angle will be roughly between 45 and 60 degrees. Please don’t get your protractor and try and measure it. Just something to allow, we everybody just how many millimeters is that, very dentist question. But just something to allow the ceramic to sort of feather in. I would try to keep that within enamel. I see. I do see people putting up pictures of baby preparation joint is the term that those people use where they do, it’s almost like a little mini crown prep or the, There’s a lot of reasons I don’t do that. I can understand why people think that they should do it because there’s lots of diagrams like they’re trying to illustrate onlay preparations where they show exactly that. To be perfectly honest, there’s very rarely enough tooth to allow you to do that. And if the tooth is enough to let you put that big joint onto it, you probably shouldn’t be covering the cusp over in the first place because it doesn’t need it. Also, it tends to mean that you’re cutting more enamel away than you need to, more tooth away than you need to. And then you sort of halfway down the tooth, you think I’ll just do a crown, and you end up doing something much more invasive. So for all those reasons that that type of joint, No, I don’t. So let’s say we’re doing an upper premolar so very visible tooth, the buccal surface will have a little bit of a bevel, the palate surface will be a flat butt joint, upper molars, maybe a bevel. And again, the advice I always gave when you’re doing these type of things the first time, an upper first molar is a good twist to practice your own because they’re commonly heavily restored on they’re far enough back that we don’t quite get the bevel quite right and learn how to blend the margin in this time. You can learn from it. Whereas an upper first premolar that’s one that you save for later when you’ve learned through the margin blending in trick because it’s a much more visible location. [Jaz]Brilliant. That’s a very good answer. And you went above and beyond to answer about hiding the margin there as well and pre molar which is very much appreciated. Thank you. Opinion on pressed Emaxs versus CAD CAM milled emax? [Chris]Oh, I’m not the person, the perfect person who’d asked that question. I’m not quite sure why or what specific properties you’re asking. But [Jaz]In my mind, I think it was probably the marginal gap in the fit of restorations. That’s why I assumed it or maybe strength or what we discussed already, I suppose but probably how well it fits in seats is there. I believe there is a difference in terms of [Chris]There is supposed to be a difference. But then if we’re saying that using heated composite to fill or composite in some shape or form to fill voids at the margins is okay, we shouldn’t get the marginal fit at these restorations is perfectly acceptable or within the acceptable range. The other things that sort of came to mind when I was thinking about that question, there are in some interesting sort of crystalline structure differences, if you look at them under the electron microscope, you think you’re looking at two completely different materials, the crystalline structure of the milled material looks very different to the pressed material, it doesn’t seem to be reflected in clinical performance. I think it’s important to broad distinction between what happens in the lab and what actually happens clinically, because the other version of CAD CAM, and we’re at an interesting time with digital dentistry that there are very few restorations that are done 100% analog, there are very few restorations that are done 100% Digital, each different stage, the technician can hop between the analog and digital workflows. So for some of the very conservative, no prep type stuff, what my technician tells me, when I torture him with one of those types of cases, they prefer to do it off a traditional analog impression. So that they can have a plaster model that they will scan, they will then take the plaster model, they will scan it in their scanner, they will then produce the coping on the computer, they will mill that from wax, rather than milling it from ceramic, and then the wax gets invested and pressed, so that they can go get about five even even at the moment of pressing. And that’s how you get the best of both worlds. So I think the best answer to that question is from a clinical level, I don’t think it’s going to make an impact on outcomes for your patient. But on a production level, I think whoever’s asked the question can have a very interesting conversation with their technician about exactly what the little foibles are. I think another bit of advice I would give to all of your listeners, the amount of CAD CAM your lab is doing is much more than you think. So I would encourage all your listeners when the world hopefully comes back to normal, get in the car, go and meet your technician, go and meet everybody in the lab and just have a chat, look at what they’re doing. Learn about how they’re making your restorations for your patients. It’s a very good way of that sort of first step on the journey of working together as a team with your technician. So do you together produce the best results for your patients. [Jaz]Brilliant. I’ve got four more questions. I think two. One is clinical, and three are actually non clinical. So the clinical one is what are your views on the BOPT techniques for those listening and watching is the Biologically Orientated Preparation Technique. There’s a paper by Ignazio Loi I shared some episodes back that you can download. But obviously the other word for it that people are now using is verti prep, Etruscan prep. Chris, can you tell us about your views on this very old preparation, which has now become in fashion if you’d like? [Chris]Okay, it’s interesting. The people who do it a lot. The first thing they often say is this is not a new technique. It’s an opposite of a traditional technique with today’s materials. So it’s basically again, it comes back to strength of our materials, we can make restorations much thinner, and they survive, we can make them then we stick them on adhesively generally, and then they work really really nicely. So it’s kind of getting the best of both worlds. A lot of the time we’re thinking about some of the gold preparation principles and applying those onto ceramic, things which previously would have been impossible because the material wasn’t strong enough and thin section. So that’s the and it means that you end up prepping teeth a lot less. What it also I think reminds us of is one of the preparations, bits of dogma that sticks in our heads, which was I was always taught that you should do half a millimeter subgingival margins when you prep the tooth. Brackets for porcelain fused to metal because that was basically the only one of the only way in my day when I was a student It was either PFM or gold. All ceramic wasn’t really done all that much. Feldspathic Jacket Crowns really, but even even they survived people’s mouth somehow. But generally with PFM or gold PFM looks ugly at the margin. So you had to hide the margin subgingival and the problem with that is that half a millimeter isn’t a very easy distance to measure at the chair side. So your brain goes there’s a special bit of your brain that develops when you do the crown and bridge course at uni. It’s the let’s take a little bit more off just to be sure gland in your brain makes you go a little bit further subgingival And the further you go subgingival the harder it is to get a decent impression. You know the classic Valder Hogg paper about 70% of subgingival margins becoming supragingival within five years. On the suggestion of biologic width invasion, I’ve heard it said that you can never diagnose a biologic width envision until you put a well fitting temporary on the tooth. More times that I see that problem, that sort of soggy, red continuous inflammation, and you put something that fits properly on and the inflammation all goes away. [Jaz]That’s awesome. Excess cement is something that [Chris]That’s been a growing problem in the implant world for the last probably 10 years and people have been openly talking about it, you’re right. So if you get something that is cleanable by the patient, a lot of the supposed biologic width envasion would actually go away. So number one, don’t prep subgingivally, if you have a choice, place your margins equigingivally or supragingivally, if you are the first person to get to the tooth. But the margin, some of it’s easy for you to get a rest and have a good impression of. So where does BOPT come in? The BOPT, It’s nicely written up there. And there’s some very nice clinical examples. I’m thinking of a paper, the one by Loi is nice. There’s another one. Journal of prosthetic dentistry Augustine Palladino, I think is the author. I can send you the reference afterwards. And he shows it very nicely. And what you got to bear in mind with that type of technique, where you’re eliminating a deeply subgingival margin, and placing something essentially knifeedge at gingival level, you’re starting from a position where you’ve got something ugly. And that idea, it’s a wonderful technique for getting you out of that situation where the tissue is absolutely unmanageable. So you cut off the old restorations, you get some beautifully fitting temporaries. And that’s either you take an impression on the lab, make acrylic provisionals the lab or option to the lab, make some shells that you spent a long time relining at the chairside. Or some of your listeners will think that they can, they’re good enough to do it with protemp, quicktemp materials like that. Honestly, the amount of time you spend, I find it disproportionate. Because if you want the gums to heal, the fit has to be 100% immaculately perfect. Otherwise, you’ve got no chance. So in my hand, that means shell provisionals that I will realign with coldcure acrylic trims some of the traditional materials. And it may take a couple of relines to get it fitting perfectly. And then you let the patient go away and keep it nice and clean. And then hopefully the tissue becomes manageable. It’s unfortunately not possible to do it without the provisional stage. Because the shrinkage and again, when you’re explaning it to the patient, you can say Look, your gums are all red and swollen and puffy, put the provisionals on your gums are going to shrink. This is good, this is them getting better. But it may mean that you’re going to get some black spaces in between the temporaries. And some of the edges of the temporaries may become visible, which is why we do them as temporaries because when things are healthy, then we make the finals. So it’s a difficult, it’s an expensive treatment plan for the patient. So your explanation skills have to be really good. So yeah, it’s the summary is it’s an excellent technique if you’re in that situation. Otherwise, the thing that I can’t understand about vertical preps is I don’t know, okay, people have different opinions on when you shouldn’t do an onlays, when should your core build up, when you place a crown. And I can argue the toss with those people over a beer at some point. But what I don’t understand if when you, if you’re doing a margin this prep supragingival magin prep, that’s great. Many people who talk about that technique, they will lut the crown with glass ionomer. And I don’t understand why they don’t take advantage of adhesive cementation, because we can bond on to Zirconia these days. Markus Blatz APC Protocol. It’s very, very easy. So I don’t understand why you go to all this trouble of doing a nice prep, making a nice Zirconia restoration and then you stick it on with GIC. I think they’re missing a trick. But maybe again, something that I’ve missed in presentations and books and other podcasts. [Jaz]I doubt that very much but Okay, fine. So then the last three questions are non clinical. One is what will happen to applications to the Advanced Dental seminars, which you know, a lot of my friends have been on. I guess the only reason I probably didn’t end up going on in my cohort was I went through various DCT restorative positions. And then I spoke to so many people have done your course I’ve learned a lot from these people and your course I think is very oversubscribed every year so people have you know when I put your Photo up. And I said, any questions? You know, it’s no surprise that this question came up what’s going to happen to applications for the next round of your year long course? [Chris]Okay, thank you. Good question. Thank you for asking that one. Right. What was supposed to happen was we were supposed to open the bookings next Tuesday, usually two weeks, a couple of weeks after the traditional time that we do it. Because of all the stuff that’s happening in the world, that’s been put off, what I would suggest for your listeners, we will be running a course next year, we need to see actually how the dust is settling down in terms of the easing of the lockdown, and how it’s going to be possible to get people into a room together to do a course together. I would encourage your listeners to follow us or follow the Advanced Dental seminars Facebook page, or keep an eye on our website. Because whatever we decide to do, we will put the information on there. So yeah, we will be doing something, I hope. If we’re all still stuck on our houses together and unable to come together, the world’s gonna be a very sad place. So I hope to see some of your listeners in London in September. [Jaz]I’ll put the Facebook link up. So those who are interested in next round, they’ll can keep up to date. The next question is, what have you been up to during lockdown? Chris, people want to know. [Chris]Right? In no particular order. I have been organizing lots of photographs, photographs, when you enter photography as a hobby, you spend a lot of time taking things, but sometimes you stick them in the hard this is how can look at it later and you don’t. So we’re doing a little bit of that. I’ve been delivering webinars for our current course participants to keep the engagement with them. I’ve been looking at how we may do some more stuff online, as opposed to face to face. I become increasingly of the opinion that all the reading that we give to people. People don’t really read it. So we need a different way of let’s be honest about the dedicated people who do and we try to not do everything to make sure but some people don’t. And I think a different way of doing that part of it might be helpful. So I’ve been looking during a lot of sort of preparatory work for that. What else I’ve been doing cooking, eating [Jaz] Brilliant. Excellent. Excellent joy.[Chriss] We’re making pizza. [Jaz]Very good. Well, the final question I haven’t even it’s been fantastic everyone. And it’s actually my favorite question is by sending by someone called [Surab]. Thanks, [Surab] sending in and it’s basically, if you graduated in 2019. And knowing all that, you know, now, would you have done anything different? [Chris]Okay, good question. I think the advice that I would give a younger version of myself, if I was graduating again, right now or any of your listeners who have graduated. Dentistry is a very practical craft, you need to hold your hand skills. And working in high volume environment becomes very, very difficult to do that. But I think I said about it earlier that you have to have experience of doing some techniques before you offer them to somebody privately. Because the private patient journey, it’s not just about the clinical outcome, it’s about the way in which the journey happens. The old version of the NHS that I worked in for a few years, it was actually pretty decent, and letting you round out your skill set. Because even then, the universities could not manufacture examples of every possible clinical procedure for you to do while you were a student. So the idea of VT as it was called it was supposed to help you round things out. And that sadly, doesn’t seem to be the case any longer. So I would suggest to your listeners that they try to make the most of what opportunities they do have, clinical photography, very important skill to develop that starting at undergraduate level now in some places, I’m happy to see that is great, but making sure that you do it routinely so that you can blaze off all those pictures, show the patients, their modes, get patient involvement, engagement. And very often the conversation about doing some of the nicer things comes from doing that. And that also allows you to practice your communication skills. It allows you to practice your treatment planning skills, not just what you’re going to do, but the backup plan in your mind as to what if this doesn’t work out exactly the way that I want? How do I manage the problem? Because often when complications arise, there’s a clinical issue and there’s a person attached to the clinical issue. And the person attached to the problem is the one that makes it the complaint, not the tooth. So all for all those things, it’s to try and take advantage of those opportunities. Also, any information that is out there, take advantage of it. This podcast is wonderful. So download all the back episodes and listen to that, because lots of very, very eminent people really done some very nice podcasts for you. What else, join all the societies of whatever you’re interested in, whatever that happens to be commonly courses in whatever you’re interested in. That’s also helpful. And I think the other thing, the environment that I grew up in is a lot of parallels, I think, between Irish families and other cultures, where your mum wants you to be a professional. And then once you become a professional, you must be a specialist in that profession. Similarities with other cultures, completely coincidental. Being a specialist is not the be all and end all. How you are with your patients. How you can talk to them. How well you can build rapport with them. That is far more important than having a paper on the wall, even though your mum might not be too happy about that. So develop communication skills. [Jaz]Brilliant. Well, thank you very much. Well, Chris, thanks for all the clinical nuggets. And right at the end there some very nice non clinical stuff as well. I wish you all the best for the rest of the lockdown. And I hope ADS can get running and soon for all the hungry people for the knowledge who after that. And thanks again for coming on. It’s been really great having you on today. [Chris]Thank you very much. Thank you. Jaz’s Outro: So there we have a fantastic episode with Chris Orr. There who you know really proved his rockstar status. Thanks so much for listening all the way to the end. And remember, if you want to claim your enhanced CPD, if you just wait a few weeks, there’s a bit of a backlog but eventually it will come on to Dentinal Tubules, where you can actually watch it there again or watch it for the first time if you’re listening to it, and then you can also answer the questions, acknowledge the aims objectives and have your fully enhanced CPD certificate. Thanks again for joining and I’ll catch you in the next one.

With ‘The Denture Guy’ Mark Bishop who was also my first ever clinical tutor 11 years ago! https://www.youtube.com/watch?v=4BkBEK01P0o Need to Read it? Check out the Full Episode Transcript below! We discussed: 🎤 Occlusion with Dentures 🎤 Identifying red flags 🎤 At what point do you need to accept that the patient NEEDS to have implants to have success with dentures 🎤 What’s more important? A technically excellent denture, or a patient with good adaptation 🎤 Why do patients who wear ‘rubbish’ dentures struggle with ‘good’ dentures 🎤 Which is the best impression material? 🎤 Which are the red flags patients for Complete Dentures? 🎤 How do you handle a patient who tells you how to do your job? 🎤 Communication Pearls via analogies 🎤 How can you achieve suction lower dentures? 🎤 Do all you dentures need to be in Class I ? 🎤 How can we improve our registration phase of complete dentures? 🎤 Why most Dentists trip up at the diagnosis stage of Complete Dentures, and how to overcome this 🎤 The importance of writing a letter to your complete denture patient The Atwoods classification and the Registration technique have been posted Protrusive Dental Community Click below for full episode transcript: Opening Snippet: Hello everyone and welcome to this episode on complete dentures with Dr. Mark Bishop... Jaz’s Introduction: Dr. Mark Bishop was actually one of my first ever, he was my first ever clinical tutor at dental school. It was in second year, early in second year doing complete dentures. And what this guy doesn’t know about complete dentures is frankly not worth knowing. We share so many great gems, as always, we talk about talking to your edentulous patients, or your dentate patients about expectations, how to manage occlusions in dentures, we talk about which is the best impression material for dentures, how can we get a lower suction denture? Is there a technique? Or is there something else that’s there to it? Another couple of things, we talked about his red flag patients and how to identify them, as well as at what point can you actually say, actually, this patient in front of you will actually benefit massively from implants. And actually, the dentures just won’t cut it. So that’s something I often think about is actually with such a resorb ridge, are they going to get any success with this complete denture I’m about to make? Or do they actually need to have implants as in NEED to have implants. So we will touch on that as well. The Protrusive Dental Pearl I have for you quite fittingly is actually mentioned in the podcast episode, but it’s something that Dr. Mark Bishop taught me about complete dentures. And it’s basically when you have a patient who has complete dentures, and also due to the complete denture, and you’re trying to adjust that bit on the or ease that denture so that it’s not rubbing against the denture anymore, so it’s a bit more comfortable for them. How do you actually know exactly where to adjust, so you’re not adjusting inappropriate areas or adjusting too much. And you only want to adjust the fitting surface where the ulcer is. So what Mark taught me to use, and when I still use this days, the only reason I have Dycal in the practice, I use the base paste of the the white one of Dycal, and I’ve put put it, dry the ulcer, and I put it a little bit around the ulcer area, and then you press the denture on, you actually inserted and you press it on and you remove it, and you’ll have the base paste of the Dycal on the fit surface of the denture. So now you know exactly where to adjust for that patient. So hope you enjoy the episode with Dr. Mark Bishop and I’ll catch you in the outro. Main Interview: [Jaz]Right. So usually is Dr. Mark Bishop for you, our relationship I know you’re happy for me to call you Mark. Mark thanks so much for coming on the podcast. [Mark]It’s a pleasure. [Jaz]You were my first ever clinical tutor in dental school Yeah, cuz [Mark]Yeah, cuz for the first thing you do is like complete dentures [Jaz]Yeah. And it was a you know, you set the bar really high. And, you know, to then to be taught by other dentists was never quite the same as being been taught by you and I’m be I’m being serious. I’m being honest. And you are an asset to dental, dental school. However, I know you don’t doing much teaching anymore. [Mark]Yes, still two days a week. And as you know, I sold my practice in November 2019. So, time for Coronavirus. Although obviously, I didn’t know it at the time, I feel very, very lucky to have been able to step away at that time. I feel really sorry for you guys, who is still having to work at the [coalface] now, it’s very difficult for you. And But no, I carried on doing two days a week. So I’m now a part time dentist, which is quite nice. [Jaz]Brilliant. And this episode is gonna be all about complete dentures and how we can make it easier, more predictable, some some tips that we can share with the listeners. So tell us as part of the introduction. How did you get into complete dentures? I know we all sort of dabble per se and now they say more and more that complete dentures has really become almost like its own postgraduate speciality. But how did you get your enjoyment and fulfillment for conformed complete dentures that you do? [Mark]Well, I always knew that I didn’t want to work five days a week in practice. So quite quickly after graduate in about 18 months after graduating. I sent a bit of a cheeky letter to Charles Clifford in Sheffield and said do you want any clinical tutors? So I ended up getting there and realize that was something that I got a bit of a loss for. And then I did a Masters which was a general restorative masters. Because you know, I didn’t just teach complete dentures, restorative as well. And I got to know a guy called David Lamb who became a little bit of a mentor for me, and I just really enjoyed it. I love the what’s the nicest way of putting it. You’re not sticking injections into people. See, you’re not potentially causing discomfort. You do full mouth rehabilitations on everyone you treat. And just, you can have kind of have a bit of a nice chat with people. And so I always find it quite a low pressure side of the job. And I never really saw it, which is dentistry. As well I’m not a happy. [Jaz]Well, I have to say, I certainly came across that way when you were teaching me both during second year and also we have a few sessions together in like, fourth and fifth year. And I’ve seen since I’ve qualified, you’ve started doing some complete denture courses around the UK. [Mark]Yeah. Trying to about three a year now because I understand this. It’s a subject that undergrad, I just don’t I mean, even in Sheffield now, I current teaching you a shared set of dentures in second year, and now we’ve moved to the same model shared set of dentures in third year. And then you go out into general practice. And very often people have done that. That’s all they’ve done. And they go out into a field, which I personally think we make it more difficult than it has to be. But we go very unprepared. And then people suddenly start treating patients realize how difficult it is. And when they need a course to maybe understand, you know, little tips that they can improve what they do on a day to day basis. [Jaz]Well, it’s the same as a crown preparations, root canal treatments. Dentists nowadays, we’re qualifying with less and less of the quota for each of these procedures. And complete dentures is no exception. So we’re going to hopefully improve the complete denture removal prosthetic Dentistry of everyone listening. And the first question I have for you Mark is, so you could have a very technically excellent denture, and you have a patient who has a certain ability to adapt. So there’s the quality of the denture on one side, and there’s a patient’s ability to adapt. I think sometimes we call this the neuromuscular adaptation, or about. So how much of the success of complete dentures comes from it being a technically excellent denture? And how much of it, it comes from the ability for the patient to adapt, which is more important. [Mark]Okay, good question. We can only work with things that are in our sort of ability to cope with, okay, so that’s the dentist and the patient. So what can we directly affect? We can directly affect the impression technique that we can take. So this good evidence base to say that the quality of the impression will have an effect on the standard of the denture, okay? And the other thing we can affect is a registration stage. So again, there’s good research to say that the registration stage gives good results, if done accurately, there are things that are way out of our control. So whether a patient can adapt or not adapt is out of our control. So really, we’ve got to concentrate on what we can do. Now going back to your question, some patients obviously adapt better than others. But most people we see I would think are having replacement dentures. A small percentage of in the first set of dentures so that people have in replacement dentures, know how to wear dentures. And what happens sometimes, with dentists, we kind of blame them that they’re not adapting to our new dentures, when realistically would have copied the good aspects of their old dentures, they probably wouldn’t have to go through a major re-learning curve. [Jaz]Fair enough. One thing that I think you taught me this, I can’t credit anyone else for this is that when someone comes in, who has a technically rubbish denture, and they’re able to get along with it, I get so happy. And if I’m the next dentist, who’s gonna make them a new denture, and they’re already adapted to this rubbish denture, and I know that I can only technically improve this denture, that for me is okay, this is gonna be hopefully a home run. [Mark]Okay, so it’s a home with some potential pitfalls. So some of these patients can be people who have worn dentures for 35, 40, 50 years, and they come in with a set of dentures and look like they’ve been through. You have been through a cement mixer or something, they’re all over the place. And then what happens people go, okay, there’s loads and loads of technical faults on these, I’m going to correct them. And what the dentist often does is makes the mistake of turning them back to the ideal denture, so they don’t measure the freeway space of the old set of dentures, and they don’t have an assessment of where that’s out. So let’s say for sake of argument, you get patients who have lost a dramatic amount of face height. They’ve had the dentures for 35, 40 years, you make them a set of dentures, technically you look at and go, Wow, they are brilliant. But you may have changed the freeway space from something like 17, 18, 19 millimeters to three. Now, there’s no way in this world that patients going to adapt to that, they’re going to have to adapt to it through stages. And in situations labor, ie, it’s part of training the patient to say, look, we can’t make you look perfect. But what we can do is maybe make your dentures a little bit bigger. And then in three years, we’ll make you another set, which we can make the dentures a little bit bigger, and gradually turn you back to having a perfect set of dentures. Although I’d like to just take the word Perfect out of that, because I think perfect and dentures and perfect in dentistry doesn’t always go together. You can’t do perfect, you can do the best you can do. [Jaz]Yep, brilliant. And I think that’s exactly what you taught in terms of the freeway space actually remember, we actually remember vividly second year clinics and we had the patient a freeway space of 12 I remember you saying we’re not going to go down to three we didn’t go down about six or seven or there abouts and actually remember you teaching that actually very vividly. The next thing want to ask you they want to start with my experience. I did my DCT one post in guys hospital. I don’t know if you know Dr. [Linden Cabo]? [Mark]No, not come across him. [Jaz]So he teaches the removable prosth at Guy’s hospital, and I did a complete denture clinic with him at hospital there. Lovely chap, very knowledgeable, very passionate like yourself about removable prosthetics. And I remember him having a study group with us. And he sat us all around. And there was about maybe eight or 10 of us DCT1s. And he went around the room asking each one of us which you have a patient in front of you, you’ve got your special tray, okay? Which impression material will you will you use? And he went out in the room and each person said, Oh, yeah, I’ll use alginate. I’ll use zinc oxide eugenol, which I know is a favorite of yours. I said, Oh, I’m going to use them monophase, I’m gonna use medium body silicon, okay. And the mistake we all made is that not one of us asked Dr. Cabo. Well, actually, what does the arch look like? What does the actual arch look like? Because that will determine what kind of material you’re going to go for. So that question leads nicely to, can you give us some guiding principles about which impression materials, when you’re choosing impression material to use, which ones do you tend to suggest? And what changes your decision making? [Mark]Okay, so a couple of things. Firstly, there isn’t a perfect impression material, you know, you can look at all the research and you can’t do a double blind clinical trial on impression materials, because you know, the clinician knows what they’re using, it’s impossible to do. So everyone gets their own little thing they like to work with. All impression materials work, okay? But the trouble is, a lot of people use them poorly. So alginates, my favorite. For discussion, so alginate works perfectly well. But alginate, like most materials works at an optimal thickness. So it works at three millimeters. Now, if you use an alginate, for a resorbed lower ridge, it’s useless, it’s impossible to use, because ultimately, you can’t really get three millimeters of space around the edges of that. And to get alginate to use in its best way. So alginate is a very, very good primary impression material. Secondary impression materials I never use alginate have ever for secondary impressions. I use zinc oxide as you say, I really, really like it. And I like monophase silicones. With monophase silicones again, you’ve got to remember that they have an optimal thickness. So if you’re going to use them monophase silicones, ideally try and get a 1.5 millimeter tissue stuck on it. And you need that space at the periphery as well, because if not, you’re going to record in your borders in the tray, which is not particularly useful. For me, the only time I steer clear of my zinc oxide is when there’s an excessive fibrous ridge, because I don’t want to compress that tissue. I want to record it in a static position. Because anything that you compress will want to bounce back into its usual form, which is not ideal under denture. And I avoid people with excessive xerostomia. And I avoided with people who have not just have a little I get a bit itchy after wearing a [plaster] for seven weeks, you know, people who have proper allergies to [plaster], apart from that I stick with it. The other case I sometimes will I do avoid it with these excessive undercuts. Because obviously you’re not going to get it back out of excessive undercuts. So really stick to what you enjoy using just use it correctly. [Jaz]Other than the undercuts, is there anything else in the anatomy that might change? You know, you’re moving from one material to a different material based on anatomical considerations? [Mark]Well, again, I think we can go back, the more atrophic the ridge is, the more you want your impression tray to simulate the inside of a denture. So the bigger the tray is, the bigger the problem you’re going to get. Because you’re not going to record those muscle movements that you want to record to get the best result. And so No really, I think fibrous ridges avoid zinc oxide. Severe undercuts avoid zinc oxide. And but I think one of the reasons I get good results is because I’m very consistent in my approach. I think a lot of young graduates, instead of thinking, what is it that caused the problem, they think it must be a panacea of an impression material, that’s going to give a perfect result. And it just doesn’t. It’s about practice and getting good at things. You know, so many people start with good intentions, they’re going to use a material, they do it two or three times they’re not getting the results. So one, they blame the material, when actually it’s takes time to practice anything. Nobody picks the guitar up and bangs out, tune straight away. [Jaz]Awesome. The next question I have then is moving away from the impression material is more about the looking at the patient in a broader perspective. Can you tell us about which red flags can we watch over in our patients. I know there’s Yeah. [Mark]The red flag patient. Okay. So this is where I think most dentists go wrong. The lack of that ability to say, do you know, I think this should be on my skill set. So you get things like endo, and it’s a multi rooted difficult endo on a seven, people wouldn’t think twice about going right, out of my skills, I don’t think I can do that. Or it could be a full mouth rehabilitation, or it could be ortho or something like that. But with dentures, we all have a go or whatever comes through the door. And that’s where the problems start. So I have got some red flags. Okay. So if anyone comes into me and says, I’ve never been happy with my lower denture, I know full well, that the chance of even me who’s done two and a half thousands dentures in this career solving that problem is massively reduced. Okay, so that’s one. Another one where people say, Look, I’ve been to so many dentures, dentist they can never get the appearance right. Again, boom, big flag starts to warn, what they’ve all not been able to do it. And you know, why will I be the one that solves that problem? There are people who want to design their own dentures. So they’ll come in and they’ll go, right, I have a loose denture and you’ll take the denture out, and the palate will be halfway back along the palate. And they’ll go Well, yeah, but I can’t have it any further back than that. And, but I want it to be tight. I’m not having that conversation to go, look, you choose what you want, because you can’t have both. So that’s another one. And [Jaz]That’s a tough conversation to have, isn’t it? To you know, for a young dentist to say someone in the, you know, latter stages of life be like, well, hang on a minute, there’s only so much you can do. It’s a difficult conversation, because there’s sometimes these patients almost tell you that they always tell you, oh, I think you need to adjust it over here like, you know, just over there. I think if you do that, that will do the trick or whatever. So I think they can be quite dictating if they see a young dentist and you know, [Mark]Yeah, absolutely. They love it. They love it and watch out for certain professions as well. So engineers, teachers, people who used to telling people how to do things. And I know it’s a generic sort of picking on certain professions. But people who have a lot of control in our life like to tell young professionals how to do things. And I have a way around that. Which is, you remember PSI paste, Jaz? [Jaz]I bought it for the practice. I mean, I still use it based on your teachings. Yeah. [Mark]Perfect. So what I do with that, with engineers and people who are quite strict, is I tell them what I’m going to do before I do it. So I said, Look, what I’m gonna do is I’m going to load up this impression material around the edge of your denture, and we’re going to press really hard. And what it will show you is where it touches your mouth. So anywhere other than the point that tells me, I want to adjust, I want to just say it because it’s not in your best interests. So if you’re getting pain from your denture, it’s not being caused by the inside of your denture. It’s being caused by something else. So it could be the way your teeth come together. Or it could be you know what, you’re very stressed as an individual and you clench your teeth, and it doesn’t matter where you adjust, if that’s the case, it’s still going to be a problem. So, yeah, so that’s I understand. As a young dentist, you need to have skill sets that you can do like go to ways of proving the point to a patient. Never, ever do that in a non scientific and a non technical way. You have to be able to say, look, this is what’s going to happen, I will show you, we’ll look what we get. And then you’ll understand why adjusting that denture is not in your best interest. [Jaz]Now, I really like how you explain that to actually show them Oh, these are areas I can adjust. And you give a reason as opposed to No, no, no, I don’t think so. You justify it. And for anyone who’s listening who doesn’t know what PSI paste is, it’s Pressure Spot Indicator, which I don’t know which company makes it [Mark]It’s made by a company called Coltene. [Jaz]Okay, Coltene. Yeah, sure. [Mark]Yeah. So it’s a must. Remember when you use it, and get your nurses to do it as well make sure they understand why one tube is wide and tube is narrow. Okay, you don’t put the same amount in, you put the same length in. But you keep the nozzles to the width. It’s really important. Otherwise, it’s going to set far too quickly. And it’ll be nondiagnostic. [Jaz]Did you have any more red flags or should we moved to next question? [Mark]Yeah, let’s have a look secret denture wearers. You had any of those, Jaz? [Jaz]I think so. Because they said they don’t want to remove their denture at nighttime so that because they don’t want their partner to see that because they don’t want them to. Is it that one? Or is it because in public? [Mark]Yeah, people who don’t want to be seen without their dentures. So that’s a red flag, there’s a potential degree of neuroticism attached to that. And it’s quite reasonable, I can understand why people wouldn’t want to be seen without it. [Jaz]Oh just thinking it, it’s very reasonable. [Mark]But when it becomes the be all and end all that I couldn’t possibly, you know, the types Jaz that you’ve met, I’m sure you’ve met them before, it would literally be the end of their world, if they were seeing without their denture. And people who say their dentures are loose. Have you ever had that where you have an upper denture patient say my denture is loose, you actually try and pull it out and you virtually have to put nail on the chest to get it out. And yet they tell you that a upper denture is loose. [Jaz]I haven’t had. That’s my lack of experience compared to you showing and I haven’t had that one. I’ve had it once in hospital where it’s a fantastic, if I may say so myself a really, you know, textbook denture, I made upper a complete fantastic suction, but it was an error I had made in the occlusion that. Okay, yeah. [Mark]That’s always the problem. So when somebody says my dentures are loose, and you try it, and you feel good retention, then it’s always occlusion. Okay? [Jaz]That was my error in that case. Yeah. [Mark]Yeah. And the other ones are, does anyone talk to the patient about use of adhesive? Do you see that, Jaz? Do you ever speak to your patient before you start about the need for denture adhesive? [Jaz]I do say, quite a lot of time, people will need a bit of adhesive now and again, so that it allows your denture to stick on, stay on better so that they are already in the mindset that it shouldn’t be a challenging case, and we cannot get adequate retention without the need for adhesive, they already mentally prep for it. [Mark]Okay, so again, that’s another red flag for me. So if a patient’s got a horror of using the adhesive and anatomically, you look at them and you go, you know what that lower denture is going to move, it’s far better to tell them at the start that you’re going to need adhesive but guess what, adhesive is not very good on lower dentures. And I explained about gravity and how the adhesive is going to come out and saliva is going to wash it away because in the end, adhesive really helps dentures and even a well fitting denture benefits from adhesive. So they’re the sort of red flags there’s quite a few like that. [Jaz]Well, following on from the last one, he said about the use of adhesive for a lower denture, lower dentures being so tricky and traditionally because of the anatomy, very difficult to get good stability and retention. At what point do you look at a ridge and say, You know what, you actually genuinely need a couple of implants maybe as part of implant retained overdenture or an implant supported prosthesis and you think that with any complete denture in the world, you will not be able to satisfy them. What is the cutoff point? I think I believe the classification of ridges, is it the atwood? [Mark]Atwood classifications [Jaz]So it can you put a classification on it? Is that how you like to teach it? Or what can you teach us to know that what point we should be looking for? You know what, actually, we better send you to an implantologist? You know quotation marks. [Mark]Okay, right. So basically, I’ve just been doing a little bit of a study with a friend of mine called [Johnny Dixon] in Sheffield. And what we’re doing is we’re looking at what comes through the door, when we see people in assessment for undergraduate care. So on the lower region, I’ve just flipped [inaudible] Okay, out of 60 patients, I saw 25, out of those 60. Were outward five and six. So that’s flat ridges or depressed ridges. Okay. So that’s the only 50% of every patient that comes through your door is going to have one of those ridges. Okay. So would all those people benefit from implants? Probably. Would they economically all be able to afford it? Definitely not. So we have to find a way of trying to solve those problems to our patients. And, again, lots of studies out there that show that patients definitely would benefit from two implants. But what’s the going rate for lower implant retained denture down there, Jaz, at the moment? [Jaz]For two implants and eventually lower denture? Yeah, 7000 pounds probably? [Mark]Yeah. So even in the north, you know, we’re looking around the five mark in some people who are reasonably priced. And we asked well, so I got people can afford? Because if you think of the demographics very often, not everybody is in that income bracket, where 5-7000 pounds can fall into their lap. So going back to your question, how would you decide? Well, economically, pretty much most of them would benefit. Economically, if they all had the money, they’d benefit but they don’t. So you have to work your way of taking accurate lower impressions. And you have to educate your patient from the word go that you know what, I show them in the mirror, I show them the upper denture I show them their upper ridge, I show them the amount of surface area I’ve got. And then I show them on the lower. And then what I do is I show them when I push their denture to the right and push their denture to the left, it’s not that the denture’s loose. It’s there’s nothing to stop it moving laterally. And again, it goes back to what I was saying to you early on, it’s all about that educational first meeting you have with your patient. If the patient’s not on board with it, they’re not the patient you can do anything for because if you’re going to fail, no matter how good your dentures are, [Jaz]Yeah, I like that tip of actually showing the patient in the mirror as you move it around. And you know, I think it really brings at home for them. [Mark]And I also talk about it a bit like a window sill. So I show them the lower ridge and I show them where the anatomy is. And I say just imagine your denture is on a window sill you open all the windows, and there’s a strong wind blowing. Okay, it’s trying to blow it in one direction, and you’re pushing from the other direction trying to push it out. You’re trying to push and the winds pushing back. If one thing overtakes ever slightly the denture is going to and you know, you can’t talk about neutral zones to patients, but if you put analogies like that, that they can visualize it helps them a lot. [Jaz]I love a good analogy. I think Raj Patel used to say a good one to patients about when they had lower dentures, and then they were in pain. And what Raj was trying to convey was the fact that actually it was the lower arch which was quite bumpy that was issued. Has bony prominences so it’s a bit like when you go to the toilet, and you sit on the on the toilet seat. And then now when you imagine you have I think like pebbles on your toilet seat and you sit on it, it won’t do so good. Even if you put some toilet roll on it it’ll still hurt like using a conditioner or something of that. So I do love a good analogy. So if you have any [Mark]Glad Raj managed to get some toilet humor in there. Very good analogy. [Jaz]He always does somehow. So the next question [Jaz]The one I like, Jaz on that. The other one I like on that is the camping analogy. So if you go camping, and you can take a thin blanket and put it on the ground and you’re in a paddy field. And you might be able to get comfortable if you just move into one position. But if you move from that position, everything’s going to start hurting. And your mucosa is that blanket. Okay, that might be [Jaz]I like that very much. Raj is full of, you know, a myriad of fantastic analogies actually, he’s [Mark]He’s a wise man. [Jaz]He certainly is. So the next question is in moving on from the the fact that lower ridges that may benefit from implants like we just discussed and the economical issues and that. Well, firstly, the way I explained to patients that look, you will benefit from implants, it’ll be much better to hold it in. And if they look like they can’t afford it, then I say we can try our best and obviously we want to try and do a technically good as job as possible, but least, you know, you’ve set the expectations, actually they’re gonna, it’s going to be loose, they’re going to struggle, and implants would be a good idea. However, a prerequisite of making an implant retained overdenture is still a good denture. [Mark]100% and [overlapping conversation] [Jaz]and hope the implants will do the rest of it. So that’s another thing worth mentioning. [Mark]If you can’t make dentures Jaz, put an implant in since it’s not going to solve that patient’s problem. [Jaz] Absolutely, [Mark] it will stop the lower denture moving and that is it, that is the only difference it will give you. [Jaz]You still need the fundamentals to get as good [Mark] 100% [Jaz] good coverage. So moving on from fundamentals as you see all these videos and I see some of your video as well. The lower complete dentures with the suction, and it’s just so magical to see that almost, you know, when you have these patients lower complete denture on suction, you know, who would believe it? You’re able to do this, I’ve had one or two patients in my career so far, we’ve been able to achieve that. And it’s a great feeling it really is. [Mark] It’s magical [Jaz] It really, really is. How do we know if how best to put to put it that how do you know if you can achieve it? Is there something like that? Is that a minimum outward classification that you can [inaudible] Can you tell us a bit more about how we can go about even thinking about getting towards that stage? [Mark]There’s a big degree at luck. So if a bit all dentists are the same, they tend to post their successes down there and anything that’s not successful, they hide. It’s exactly the same. So you’ve seen some of my dentures that have suction. Not all my lower dentures have suction. So there is a degree of luck in that, there’s no guaranteed way of doing it. Mr. Albay seems to believe that he can do every time and he may be able to. Good luck to him if he can. But without seeing every suction that he makes I’m not going to buy into that straight away. And so realistically, all you can do is do the best impression you can do. And then the most important part is make sure the occlusion’s right, because if those dentures are being discluded every time there is no way that suction is going to stop it from moving, it will break. So there’s no perfect answer, Jaz. [Jaz]So you need a bit of luck and good fundamentals, [Mark]Good fundamentals, a little bit of luck, if you have a really big ridge very often it’s harder to get that suction because if you’ve got big ridges with undercuts and you have to block those undercuts out, you get air gaps which are underneath which are too big for this sort of atmospheric pressure to work and it doesn’t help. So there’s no real perfect ridge. There’s no real perfect ridge. [Jaz]Well, you mentioned a good occlusion on dentures as being important in getting stability. Can you give us a quick summary of what are the main things the principles of a good denture occlusion? Is it always lingualized or a you know the whole bull technique to get a balanced or lingual lines occlusion, is that we need in every case? [Mark]I think a lot of it depends on the patient. Okay, so you’ll get a lot of patients who if they are it’s a bit like the dogs and sheep thing isn’t it? Some of us like dogs we incised our food, denture wearers, a sheep they’re ruminants they move their jaw from side to side. So the more parafunctional activity a patient has, the more you occlusion might be right. Okay? You get loads of people who never complain and you know their occlusion is awful on the denture he look at him and go I can’t believe you’re not struggling with this and they get on fine with it. So I think going to occlusion what I would say is that if you get the occlusion right, sometimes you’re going to find this difficult to achieve that the patient wants because in the end, denture teeth come out of a packet looking like 12 year olds teeth, you know, they’ve all got sharp, pointy canines, etc. But when you get to my age naturally with your own natural teeth, you quickly notice that you get wear facets and grooves etc. So everything you’ve learned about dentate occlusion, reverse it round for edentulous occlusion. So canine guidance is a bad thing in dentures. It’s great thing in dentate patients and non working side contact is a bad thing in the dentate patient but in a denture patient, it’s what you want. Okay? And when you protrude, you don’t want disclusion on your back teeth. However trying to get that in denture cases is really difficult to get the back tooth come in into contract, getting contact in protrusion. But they’re desirables. If you aim to get those on bruxist patients, on parafunctional patients, that’s where you’re going to get a degree of better success. I mean, the key thing with dentures is communication. It’s communication. It’s about talking to your patient about what is achievable. [Jaz]One, That’s amazing. I like how you talked about the different chewing patterns. So you say, dogs and sheep, I also might say, you know, the whole rats and cows, you can say what you like then that’s a good way to think about it. So to be more careful in the cows, then, you know, be careful with everyone, but your cows are particularly important, or your sheep are particularly important to get that occlusion just right. Because then they can run to more problems. Now, one mistake I used to make or think about is that every patient must look class one, or have a class one incisor relationship. [Mark]Here we go. Right. This is going to be an interesting one, Jaz, I’m going to enjoy this one. Go on. [Jaz]Okay, good. Good, because that’s the mistake I used to make when I realized Hang on a minute, whether their class 123 is dictated by their skeletal form. So we need to [Mark]100% [Jaz]go by their skeletal or so then I started to make dentures that were more occludes correct compared to what they probably had before. Their class two div one before then I like to make their dentures a bit more class class two div one, the only issue I want to ask you is that, Would that is A) Am I doing the right thing? And B) is if their class two div one, then you’re not going to get any anterior teeth contact? Is that going to be generally okay? [Mark]And do they get anterior tooth contact with other natural teeth? [Jaz]No, not at all. [Mark]So why do we create that when we make dentures? I mean, it’s a really interesting debate, I’ve heard people who are really quite qualified in the profession, who kind of insist every denture gets made as a class one, it’s nonsense, you know, one of the things I do when a patient comes in, I checked their sort of profile view. And I make an assumption on whether they’re class one, class two, or class three, okay? And by doing that, again, I can have a conversation with a patient and say, your front teeth are probably not going to meet when I make you the right set of dentures for you. And I’ll go on my front teeth meet on these dentures. And then I’ll go but your lower denture moves. And they’ll say, Yeah, but I don’t want my lower denture to move. And I’ll say, well, we need to set you so your front teeth don’t meet, and then it becomes a bit of a circle again, going round. And again, I try and explain to them I say, look, if you’ve got any photos of you, when you’re 12, or 14, and your school photos, I’ll be able to show you what your teeth look like. And, again, it’s having that conversation at the start, not at the end when they’ve got a different pattern of teeth than they thought they were going to get. Now going back to that study I did again, so one of the complete, one of the things myself and Johnny are working on is trying to think of a way that we can allow guys like you to assess your patient before you start to see what degree of difficulty that patient will be. Okay? So what we’re trying to work on, [Jaz]like an index? [Mark]So. Like an index, so you can work through like a little tick box. So in these 60 patients, significant class two, so what I’m looking for people, I can see a significantly class two. So 12% of patients are significantly class two. So that takes out all those people who had a slight overjet, these are people whose skeletal patterns are massively discrepancies, massive discrepancies there. And in class threes, there are 9%. So instantly, you’ve got 20% of the population, I’ve got quite severe skeletal discrepancies. Now the way I get that round to your patient is I talked about your upper denture is for beauty, and your lower denture is for function. Okay? So we have to put your lower teeth in the correct place over your ridge as close as possible to where your natural teeth would have been. And that’s the way I get around that. And that’s a conversation I have. [Jaz]Brilliant and it’s good to ask like you say for the old photos, not only for the occlusal element, but also for designing the teeth setup as well. So leading onto that. [Mark]I’ll ask you a question on thatm Jaz. [Jaz]Sure [Mark]So if you were going to place your canine tooth and your first premolar tooth in relation to the lower ridge, okay? Where would you place them in relation to the lower ridge? Would you place them buccally? Lingually? or on the ridge? Sorry to put you on the spot [Jaz]No, fantastic. So you’re talking about your upper denture? Where to where you put your teeth? [Mark]No, no. [Jaz]we’re talking about lowers [Mark]Bacause lower is one that people have problems with. Okay? [Jaz]So, in terms of positionally, whether the teeth themselves the long axis of the teeth are on the ridge, buccal or lingual. I think on the ridge. Something I must be honest with you. I don’t I haven’t thought about that much. [Mark]Okay, so you’re correct. It’s on the ridge. So the question I say is why? Okay, why on the ridge? So those teeth that you take out, your canines, and the lower premolars, how do we take them out because dentistry all links up. So we’ve talked about orthodontics skeletal patterns. So if you take out a lower canine or a lower premolar, how would you take that tooth out? You rotate it, you don’t lean it buccally, you don’t lean it lingually. It’s a rotational thing because that kind of [inaudible]. So therefore you get similar pattern a bone loss buccal and lingual. Okay? So your canines and your premolars have to be directly over the ridge. And that’s a fundamental of denture making. And I see so many dentures when they come in to me and those teeth are massively buccal to the ridge on why is that because you’ve tried to turn a class two into a class one. [Jaz]Well, if you just think about engineering and physics, if they’re buccal to the ridge, there’s causing like a cantilever leaving sort of effect in that area, it’s not going down the you know, the force is not being going, it’s not going down the correct path. [Mark]Well, that’s true base more against the balance of muscles really, because the modiolus muscle will push all the modiolus insertion will push those teeth if they place buccally, they’ll go lingually. So your muscles are not imbalanced. And it goes back to the analogy with a windows as I said earlier, you know, that’s you pushing on a day, that’s not very windy. [Jaz]On that note about ridges. Is it true that if you have a flat Ridge, your teeth shape should be flatter than if you’ve got like a pointy a bigger ridge than you can afford to have deeper Fauci on their teeth, like actual, like sharper teeth, if you like. Is that is that a [Mark]So my question would be Why would you want sharp fossa teeth anyway, on set of dentures, because ultimately, you don’t, you’re not going to help anyone, your occlusion is going to have to be so nailed on perfect in that case. So really, you need to be flattening cusps anyway, on dentures, I’m not saying go back to having flat cusp teeth, but you don’t want anything sharp. And again, it’s one of the common mistakes people makes and it comes in with a 40 year old set of dentures. There’s no curse on those teeth. And then what we do is we give them a new set of teeth with beautiful cusps. And you know what, weirdly, they can’t slide the teeth from side to side anymore because they’re locked into an occlusion [Jaz]Laboratories, when they actually take the stock teeth, did they have like a stock teeth, which are pre flattened or worn, like age appropriate measures? Or do they? [Mark]You can’t. Certain companies do have those, yeah, so it [Jaz]Just makes sense, doesn’t it, Really. [Mark]It makes total sense. Yeah, I you know, if you, I’m in my 50s now, you know, I’ve got wear facets on my teeth, and I mentioned it earlier, you know, you wear things down, you get used to things. And all of a sudden, if you, if somebody can’t make those free excursions, when they get their new dentures, they’re going to get, the lower denture is going to move, because there’s nothing to stop it if their teeth are together, they’re trying to slide, the denture’s going to move, they’re going to get more pain, they’re going to get TMJ pain, they’re going to get muscle pain, they’re going to get all sorts of pain. [Jaz]Fine. So in the interest of time, I’ve got one last question before you can give any final closing comments. And that question is regarding probably the stage of complete denture, sort of appointments, where which is I found the trickiest and are probably still that one of the most important ones and the trickiest ones I find is the wax jaw registration stage. I remember as a student on the PlayStation playing FIFA with my friend and my flatmate Harmeet and I’m playing I was at two o’clock I’ve got a patient I’ve got wax jaw reg, Can we just quickly revise like what the five things got to record? And actually remember a lot of time let’s have a conversation remember, what the five things to record. So can you give us, the listeners your main things to record and top tips for the wax jaw registration stage? [Mark]Okay, so if you want those, the best way of doing it is there’s some Facebook groups around. So I did I’m trying to do a post a month at the moment to help people with their dentures. I think it was a march post on the by dentists for dents- for dentist by dentists, I think and also on the there’s one called food. It used to be called foundation dentist but now it’s called [food]. I expected a real- [Jaz]I like food [Mark]You like food? What genuinely or just the website, [Jaz]both group and generally [Mark]The group. Okay. And I did a whole blog, I did a whole thing about it. And the big tip for me is if you know that your lower teeth has to go somewhere in relation to that ridge, and it’s non negotiable. Okay? Why do we need such big wax blocks? We don’t need wax blocks. So I used something called a three pillar technique where are the small anterior pillar And a small pillar in both molar regions. And by doing that, you’re taking a lot of error out of it. Because all you’ve got to do is make sure three things gently touch at the same time, rather than a seven to seven wax block. So I think the best way of answering that is go on to the website, go on to those Facebook groups, and put [Jaz]I’ll put those links on them. Yeah, I’ll put those posts on so that they can access those groups. And also [Jaz]And they can go directly to them. [Jaz]Yeah I’ll add on [Mark]Did you see it Jaz? The one did? [Jaz]Yeah, I did.I saw it. Yeah, it’s very nice. [Mark]So I think that will help people because it’s very visual. [Jaz]So everyone, I’ll add that on. So you can read more about those tips about the wax jaw registration. So Mark, any closing comments that you want to pass on to listeners about how to improve their complete dentures? I think we’ve covered quite a few things about anatomy, patient exploitation, psychology, problem solving, actually, problem solving, we need to actually just cover a little bit about in terms of the patient that comes in for review appointments, and they’re having pain problems. You’ve taught me so much I mean, I still, the only reason I have Dycal in the practice is because of you, about for complete dentures and the nurses give me a funny look, every time I asked for a Dycal for dentures. But that’s what you taught me. [Mark]You want to know a funny story about CQC and Dycal. So I still use that. I still use that technique, where I use the white from the Dycal just to dry this ulcerated tender area. Dab it on the mucosa, put the denture in, it picks up on the denture, just the denture. It was one thing that we got a slightly negative mark on because the Dycal is out of date. Apparently a little tip for people if you are going to use things that are out of date, make sure you put in a box saying out of date materials and you find [Jaz]Okay, that’s a good idea actually in same goes with composites actually if you’re using comps it’s out of date for like shade checking or mock ups. [Mark]Yeah. So put everything in a box say, not to be used for the purpose or intended and you can save these out of date materials for now. [Jaz]You have saved a lot of people in front of the CQC in that. So Mark, any closing comments? [Mark]Closing comments is take longer for your dental checkup on denture patients. Take a very, very good history. If you think you can’t, if you think the dentures are very, very good. And you’re not sure you can work out what’s wrong with them, don’t start making a new set of dentures. If you can’t diagnose what’s wrong with the old dentures, you’ve pretty much no chance of making an improvement. So that would be my finishing thing and be prepared to say to patients, I’m sorry, I think you need a more experienced prosthodontist for this. [Jaz]Thank you very much. And then that all those gems were amazing. And I’ll put all the other sort of links to that post on as well. And one thing that we talked about on Facebook, and I can mention it now is just touching on what you just said is the importance of the diagnosis. Now a lot of times the dentist, the diagnosis is going to be edentulous ridges, and the treatment plan will be complete dentures. [Mark]Right? Shall I put you out of treatment plan? Give me a minute. Okay, so here it is. I put this up because I thought we might discuss it. So he’s [Jaz]It just reminded me now. [Mark]It’s an example of a treatment plan. So here we go. I’ve got it post from my course. Course if anyone’s interested www.thedentureguy.uk. [Jaz]I’ll put one on my website, the link as well. [Mark]Thanks, Jaz. So treatment plan. So this is just an example of somebody that I’ve seen. So I put recommend that the patient sees the GDP for alternative medication. So the reason I’ve done that is a patient’s on lots of service stomach medications. And no matter what I do, if they’re on a load of things that make their mouth dry, they’re going to get more ulcers. Okay? So next thing recommend Biotène® for dry mouth. So this is just the treatment plan for this patient make new dentures at an increased OBD. To increase the OBD by four to five millimeters. So before I start, I already know what I want to do and ensure that we pick slightly lighter teeth and a similar mold and send an impression of the old one, of the old denture to the lab with a photo. Okay, extend the lower onto a retromolar pad and increase the retention and stability. Add an appeal labial flange because this was somebody who came in who’d got no flange at the front but they now can have one and correct the centerline. So that’s one of my dream of plans. Not very fulfilled. [Jaz]Exactly. Which is just funny when you think about this. I am very very thorough, very, very it’s like almost like create a little tick box for you as a guide for you to actually what you’re doing. [Mark]I have to have tick boxes, Jaz, I’m quite simple guy [Jaz]I love it. So, Mark [Mark]One very quick thing before we go, Jaz, letter writing as well, I write to everybody I ever make dentures for. I write what I’ve said, I’m going to do for them, why I’m going to do it. And if you get a template letter, it’s that easy to do, it takes 15 minutes to adjust the template letter. And if that saves you having to remake a set of dentures at the end, it’s time well spent. [Jaz]That’s a very good idea. Just it’s a part of your consent process as well. So absolutely. Mark, thanks so much for sharing all your pearls and wisdoms. It’s always lovely to speak to you again, it reminds me of being a dental student again, back all those years ago. And it’s been a great pleasure, thank you. [Mark]And Jaz one thing, keep up the good work. It’s lovely to see somebody who is an ethical guy who wants to do dentistry nicely, giving these podcasts to people, giving people a little bit of hope that it can be done. So just keep on doing it. [Jaz]Really appreciate that. Thank you. I’m enjoying it very much. And the plan so far is to keep doing them because it’s great. I’m learning I mean, I learned a few gems from you there. And just with every guest I have on it’s just Yeah, lots of fun. Jaz’s Outro: Thank you so much for watching and listening all the way to the end. I hope you enjoyed that. Anything that I promise in terms of the Facebook group that Mark mentioned, and the Atwood classification. I’ll put that on in the Protrusive Dental community Facebook group. Otherwise, I’ll catch you next episode. Please, if you enjoyed this content, share it with your friends, share it with your prosthodontic colleagues, share it with your dental students if you know any and also if you can leave me a review on your podcast platform. I’d really appreciate that. Thank you everyone. Goodbye.

I love Dentistry…but I FREAKING HATE CRACKS. CRACKS = DIFFICULT CONVERSATIONS with our patients. https://www.youtube.com/watch?v=IIsjE2Km-po Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: When checking for cracked cusp syndrome using a tooth slooth, make sure to jiggle it a little bit because it can help to get a more accurate result! I am joined by Endo Queen Dr. Kreena Patel – @kreenaspecialistendodontics to discuss all things cracks to make our decision making process clearer in General Practice! We discuss: How do you manage situations where pain is difficult to localise and you’re in a diagnostic dilemma? What if you just CANNOT find out which tooth it is? What should you say to the patient? 🤔 What % chance of success should you give to the patient based on clinical findings? Can you use a cotton wool roll as an alternative to a tooth slooth? SHOULD YOU CHASE A CRACK??? When you open a molar access cavity and trace a crack – where is the cut off for the extent of the crack before it is deemed not worth saving? Any advice for GDPs dealing with CTS? What is the evidence for RCT in patients with cracks? What is the consent conversation you have regarding cracks? And right at the start we touch on: Impact of CBCT in Endodontics Can you spot a crack on a CBCT? Click below for full episode transcript: Opening Snippet: Hello guys and welcome to another episode of the Protrusive Dental podcast... Jaz’s Introduction: Today I’ve got endo Queen, Kreena Patel on the show today and we’re talking all about cracked teeth, something as you will hear, I absolutely despise in general practice, I think it’s the bane of my existence. It’s one of the most difficult things to sort of diagnose sometimes. And the amount of conversation that’s involved with the patient, the amount of sort of discussion and complexities and nuances and possibilities your tooth might not be able to, might not even be able to save your tooth, we might have to put a crown on. But if then it fails, you might end up have to remove it. You may or may not be better off having an implant, the success isn’t that good. I’m not even sure which tooth it is. These are sort of things that you sort of end up discussing when it comes to cracked teeth. So we’re going to be discussing things like how far into a canal orifice does a crack need to extend before you look and say, You know what, this is unrestorable and when discuss about diagnosis of cracked tooth, which is one most challenging aspects of cracked teeth. And we’ll also discuss about how Kreena suggests is managed endodontically and also buy us in terms of cuspal coverage. So I hope you enjoy the episode. The episode as well as everything from Episode 20 onwards is going to be eventually on Dentinal Tubules for enhanced CPD, so thank you Dentinal Tubules for quality assuring my CPD. So if you wanted to get your CPD hours in, then you can go to Dentinal Tubules search Protrusive Dental podcast and answer a few questions, acknowledged the aims objectives and they are you will have CPD, enhanced CPD for this meeting. We know with all the outcomes written there. It’s all well and proper. So the Protrusive Dental Pearl I have for you is an endodontic one. And it’s the one that actually Kreena gave me in the middle of the episode actually, she told me when we’re using a tooth slooth, which is one of those rigid plastic thingies that you put on the teeth, and you get the patient to bite together and what it does is it flexes the tooth to then see if you are confirming the diagnosis of cracked tooth basically is essentially how you do it. And Kreena talks a little bit more about that. When you’re using that one thing that I don’t do as much at the moment I had an occasion I found Oh yes, this helps. But I never really made it protocol was to actually once you get the patient to bite down on the tooth slooth, you jiggle it a little bit, just jiggle it because that sort of jiggling can then sometimes be the difference between being a negative result and a positive result. And that positive result is obviously important in your diagnosis. So the Protrusive Dental pearl donated by Kreena Patel is when you’re using a tooth slooth, make sure you jiggle it. So I hope you enjoy the episode. If you’re listening to it, then awesome. If you’re watching on YouTube, then even better because there’s at one stage a photo of a cracked tooth that I show. So if you are listening, then reference back to the video version on YouTube and igtv to look and assess that clinical photo of a crack that I will show because it’s an interesting point that she raises about the width of the crack. So sometimes it’s helpful to see the crack. So let’s all learn from Kreena. Main Interview: [Jaz]Kreena, Kreena Patel, welcome to the Protrusive Dental podcast. It’s great to finally have you on and we’re going to talk all things about cracks today. How are you? [Kreena]Yeah, very good. Thank you so much for having me on. [Jaz]No, it’s really something that’s been a long time coming and for to put some context into this right now. We’re in the middle of COVID-19 lockdown. So if you’re listening in the year 2025. That’s what’s happening right now. And Kreena is going to be giving us some expert knowledge and advice about cracked teeth because this is the time to sort of gain more knowledge and skills so that when we go back into work, we’re fully charged and ready to go. So Kreena, for those very few people out there in the world of dentistry who don’t know who you are, can you please tell them about who you are, what you do, but I’m going to give you a little introduction in sense that you are one of the most proactive, most approachable, friendly and giving endodontists I’ve ever met. So now over to you. [Kreena]Oh, that’s lovely. Thank you Jaz. And yes, I’m a, I graduated for Manchester 2010. And following a couple of years in general practice doing DFT. I then moved on and did my specialist training at King’s College London, and I graduated from there in 2016. So since then I’ve been working mainly in specialist practice. And so I work based over in Croydon and in Reading. And I also teach one day a week on the MClinDent specialist program for King’s College London as well. So it’s quite nice having a little bit of variation in my week, which is always nice. It’s also quite nice giving something back so being able to do a little bit of teaching, whether that’s lecturing or working at Kings, just keeps you nice and fresh and motivated. [Jaz]I can see that you enjoy the education part of it from you know based from what I see on your Instagram and I think you’re something, I can sense something you enjoy. [Kreena]Oh, definitely. Yeah, I mean, I think when everyone start, endo’s never the thing that you know people love, but with practice, I think endo can be really fulfilling, there’s so many different aspects to it. And I feel like every case I treat, I find something different or I learned something different. And endo has as well as being obviously quite restorative speciality, there’s quite a lot of surgery involved in it as well. So it’s got quite a good variation. And the surgery is, you know, fairly complex surgery. And so I just think there’s, things in there that mean that you’ll never get bored. So, yeah, I highly encourage people to think about it. [Jaz]Brilliant. Two things I want to ask you before we talk about the main theme of cracked teeth. And the two things is one, what percentage of your practice is surgery at the moment? And the second one is, how big of an impact has CBCT made in the last five years in your daily practice? [Kreena]And so not a very large percentage of surgery, actually, I’d love to do more. And it’s just when you learn about doing endo surgery, you realize case selection is so important. And the majority of cases can be treated nonsurgically. So as long as they’re treated well quite a significant portion heal with root canal treatment or root canal retreatment. So, if most of my week is doing that, I’d say about 5% is surgery, I do a little bit more at my teaching job where I supervise surgeries for the postgrads so that keeps me quite involved in it. But yeah, I mean, I wish I would do more, but it’s just that, you know, most things heal without surgery, which is a good thing for the patient, I guess. [Jaz]And then how about CBCT? [Kreena]Yeah, I mean, CBCT had a massive impact. It’s almost like a whole lecture. There’s so many applications to CBCT and endodontics. From you know, whether it’s diagnosing periapical lesions, because quite often on radiographs, they’re 2d X rays. So you know, sometimes for patients with difficult you know, signs and symptoms, we can’t really diagnose properly. A CB CT game changing because you suddenly see where the problem is, because we see significantly more periapical lesions on CB CT, then pair of radiographs, also things like resorption. And so things like internal resorptions, external resorptions, you know, it allows us to plan these cases without, you know, going in surgery, or doing any invasive treatment, we can instantly see what we’re looking at. So it’s game changing for that. And even things like endo surgery, it’s fantastic. We can plan the treatment, we can see the proximity of lesions to the sinus, mental nerve, ID nerve, that allows us to do more complex treatment, you know, surgeries on lower molars, which we probably wouldn’t have taken the risk to do before. Full mouth, fantastic for trauma. So many applications for CBCT and endo. So we’ve actually just bought one for Oaktree Dental practice. And you have to be a little bit more careful when choosing cone beams for endodontics. Because you need a much sharper image compared to for implant surgery, because we’re looking at obviously tiny canals. And you need to see that sort of detail. So it’s a little bit more difficult to pick a scanner when it comes to endo. [Jaz]Yeah, we do have a in the Richmond practice, there is a very good CB CT scan with an endo mode. And I think that’s what you know, it’s just higher detail in that area for when you need it. So it is different. So on the topic, I mean, I’ve got a list of questions, I want to ask you about cracked teeth, but now on the cuff of cracked teeth, and cbct. You know, when you take a PA and we all do this, we take a PA and we show the patient and we suspect cracked tooth. And well the first thing we say to the patient is, well, I need this x ray, but I’m not expecting to see the crack on this x ray. And we all say that, where do you do see cracks on CBCTs? [Kreena]It depends on the size of the crack. So there’s been quite a lot of research that came out on this and the initial research said, we can’t see cracks and but what they were doing with that research is they were making the cracks a little bit wider than what we would you know, something that we would see in the mouth, for example, that we would need a cone beam for. So initially, a lot of the studies said you know cone beam is very useful for diagnosing cracks. And the latest studies were making very hairline cracks in teeth and then looking at that, and what we found is actually on cone beam we don’t see cracks at al, very fine cracks that is on a cone beam. In fact it because cone beam has a smaller resolution than periapical radiographs, we’re less likely to see it on a CB CT compared to a radiograph for example. [Jaz] All right [Kreena] and the thing that we do see though, is we quite often see the bone loss associated with a crack. So if we have a vertical root fracture, you know, quite often clinically we get a localized deep pocket associated with that. And that would be you know, there’d be bone loss associated with that and those fine details we see a lot better on a cone beam. So the associated signs there but not the crack. [Jaz]Well, I think it’s fair to say that if you can see a crack on the CBCT that tooth is probably for the bin [Kreena]yeah [Jaz] Fine [Kreena] That is exactly right. [Jaz]So the reason why I chose a cracked teeth is that although I love clinical dentistry, I hate cracked teeth with a passion, I hate dealing with it. Because it’s just there’s so many challenges and variable. So the way I say is, if there’s a cavity in a tooth just caries with no associated crack, there is a degree of predictability in the sense that when you’re communicating with the patient, you can be a bit more definitive that, okay, there’s a low chance or medium chance, depending on symptoms, stuff, whether you may end up needing root canal treatment. But when it comes to a cracked tooth, there’s so much explanation in like a flow chart you have to explain Well, if you then end up having pain, then we can hold your root canal. But if the crack is too big, then we can’t save it, we’ll only really know at this point. So I find it’s just a nightmare in that sense. So that’s why I’m going to speak about and so [Kreena]And we say much more. I don’t know about I mean, I feel like I’m treating, one or two cases a week, which never used to be the case a couple of years ago. Yeah, it’s definitely getting more and more. Probably because people are more stressed. You know, I mean, I’ve got cracking my teeth. And then it’s probably from all these exams that I’ve sat but [Jaz]Are you parafunction or what have you, do you have a history of parafunction? [Kreena]I can’t say. I don’t tend to night grind. I think I used to do but I definitely clench a lot. And my Yeah, my lower sevens got a crack in it. [Jaz]I’m going to ask you my list of questions. So we’ll have them have my phone out, please don’t think I’m texting someone. I’m actually looking at my questions. Okay? So if a patient comes in how do you manage your situations where pain is difficult to localize, and you’re in a diagnostic dilemma, and you suspect a crack? What is the sort of your standard protocol of ‘Okay, I suspect cracked tooth, I don’t exactly know which tooth’ because sometimes you just can’t see which tooth it could be. So talk us through how you’d manage that. [Kreena]But I think just starting from the basics, because I find that really helps a good history before we actually start the exam. So I run through SOCRATES, and so Sites, you know, where they think it’s coming from, and there’s been studies that have shown that, you know, patients that think it’s coming from a certainty, quite likely it’s coming from that. So, I mean, I think, you know, having a good conversation quite often with these cases, the patient isn’t sure they might, it could be this one, it could be this one, I think it’s more likely this one. And so I think that is very important, actually just get, you know, right from the onset. And the second is the Onset. So when it started, because sometimes patients they present to you with irreversible pulpitis, and, you know, it’s very severe pain. But if you ask them the history, then, you know, they might have said, you know, I had pain on biting from around this tooth for about a year or after that restoration was done. And it never felt right. And now I suppose a bit of pain. So I think if that really helps, and quite often you find with patients, they’re not willing to divulge that information. And they just say I’ve got a bit of pain, and then you get on with it. But I think the history is actually very important. And even the radiation, so you know, if they’ve got, for example, ear pain associated with it, we’re now thinking lower molars, potentially, if they’ve got pain in their eye, you know, canines, things like that. Even exact things that are stimulating the pain, so hot and cold, because those things will help me during my clinical examination. So when it comes to a patient and their exam, I start from all the basics. So what’s tender to percussion, starting from the adjacent teeth, which aren’t tender, and if you know if there’s two teeth, which are both tender to percussion, and then again, I’ll try and look for cracks. Magnification is really important. So I think with cracks, you do have to be using loupes, and a light if you can, ideally, a microscope is lovely to have that I think loupes and a light you see, you know, a lot more than just with you know, normal vision. [Jaz]What’s the minimum level of magnification you think someone should be using for exploring a crank? Do you have an opinion on that? [Kreena]Yeah, I mean, I think if you’ve got loupes, it’d be five times magnification because it’s very difficult to see where the crack extends without that sort of magnification because you might think it’s a lot more coronal than it actually is because they go very hairline as they traveled down the tooth and say, I think five times is the absolute minimum when [overlapping conversation] [Jaz]The advice I give to lots of young dentists, students and stuff coming out and they’re buying the first pair of loupes is just skip the 2.5 and 3, go straight to the five because you know I went five in that, I now want eight or something you know, also on Fridays where I get to use a scope I’m like, Oh, this is so much better. So you know that’s one side thing I want to say, more magnification the better with good lighting as well as you said, [Kreena]Yeah harder to get used to in the first instance but within two weeks, I think you’re there you know, so I totally agree with what you’re saying there. And also the bite test. So using a tooth slooth, so testing individual cusps, when they get when they bite down on the tooth on an individual cusp. I tend to jiggle the end of the tube slooth, because that sort of gives lateral pressure on the cusps. And I find that very useful. And [Jaz]Can we just talk about the tooth slooth actually, because people actually use it without knowing the proper way to use it. So the, you know, the curved or spoony side and whatnot. And also want to answer this for me, which is, is there any evidence suggests that the using an actual rigid tooth slooth is superior to what a lot of GDPs use is a cotton wool. [Kreena]Yeah, I think the problem with cotton wool is you don’t get the same sensation as when you use a tooth slooth, so tooth slooth tends to separate the tooth a little bit better because the so as you mentioned with the tooth slooth, you can have one end which has got a little component that’s meant to sit directly on each of the cusps individually. So you test one at a time. And so you put the cup end on the cusp tip, get them to bite down and on the flat end, and then you jiggle the end of it. And what that does is it puts lateral pressure on each of the cusps individually, which I think cotton woll just really can’t do. So I think that you know tooth sloot aren’t very expensive, but they total game changers when it comes to diagnosis. So I definitely recommend so. [Jaz]It’s a good tip you give them of jiggling. I think that is something I don’t always do. So I think that’s a good point. [Kreena]Yeah, I mean, some people will feel it instantly. But some people it’s the jiggle that does it. So it’s a good idea. And I also find sensibility testing really good. So the other thing that I mean I all these things that mistakes that I’ve made in during undergraduate I never got taught how to use a tooth slooth. With sensibility testing, it was always ether chloride and the [inaudible] No, exactly, yeah, the teeth, I mean, it felt great about -5 degrees. Whereas if you’re using something like endo frost, it’s -50. And so you were much like you know, much more likely to get a good response with something a lot colder. So, Endo Frost is the first thing I pick up. There are some cases of you know how you mentioned, it’s very difficult to diagnose where the where the pain is coming from. And a good tip that I’ve learned recently is I tend to use a hot test. So you know, you’re taught you need to do get some warmed GP and put it on the tooth, but that doesn’t work very well at all. So what I tend to do is I’ll get my nurse to boil the kettle, and then I will put the warm water in an endo syringe and not boiling hot, obviously, but just warm, fairly warm. And then I will individually isolate each of the teeth on that quadrant with rubberdam and put the hot water on it. And you know what the patients that tell you they’ve got hot pain, instantly, you’ll know which tooth it’s coming from. Because they’re the ones you know, with irreversible pulpitis they find it very difficult to differentiate which tooth it’s coming from. It’s quite a little bit painful for them, obviously, you need to tell them it’s not very nice in terms of doing it. But I get the nurse ready with the suction so she can suck up the water as soon as it’s done. But I find that test really useful. I had a couple of patients referred to me recently that the dentist hasn’t been able to diagnose which teeth it’s coming from. And the only way that I managed to is do it with that test. So [Jaz]That’s a really good tip for anyone listening use the hot water in a syringe, isolate each tooth with rubber dam and you know that might figure out which tooth it is. I have a story whereby I was dealing with a patient who ultimately end up having cracked tooth but the symptoms were severe pain, irreversible pulpitis type, apical periodontitis, and we’re trying to figure out is it from the top, is it from the lower and an upper right first molar was very TTP. And we both agreed that okay, it could be this one but I wasn’t 100% convinced. But he literally begged me to remove the upper right molar. And literally in my notes patient begged me to remove an upper molar. I was like look, I’m not 100% sure it could be a lower tooth as well anyway, took the tooth out, patient said thank you, anyway comes in next day. Obviously he’s not out of pain yet. It was a bottom tooth. And we’re looking at you know, get my loupes on again. And look, actually you can see this microchip on the marginal ridge of a lower molar. And then actually, that’s where it was a crack with anyway and that removing that tooth and I could visualize the crack beautifully. Anyway, the patient was very understanding because he literally begged me to remove that tooth. But you know, we’ve all made a lot of us have made mistakes like that. So this is why it’s so important to make sure you get it right. [Kreena]Yeah, I mean, I think you highlight a very important point though that I mean, your consent process was exactly right. You know you with these sorts of teeth, even if I am pretty sure it’s that tooth with cracked teeth when they’re in that sort of state irreversible pulpitis, patient struggling to identify what tooth it’s coming from. I think it’s always important to, you know, say to them, Look, I you know, I’ll normally say I’m 80% sure, I’m 90% sure it’s coming from this one. However, your symptoms aren’t, you know, 100% we’ve got a couple of options. You either wait and let it localize more, which you know, sometimes some patients will say, Okay, do that and you warn them the negatives of doing that is that you can end up with a non restorable tooth because it can end up completely fracturing Or, you know, we treat this with you understanding that, you know, where it could be another tooth, which is exactly, you know how you handle that. And I think, you know, having that discussion with the patient is just really important because, you know, we can’t be 100% sure all the time, especially with these sorts of teeth. [Jaz]I think it’s important for the patient to sense that actually, one, it’s totally okay not to be sure and to be straight with the patient, rather than I think we’ll remove this one. And then when you’re wrong, everything happened. I like the way you know, I think, is this percentage sure, what do you want to do, then the patient could take some ownership as well of that. So that was just my little story. So now, you mentioned about the actual diagnosis being pulpitis, necrotic, that sort of stuff. So can you tell us about the crack teeth with associated what’s happening with the pulp because that’s essentially what it’s all about, you know, you can have a cracked tooth and correct me if I’m wrong, we can have a cracked tooth with no pulpitis at all. And that too, is just needs cuspal coverage, for example whereas a cracked tooth with the whole sequelae. So tell us a little bit about the sort of different types of diagnoses you can have with a cracked tooth. [Kreena]So, cracked tooth syndrome means that the tooth is vital. And so that’s not a diagnosis for an necrotic pulp. And so you have cracked tooth syndrome with a reversible pulpitis. And for that, obviously, patients have got maybe pain on biting that constant ache, pain that doesn’t last more than a couple of seconds, all the normal things, and then you’ve got cracked tooth syndrome with irreversible pulpitis. And for irreversible pulpitis, I tend to tell the patient you know, there’s a couple of ways of managing this, one is, you know, we could do root canal treatment, if you know, that would be, we take the pulp out and any you know, it’s also a problem as in terms of your symptoms, or we could handle it more conservatively and just put a cuspal coverage restoration on it. And, you know, most patients will say that’s what they want, because every patient wants the most conservative treatment possible. And there’s quite good evidence for this. So there’s two studies, one by [M sigma et al], in 2007. And I think it reached about 43 teeth with reversible pulpitis with a crack that was diagnosed and he put a direct composite onlay on them. And I think about 96% or 95% were asymptomatic at six years, which is fantastic results. You know, they’ve got reversible pulpitis they have an onlay on it, and everything, you know, everything gets fixed for them. But there was another study done in a similar year by Krell and Rivera and they said about 20% of teeth that had cracks and reversible pulipitis became symptomatic after a crown was done. So I think that that’s quite interesting actually because the first study did an onlay, composite onlay quite technique sensitive and the second study did crowns. So it I think the main difference in the results there was mainly because an onlay was done. So I think for teeth with reversible pulpitis and cracked teeth, we should be placing onlays and we should be hopefully you know doing things like immediate dentin sealing and making sure the temporary onlay we put on there is very good. So we’re not getting leakage because this will helps preserve the vitality of the pulp. However, you know if you are doing that I’ll always say to patients you know there is always a risk that the tooth can become necrotic or symptomatic. And in that case, we are going to have to strip this restoration off it, investigate the crack. See if it’s restorable, if it is, we’re going to put something else on there. So that conversation is very important because every procedure or any crack or caries you know, it’s all an insult to the pulp So we’ve got this tooth which is had a little bit of an insult because it’s got a crack in it, probably a restoration in it. And then we’re doing another insult by putting this onlay on it. And so you know that’s enough to sometimes just tip a tooth with reversible pulpitis over the edge. I think that consent process is very important. [Jaz]Well Kreena if money was no object, I would always in that situation where my diagnosis is cracked tooth syndrome, and we have a reversible pulpitis, if money was no object, I would go for an indirect onlay so be it gold or lithium disilicate, whatever, for example. However, it’s not nice when you’ve had to deal with a cracked tooth with reversible pulpitis and then after your intervention, it becomes irreversible pulpitis or becomes necrotic without the patient realizing and then eventually it’s an abscess, and then you’re drilling through your investment or the patient’s investment or the cusapl coverage what you’ve done so sometimes a good interim is like you said, a composite direct, I do a lot of these cuspal coverage just to see how it’s going to go and I consent the patient that look if it after a couple years, if it all is good. I think we really should for longevity reasons. Then progress to an indirect restoration. [Kreena]Yeah, I mean, 100% agree, I think some sort of temporary measure is always good. Only thing I don’t like about the direct composite onlays is I feel like the indirect ones are a little bit more stronger in the sense that when they were biting on the tooth got a bit more stability to hold the crack together. And so maybe I mean a short, slightly shorter term and how it goes and then put it indirect on there but sooner. [Jaz]I completely agree and something that Jason Smithson taught me he’s not that big of a fan of composite onlays to be honest with you, because he shows all these studies where the rigidity of ceramic is needed to really get that you know, cuspal coverage and actually prevent the fracture of a tooth. So the point well taken, so I think what we’re left off is right, where I sort of injected with the story was, you were talking about now reversable pulpitis part of the crack tooth syndrome. [Kreena]Yeah. So if the symptoms are going a bit further, and we were irreversible pulpitis now, I think that’s what you mentioned. Yeah. So from irreversible pulpitis now, we manage that very similar to if a tooth is necrotic, so those two are managed the same. So what I would do is I would then explain to the patient, on the outset that the treatment of these teeth is a lot more unpredictable, and both in the short term and in the long term. So short term, and we’re going to invest our treatment plan would be to investigate the crack. So what I would tend to do is if irreversible pulpitis, extirpate, and see how far that crack is going. Same if it’s necrotic, I would go into it and have a little look. At that point, we’ve got a lot more information on the extent of the crack. But in the short term, it’s unpredictable, because say we do treat these teeth, the crack may have extended further than what we can physically see. So we stand the best chance of seeing how far it’s extended with a microscope or with high magnification loupes. But even with those sort of devices, potentially there could be microcracks that have gone beyond the level that we can see. So short term treatment can be unpredictable. Although we try and minimize the unpredictability. [Jaz]This is what I mean with patients you know, cracked teeth are so complicated because of that, and you’re constantly sort of having to defend yourself, you’re constantly digging in front of the patient. This is why I hate cracked teeth so much. [Kreena]Do you know the way I find it very useful to show them a picture. So I’ve got one folder on my desktop with the cracked tooth in it. And I’ve got these this sort of sequential look at tooth all throughout me investigating the crack. And I find that patients don’t understand what I’m saying until I show them those pictures. And when I see them, it’s like a light goes on in their eye. And they’re like, ‘Oh, I understand why now you don’t know, you know why you can’t tell me because it you know, I can’t see where it goes.’ So you can show them the pictures and I find that very useful. [Jaz]Well, this might be a good point for me to show the people watching right now. And you have a cracked tooth which I opened up due to irreversible pulpitis and see what it looks like and then get your What do you see from your lens of the world? Can we do that? [Kreena]Yeah, of course. [Jaz]Fine. So share screen. So let’s make that bigger. So this is a lower right molar, diagnosis was irreversible pulpitis, raging lots of toothache and we opened it up, hyperemic pulp and what we’re looking at here is the distal marginal ridge, the crack extending into pretty much the pulp chamber. Now if I was to zoom in, I mean, this is very clear where my mouse is now the sort of higher part that’s very clearly crack. The bottom you can still see the crack line. So tell me, is this one for the bin Or not? Or do you need more information? [Kreena]And for me, this is probably one for the bin, not because if the extent of where the crack goes to, because I think that you know, it’s going into slightly into the black area, but it looks you know that doesn’t bother me as much. What does bother me is the width of the crack and the coronal aspect. So we can see the tooth is pretty much in two parts, you can almost see debris coming in, you know, pretty much at the level of the CEJ, I can see that crack is about, you know, point one or two millimeters wide, you got debris in there. So I think that is the reason that crack width is the problem for me, not the extent that it’s going to because, you know, when I look at cracks, as long as it’s not crossing the pulp floor or it’s extending, you know, very far into the canal orifice, usually even a millimeter into the canal orifice. I will treat that sort of tooth if the patient is keen for me to but the width of this crack is what I think is in some restorable. [Jaz]Well, that was a massive dilemma for me at the time, was really arming and arring and the patient. So I ended up doing a root filling for this tooth. But I take your point, I think now if I was look back at it, assessing the width is very reasonable say you shouldn’t treat that. I think it’s been three years now touch with all is good, but I don’t think this will be there in another five years personally. But it’s interesting how you say that. Yeah, I enjoy your sort of a look on it. And I learned something there to actually not just assess the depth, but also look at the width. And you see that you can see debris coming in. And that’s a red flag, I think. [Kreena]Yeah, I mean, to be honest, there isn’t much evidence when it comes to, you know, which teeth we should treat and what teeth we shouldn’t treat. There was actually I was going, I was going to do my own study on it, because I was treating a lot of these teeth, which, if you look at the previous papers, they were saying that they were unestorable you know, before, if you look at the evidence, it said that, if a crack is going, you know, to the level of the canal orifice, that’s for the bin and then you know, there’s very you know, high risk of failure when it comes to treating cracks. But if I did that, then so many of my patients would lose their tooth, and in my mouth, I would be treating these. So I started treating these sort of more severe cracks about five years ago, I had a great success with it. And there was a paper that came out last year actually, and which has shown very similar results, they treated quite extensive cracks and the cracks that extended just into the canal orifice. So if there was that five millimeters pocketing, you know, isolated pocketing associated with the cracks, and they had a great success rate, they had about 100% survival at two years, and 96% survival at four years. So I think actually, you know, as long as they were treated properly, which I’m sure we’re going to go on to the management. But as long as they were treated properly, the success rate was very, very good. And I think the main thing, I mean, as you treated with that one, it would be just telling the patient actually, you know, normally for me, when I’m treating these cases, I before I even started it, I won’t know if I can treat this or not until I open it up and investigate it. Once I have opened it up, I can give you a rough percentage of what I think so, for example, with that tooth, I would have said, you know, 50-50, or 40%, or whatever. And I would have given the represent digit that stage once I’d opened it up. And I think most patients are happy with that. And it’s that percentage that they then decide, I mean, I’ve treated a dentist a couple of years ago. And, you know, obviously he’s well informed. He, you know, very understands everything. And I said to him ‘Look, I think 50-50 for this, it was a you know, could see the crack, it was an isolated five millimeter pocket with the crack line.’ And I’ve chased it and it’s still in, you know, still in his mouth. So I think as long as we’ve properly consented patients, and spoken to them about the risks, you know, long term, short term, we should be treating them. [Jaz]I think just an interesting observation, I think with all realms of dentistry, the decisions that we make as clinicians, now if you’re someone who’s quite good at placing implants, and you come across a 50-50 crack, you’re probably gonna go towards the implant, because you know, everything, when you have a hammer, everything looks like a nail. Or if you have a really good endodontist beside you, or if you’re really good at endodontics, you probably have a crack at that, excuse the pun. So it’s just one of those things in life. So you’ve answered one of my next questions, which was how far into the orifice? You said about a millimeter even then, obviously, look, you know taking into account all the other factors as well. [Kreena]So if the crack extends across the pulp floor, for me, that’s a definite No, No.[Jaz] Sure. [Kreena] If there is an isolated pocket more than about five to six millimeters for me, that’s a no, no, although there have been studies that have shown good success rate with up to seven millimeter pocketing. [Jaz] Wow. [Kreena] But that pocket indicates that the crack has gone into the root, you know, it’s traveled into the root there. So five millimeters for me is a cut off. And if I do have any isolated pocket, that’s an immediate me telling the patient look short term, this is a lot more unpredictable. Yeah, and crack width is very important. So yeah, but those are the the factors that I look at. [Jaz]Brilliant. So the next question is, I think you’ve said the answer on this already, basically, about the evidence based for how long a root canal treatment can last, with patients with cracks. Do you want to mention anything else? [Kreena]And well, there was also a systematic review that was carried out last year, I’ve got the name here somewhere. Oliveira et al. It was a systematic review on all the evidence for cracks. And they said that there was an 88% survival at one year and an 82% success rate one year. The main significant factors that they found was it how many cracks the tooth had, or the tooth too tight, or the status of the pulps, if it was necrotic or reversible pulpitis. But it was more that if there was a perio pocket associated with it. So that was the main factor. But it was the Davis and Shariff study that I mentioned earlier than the one that I think is very, very good. And the main sort of outcomes of that study were that we place an intra canal barrier. So for example, with teeth that with cracks are the one that you showed, for example, what I would do is I would once I’ve obturated that tooth, I would put I’ve normally put composite below the level that I can see the crack extending, because we know that gp leaks. It’s not a very good material. It’s only for root canal fillings, it’s not good at preventing leakage. So one of the main outcomes is for this study was putting a microscope assisted into canal barrier. So sort of going, you know, far down the canal. And I think that makes a significant difference. And the other outcome was, what they said is they took the two paths of occlusion, and then they recommended a cuspal coverage restoration as soon as possible. And so when I treat these teeth, I tend to put a ortho band around the tooth, because dentist, so you don’t know, you know, when we’re treating difficult cracks, especially the bigger ones, you worry that I mean, I normally put a composite core in the tooth and leave it like that. But ones that are bigger, I find an ortho band really useful. And so I just take a very thin slice mesially, and distally which is what would you know, what the dentist would take when they put a cuspal coverage anyway, and I cement an ortho band with GIC. So as I pick a band that’s very going to be very tight fitting and bite stick for the ortho band so that they just bite on, it clips on and very easy to place, it doesn’t take very long. And that just holds that tooth stable until the cuspal coverage restoration is done. Because dentists get busy, you know, if they can’t, if you can’t get that patient back in your diary for another month or something like that, I think the band is really useful to help hold things together. But I think that’s another conversation for the patient, you know, before you start it, saying that, you know, you’re putting a big investment in this tooth, you’re gonna have a root canal treatment, and then for me, you’re going to have a cuspal coverage straightaway. And then we see how it goes, you know, if this doesn’t work, then it will have to still come out. You know, and if it does work, it might last you many years, but there is a risk long term, the crack can extend and the tooth may need to come out as well. And it’s a hard conversation to have witha the patient, you know, because, you know, it’s not easy. It does take time, you know, it’s to have that conversation. But I think it’s so important, because then they suddenly, you know, they understand you and them if we’re in the same boat, and you’re traveling, you know, this line together. And I find that the reviews, they come back and they say, you know, Kreena, it’s still there, it’s fine. You know, it’s we both celebrate together, you know, [Jaz]It’s undersell overdeliver, isn’t it? Really, the crux of all treatment conversations and consent it does a very important part of it, especially with cracks. And that’s why I hate it so much I don’t like like giving patients bad news all the time, like, Well, you know, it’s really dubious, and it’s just been a cracked tooth involved. I’m always like, super pessimistic. [Kreena]Yeah, me too. I mean, I give them the percentages, the rough percentages, and just then I sort of stand there. And it’s hard to be silent in that time while they decide. But I think the main thing is just be silent. Let them make the decision. [Jaz]Young dentists communication wise, is that never own the patient’s problem. Remember, the crack is in the patient’s tooth, not in your tooth. So make sure you dissociate yourself from that problem. The problem is out of your body, it’s in someone else’s mouth and their tooth specifically. So really give them as a professional, all the information you need to give and let them come up with the decision. don’t own it. Don’t get emotionally involved in that patient’s decision. I used to do that quite a bit. I think. Do you do it? [Kreena]Yeah, I’m very guilty of it, I think, you know, I’ll be thinking sometimes of a tooth that I should have treated or not treated, and I’m thinking about it at nighttime, you know, and it’s not a good thing to do. I think the more you practice that conversation and say, you know, you have it few times, and you get used to saying okay, this is your tooth, I’ve had the same problem. I mean, I normally tell them about my story, actually, because I was getting pain when eating raw [inaudible] I would get short, sharp pain when eating. And I was convinced it was my six. And it was my seven, I mean, the most common teeth to crack in the mouth are lower sevens first, then upper sixes then upper fours and five. So studies have shown that it was my lower seven, I was very close to getting a cuspal coverage, put on my number 6 tooth. And it was only you know, a little bit later, I had a raspberry seed and I asked someone, well, where is it and it was on my lower seven. And so I always tell them that story. And I find that patients quite like that if you tell them a story, you know, something that happened to you. They’re like, okay, she understands you know that this is a problem. [Jaz]Now, that’s a great way to communicate with your patients. So the last question I have, I think, was there any other points you want to raise about the consent conversation? Because one thing I want to say actually was, when I’m consenting patients for any treatment, not just root canal and crack, I always love to give them percentages, according to the evidence. I think that’s a very good thing to do, medical legally. So for example, if I’m doing a resin bonded bridge, I say, well, the study showed that if they last four years, they will then go on to last eight years or 10 years and 80% success rate at that point. I’d like to give them that sort of information. So what do you do in terms of consent? And do you give them like that sort of information that I’ve just described? [Kreena]Yeah, I mean, it’s difficult because there isn’t much evidence out there apart from this paper that I mentioned to you. And so the two papers, the Davis and Shariff one and the Oliveira one. Yeah, I mean, those are those are the two main papers, and they’ve got very good success rates. And so I don’t like to quote that, because obviously, it is difficult. So normally, what I will say is, if it’s a very minor crack, I will probably give them about 85%. That’s when I start. And if the crack is very extensive, so probably the one that you showed, that for me is, you know, 50-50, something like that. So it varies on how wide it is, if there is nice if there’s an isolated pocket, it instantly goes down for me to about 75%. Just because these things are unpredictable. And I think it’s you know, it’s a large investment for a patient. So it’s very important that that you like exactly how you said that you sort of undersell and overdeliver. And so yeah, those are the sort of percentages that I tend to give. [Jaz]I take your point, I think maybe you’re right, maybe with endodontics and cracked teeth, you don’t want to be quoting them as good as figures as in the studies because it sort of goes against the philosophy of undersell overdeliver and it’s just so variable and unpredictable and you know, that sort of stuff. So last question. [Kreena]Fantasctic variance actually, the success rate is over about 90%? I think. So [Jaz]I think because it’s you [Kreena]No but I do think I mean, even your patient, the one that you treated, you know, that’s fantastic result that you’ve got that patient three years out, is it three years? [Jaz]Three so far? [Kreena]Yeah, I mean, it’s fantastic result, you know, patients kept that tooth for three years. And for me in my mouth, that’s, you know, I’m definitely going for that sort of option. But I think sometimes for other patients, we you know, we’re so scared in this litigious world you know to treat something and then be told off you know, trying your best. So I think it’s, you have to be careful, but at the same time, like we want to, like do the best for our patients. [Jaz]Well, you’re completely right there, we’re less inclined to give it a go anymore, because of the climate we’re in. So the last question I have for you is, is there any evidence perhaps about? Well, some people say that when you have a crack, that you should chase the crack until you don’t see any crack anymore, whereas others are like, no, don’t chase the crack, because the theory is that the vibration of your bur is actually causing more microcracks. And that’s the camp I’m in actually. So I follow the principles of someone called Pasquale Venuti, who’s a fantastic general dentist in Italy, who lectures all over the world. I saw him in Sydney few years ago, and he was talking all that cracks and whatnot, and how he doesn’t chase crack. So I changed my practice based on that, but I don’t know, am I doing the right thing by not overzealously, chasing cracks? [Kreena]It’s difficult to say because again, there’s very little evidence on all of it. And if there is a vital tooth with reversible pulpitis, then I definitely wouldn’t be chasing any crack, I would be going straight from my cuspal coverage. And what I find is, when I do, I don’t chase them so that they disappear. But what I like to do is I quite like to open the tooth, so that I can probe directly at the level of where the crack is. So for example, if there is a proximal contact, we can’t probe properly, incidentally. So what I will tend to do is I’ll open the crack just enough, so I’ve removed the contact, so that I can probe directly where the edge of that crack is. And the reason I do that is I think it does change my percentage of success that I offer the patient because some cracks look, you know, not too bad, you open that there, suddenly, you’ve got an eight to nine millimeter pocket at that level, which would significantly change my management, whereas for others, you probe, you know, they’re a little bit wider initially, and you probe and there’s no pocket there. And it may be that I would then go and save that tooth. So I don’t agree with tracing it to get rid of the crack by any means. But I do like to know it for me, it impacts on my treatment. So I quite like to open it up just so I can probe that that contact there. [Jaz]That makes perfect sense because you’re opening your way essentially doing is you’re opening the contact, which is something that would have happened anyway because that tooth would have been needed a cuspal coverage restoration because that’s exactly what the crack is anyway. [Kreena]Yeah, potentially. I mean, it’s not ideal because if we remove the marginal ridge on a tooth, we do significantly lower the strength of that too. So if we could preserve it, it’s nicer I think it just I don’t get the information I need from doing that. So at the moment I am enlarging those ones so that I can probe and check. If the crack is very small. Then I don’t. So if I’ve opened that access and the crack is very hairline, it’s not got any staining coming through it you know sometimes you see cracks and you can just see that there is a crack there but it’s not got any black staining or anything like that, for those I won’t bother because I’m thinking you know it’s fairly minor anyway. The only time I do sort of check when I open them is when I worried at that tooth has become necrotic due to the crack. So if we look at most teeth that we treat, you know, if we take out an amalgam quite often we see minor crack lines, those I will never Chase, but if it’s a tooth that’s, you know, become necrotic or pulpitic because of the crack. That’s what I want to investigate on a bit further. [Jaz]Okay, brilliant. Well, the only thing that left a question with me now, based on what you said, was, I’m trying to think of my references now, but I think it’s either Ray & Trope 1985 or Aquilino, 2002, I think, or 1998. I’m trying think which year it was. But the whole thing about cuspal coverage after endodontics and how the loss of marginal ridge significantly weaken the tooth. Now, in those situations, typically in the absence of cracked tooth, if you’ve got the example occlusal caries in a molar, and that has led to let’s say, irreversible pulpitis or necrotic tooth, because the marginal ridge is around the entire 360 degrees a tooth is preserved for me in my book that it can often get away without a cuspal coverage restoration or just a well bonded composite can do the trick. Whereas if you have endodontics, and a marginal ridge involved, then I for me, my default is a onlay or you know a crown if necessary. But if you have a scenario where you sort of describe whereby you might have a cracked tooth with irreversible pulpitis, but there is no previous restoration, there’s no involvement of a marginal ridge. See, because it’s a cracked tooth, I will still be inclined to put a cuspal coverage restoration on it. [Kreena]Yeah, 100% I think if there is a crack in the tooth, that tooth definitely need cuspal coverage restoration, because I mean teeth when you’ve had endodontic treatment, they become weaker for a variety of reasons. One that you mentioned is the loss of tooth structure. And there’s a great study by Krell et al, which shows that if the marginal ridges removed, it reduces the strength of that tooth by about 63%. Whereas for small occlusal access it’s about 5%. Occlusal axis doesn’t contribute loads as long as we’ve kept it fairly minimal. But there’s other reasons why the tooth becomes problematic. One is proprioception. So you know, there’s pluses or minuses that proprioception, the pulp, isn’t there proprioception in the pulp, but there have been studies that have been done. [inaudible] actually, yeah, so there’s a really good study called them by And what they did was they put force on non vital teeth and vital teeth, and they found that non vital teeth took at least two times more occlusal load than vital teeth so that it shows that there probably is proprioceptive fibers in the pulp. Because non vital teeth you can put a lot more pressure on them without you knowing, you know. [Jaz]Are you sure you mean non vital? You mean vital? You can put more force in the- Yes. [Kreena] on non vital. [Jaz] Yeah, you can put- I see. So in the mouth, when there’s a non vital tooth it can take more force because there’s no proprioception to warn it that there’s this force. Okay, fine. [Kreena]Exactly. Yeah. And actually, they had to abandon that study because they kept breaking the non vital teeth. So that there’s obviously the medicaments and irrigations, we use. So sodium hypochlorite. All of that causes problems with the dentine and can can result in fracture there’s lots of reasons why endo itself weakens the tooth. So that in itself means that a cuspal coverage, restoration is a good idea. In terms of if there is just a smooth, small occlusal access, sometimes I will still recommend a cuspal coverage restoration on those patients depending on if they’re a parafunction patient or not. So if that patient has parafunction. And you know, all these factors when it with endo associated can cause problems in terms of how brittle the tooth is, and all those sorts of things. So, I will still sometimes in some cases recommend a cuspal coverage restoration even with a small occlusal access. But yeah, if there’s a crack definitely because we want to bring that tooth under compression rather than flexion. So the cuspal coverage restoration will mean that when we’re biting on the tooth, it’s under compression, rather than the two cusps flexing apart and being on deflection. [Jaz]Awesome. Well, I think that’s quite a comprehensive, I don’t know 40 minutes, whatever we’ve been done on crack teeth, anything else you want tell the listeners about cracked teeth in terms of something that might think is relevant to them. [Kreena]I mean, I think it’s only when it came to the diagnosis part. And the other few tips are transillumination is very good, staining can be very good in using something like methylene blue, and you can get dye that because sometimes helps you identify cracks. And sometimes if there’s a large restoration in the tooth, we can’t see cracks at all visually. So if you are very stuck on which tooth is causing the problem, you can just ask that, you know, say to the patient, look, I’m not sure we can remove the restoration in the one that’s more likely see if I can see a crack. If not, maybe, you know move on to another one. So those are just little tips on on diagnosis as well. [Jaz]I mean in as a GDP, there’s so many restorations I removed to reveal these nasty cracks. And at that point, you know, you pull out your camera, you take your photo out, you show the patient is all part of the consent process. [Kreena]Yeah, definitely. [Jaz]But it will. Kreena, it’s been amazing time has flown by speaking to you about cracks. And I think you’ve really given me some good definitive answers of the questions I wanted. And I’ve learned a few things about assessing the width, the jiggling of the tooth slooth. And also I do agree with you parafunctional patients, even if they’re only got a sort of a small access cavity, I am a bit more inclined towards cuspal coverage. So then loads of gems there. Thank you so much, Kreena. [Kreena]Thank you so much for having me. I really appreciate it. [Jaz]If you want to learn more, how can we sort of follow you and find out which other education that you’re involved with? [Kreena]I guess I post a lot of my cases for anyone that’s interested in and I post a lot of my cases on my Instagram, which is @kreenaspecialistendodontics. And I’m starting up an online endo course because I don’t think there is very much out there. And I constantly get asked about, you know, from people, different countries, even this country, because online learning is so important now, as with your podcasts, you know if you can learn from the comfort of your own home, it’s very nice. So I’m trying to, I’m launching my own online endo course, pretty soon. So yeah, watch that space. Jaz’s Outro: So thanks again for listening all the way to the end. And within a couple of weeks, I imagine you can go on to Dentinal Tubules and answer the questions and get your enhanced CPD for that. Gosh, I hope by the time this episode’s out that lockdown is finished with some recording in the midst of lockdown. So I hope everyone is safe and well and their families are all good. And we’re going to hit back into practice with all guns blazing. And as always, thanks so much for listening. If you like the content, please subscribe, like and share with your Dental colleagues. And please, of course, leave me a five star rating on your podcast platform. That’s how my podcast actually grows. So please, that’s very important. I really appreciate it.

This episode aims to navigate the Dentist around the complicated world of Respiratory Protective Equipment (RPE). I literally start from the basics and we build up – hope this helps! https://www.youtube.com/watch?v=30dNlplwdoI Need to Read it? Check out the Full Episode Transcript below! What is a Fit test vs Fit check Who should be paying for the FFP masks?! Associates?! Oops I failed my fit test – what now? Should we just drop FFP2/FFP3 and just use re-usable RPE that is way more cost effective? UDCs are reportedly keeping the same FFP3 mask on for several patients (1 per session) with a surgical mask on top – if they are getting away with it, can we do it in practice to save money? Does FFP2 NEED to be fit tested? Can you get away without one if you compensate with a face shield? What’s the difference between FFP2 and FFP3? What does a FFP even mean? Should you be stocking up now? Watch out for the fakes! Will there be a phased return or ‘chaotic return’? If I am antibody positive, do I need to bother with all this? DO we need more fit testers? How to get involved? How are we going to meet the healthcare demand of fit testing? When do you think I’ll get to place composites again?! Click below for full episode transcript: Opening Snippet: Hi, guys, welcome to another episode of Protrusive Dental podcast... Main Interview: [Jaz]This one’s all about respiratory protective equipment. It’s a massive, massive topic at the moment. And I just want to help out by covering a little bit mostly because I felt as though I knew nothing. And I had some people reach out to me, what do we do about our beards? Do we get FFP2s, fit test it, this will make a good topic for your podcast. So I reached out some guys, it culminated in this episode, which is going to cover all the very basics of the more sort of political ethical questions around RPE in dentistry, for whatever it is that we’ll be getting back to work. I know the UDCs are working under some conditions whereby they have access to some forms of RPE. So discussing all that, I have to give a disclaimer that one of the reasons I made this episode was because I am concerned as a Sikh man, with a turban and a beard, but how I’m going to go back to work and certainly for those in my community, how are we going to get back to work and I want voice or my community to be heard. So that’s one of the reasons but that makes up around about 0.2% of this podcast. This podcast episode is applicable to everyone. But I do want to reach out to my community and sort of offer them something. And basically, there’s not much in it in terms of how I can help people with beards, Muslims, Jews, Sikhs, those of us who have facial hair, essentially, we are at the mercy of the higher powers, the WHO, Public Health England, the CDO, NHS England. So all these bodies are advising us. And actually, they are all blind. And what I mean by that is that there is just not enough evidence yet. So I think the method that everyone is now adopting is a better safe than sorry, hence why at the moment, the guidance suggests that you should be using a filtering SPS for any AGP related procedures. So that’s where that guidance comes from. It may be that just a surgical mask and a visor is just as good. But the thing is, we don’t know yet. I think the due to political reasons, and due to safety first and being better to be safe than sorry, that’s the reason that we’re going a bit extreme into some of the guidance recommendations in terms of worker needs to wear these FFP2 or FFP3 masks. So I think that’s where that comes from. The only thing I can say is that I was surprised to learn a little bit that all this RPE that we wear is actually mostly to do with protecting us, not so much the patient. Yes, the patient’s important as a byproduct, the patient should be protected. But we’ll also think about how to protect us as interesting that, for example, if I was to wear an FFP2 mask with my beard, technically, I wouldn’t get certified to wear it because one of the guidelines is that you should be clean shaven. So we know that the seal actually degrades and you can’t be certain that every time you do a fit check that you’ve got a perfect seal. So for that reason, we think that yes, the dentist is not protected, but actually the patient, maybe we just don’t know, because the dentist can still exhale. And we don’t know how much of that exhalation can affect the patient. We don’t know how much of the viral load is carried in exhalation yet. We just don’t know the answer. And of course, the majority of the masks that are available, RPE that is available in UDCs due to political reasons and supply reasons actually have an exhalation valve. So the air, the exhalation, air is actually coming out anyway. So that to me, that seems no different to me, wearing FFP3 and knowing that I don’t have 100% seal. So I don’t really see that being any different. So there are lots of unanswered questions for people with beards and stuff. So that’s the best I can offer. We really need a solution that not going to depend on hoods, because they’re so cumbersome. Anyway, we cover all that and much, much, much more. Like I said, the beard thing is only a small part of this podcast. I really hope this helps everyone to understand about fit testing, fit checking which mask do we need? Why? Is it a legal requirement to wear these masks? Who is protected? Who’s not? How much these costs? Is it better to just buy a reusable one than a disposable one? So all these things we covered, I generally hope that you find this useful. Thanks so much for tuning in. [Tarik]That’s number one. Number two, we don’t know there’s a lack of evidence or there’s no evidence on aerosols and risk of transmission, so we don’t know. So there may be the fact that we get more evidence, there is, maybe we will get different respirators that would come onto the market. And maybe we don’t need them. Unknown SpeakerWelcome to the protrusive Dental podcast, the forward thinking podcast for dental professionals. Join us as we discuss hot topics and dentistry, clinical tips, continuing education and adding value to your life and career with your host, Jaz Gulati. [Jaz]Right and Gentlemen, welcome to Protrusive Dental podcast. It’s great to have have you on. I want to make this the most impactful episode about PPE and RPE in the current climate. Let’s start with some introductions. Tarik, thanks for reaching out to me. Please tell us about yourself and what makes you qualified if I say to talk about PPE and RPE? [Tarik]So my name is Tarik Shembesh. I’m a dentist, oral surgeon. And for the last eight weeks, I’ve been redeployed as a fit tester. I’ve been testing qualitatively and quantitatively, have coordinated a large team of multidisciplinary dental professionals in fit testing, supervising them, educating them to colleagues, I’ve been conducting respiratory protection education, as well as raising awareness about respirators and fit testing. [Jaz]Perfect. How about you, Kareem? [Kareem]Hi, Jaz. Thank you very much for having me. On the show, my name is Karim dadly. I’m a consultant and the statistics at a London COVID teaching hospital where we have a large population of COVID patients that have been through our doors in the last two months or so. What makes me qualified is that I have not seen a patient that does not have COVID in the last two months, I only look after COVID patients at the moment. So therefore, I wear RPE and PPE every day when I’m at work. I’m also the research lead for our Directorate. And so I’ve done a little bit of research on amongst other things, but on COVID and RPE and PPE, I’m by no means an expert. But I would say that I’m equipped to talk about the RPE and PPE from a day to day experience basis as well. [Jaz]That is fantastic. And I think we’re going to learn a lot from your experiences because what we’re about to face is dentist going to the work and Doc Sami, please tell us about yourself. [Sami]So I’m an oral surgeon I’m Sami Darwish an oral surgeon and a periodontist. And I am not on the front line, like these two chaps are. But together we have created an organization where we have been going around fit testing dentists in preparation for them providing clinical services. So far, it’s just been the UDCs. But we’re moving into helping the other dental practices open up and ready for service. That like Kareem is the lead researcher in his unit. And I’ve had a couple of publications out there in the dental literature. So I guess together the three of us and the huge team that we’ve managed to put together now of over 40 fit testers, we now created a network of fit testers that’s providing the service according to the need, and put ourselves in a good system going in getting people ready to go back to dentistry. [Jaz]Brilliant, thank you to all three of you for your roles in what you’re doing. And during this time. Whether you’re on the front line, or you’re like do something behind the scenes, it’s great that you’re doing this work. Do you know how many people or how many healthcare professionals have been fit tested by yourselves? Do you have a like a rough number? [Sami]Last count was a few days ago, which was 500 and something [Kareem]Yeah, top 560 570. [Jaz]Brilliant. And what are the main things that you’ve learned from doing it? What is it? Well, I want to know is what’s the pass rate of fit testing? So you’ve done 500 people, but their first time when you test them and then maybe what percentage pass and then maybe then you have to try another brand. Give us a flavor of what’s going on behind the scenes for someone some of the dentists who have no idea who haven’t been to the centers to be fit tested. What actually goes on? [Tarik]Let me start by saying what’s a fit test? Fit Test is just a confirmation or a an assessment of the performance of that respirator on somebody’s face essentially, is it compatible with the person his facial features and in particularly the lower mid face. Now we are a dentist where our team is multidisciplinary dental professionals. We measure the face, we use 3d scanning as well. And with that techniques, we’ve managed to find out with our experience and as we go along, what is the most suitable Or what’s the most likely to be the most suitable RPE, but also constrained with what’s available. So to answer your question, what’s the pass rate? It depends on what variety of RPE we have, and what the demographic that we’re faced with. So in a session where it’s mainly petite women, then probably the pass rate will be low, as low as 30%, where we have mainly a male demographic, and we have a variety of respirators, then we would have as high as 80 to 100%. So changes from session to session. Overall, I’d probably say around 70% mark [Jaz]70% is a pass rate. Yeah. [Sami]Yes. Over all 70% pass. But Tarik, do you want to just elaborate slightly on why the petite female group are more likely to not pass [Jaz]Because that petite female group is a large percentage of our current, you know, healthcare professionals, my wife included who failed the test. [Tarik]So there are many reasons, Jaz, first of all, respirators are traditionally the respirators essentially that we’re using our industrial products. And we know in industry, it’s mainly men, larger sizes, that’s number one. Number two, we are in a pandemic, where there is shortage of PPEs, shortage of variety of RPEs, ideally, a fit tester should arrive somewhere with a variety of RPEs different sizes, different shapes, and then they see the most suitable, the same as somebody where if you were buying a pair of jeans, you would go to somewhere, they will have all the different sizes, they would have all the different styles. And based on your shape, your size, what you were wanting to do with it, you may get with a stretchy one, you may go with a different color one, and you end up with a best pair of pants that you want to do for that job that you’re doing. [Jaz]The supply is limited, the variety is probably limited during this time. Kareem, you raise your hand, please. What are your experience has been? [Kareem]Yeah, effectively. Really, the problem with RPEs as Tarik highlighted, they’re all designed for white men. And so if you’re not a white man, your chances of passing a fit test are diminished. The studies have shown that up to across all backgrounds around a fifth of of people do not pass the Fit Test. Now, of course, the demographics in the UK. And the demographics in dental practices may be slightly different to the general population demographics, of course, and so the chances of you not successfully passing a fit test might be affected by that as well. [Jaz]So then, logically, the next thing want to check then is this significant percentage of the population who may be due to the lack of variety available at the moment, and their facial features will not pass these fit tests, what are we gonna do? Let’s say the government said, or the powers that be that say that we can go back to work on the Fourth of July just made up a random date. What are we going to do? [Sami]We need to I mean, that’s the whole point of fit testing. I mean, what we aim to do, as fit testers is seek a answer to what the effect of the mask that the dentist is holding. Is that functional or not? But what we aim to do is also test them on a variety. So if they fail on one mask, then there’ll be other masks to test them on. [Jaz] Hopefully. [Sami] Oh, hopefully, yes, hopefully. I mean, as the chaps just said, is that traditionally this mask has been designed for the firemen and the construction worker. And one may hope that the industry might change to make masks for the medical and the dental profession. And I’d expect exactly that to happen. But notwithstanding that there will still be masks that dentists will fit. So if the first one that they’re holding ends up being the one that doesn’t fit them, then we can access alternatives for them, test them on it, and one would hope and the second, third or fourth attempts of a different mask, we find one that does fit them. Once we do, then that’s the one that we tell them, this is the one that fits you. So that’s the one that they need to go and look for and buy. [Tarik]The reason why there is fit testing now is because mainly we are dealing with what’s available to us. And we are in a middle of a peak of a pandemic. Yeah. So we don’t know what will be normal routine dentistry, and we may not need respiratory protection. That’s the first thing. Yeah. And I hope that we don’t, because it’s not the most practical. And to be honest, I used to love how I used to practice dentistry. And at the moment, I don’t love it as much. But at certain aspects of it, falling in love the slowness of it, the flow of it. But I’m not a big fan of having something bulky in front of my face and for my patient. Last week, a 10 year old child having to see me with that respirator on. That’s number one. Number two, we don’t know there’s a lack of evidence or there’s no evidence on aerosols and risk of transmission, so we don’t know. So there may be the fact that we will get more evidence there is maybe we will get different respirators that will come onto the market. And maybe we don’t need them. Also, don’t forget that we were taught in respirator terms on respiratory protection, there are two classes of respirators, there are close fitting respirators, and there are loose fitting respirators. Loose fitting respirators don’t need to be fit tested. And they are adequate and suitable for any shape, any size. Again, they’re not the most, they’re designed mainly in for industrial applications. But [Jaz] Can you name some examples? [Tarik] So there is the one that has been developed in Southampton University, I believe. And it’s Persil, which is an alternate system which can be perhaps adapted and perhaps developed further. There’s also a MaxAir, which I believe Kareem has some experience with. And perhaps Kareem can tell us more about it. [Kareem]Of course I experienced with the MaxAir. And these are effectively powered air purifying respirators. So these the PAPR is Powered Air Purifying Respirators are effectively a hood that you will have seen people wearing before. And what they have is they’ve got a pump. And that pump effectively produces positive pressure within your compartment where you’re breathing within your head. And then that positive pressure effectively forces air out course the pump, and the fan has a filter on it. Okay, so it’s a highly efficient filter usually, and you don’t have any tight fitting mask on your face. But you’re effectively within this hood. There’s various types of powered air purifying respirators, of course. And Tarik has named a couple and they’ve got different designs, some of them have the pump that sits on top of your head, some of them have a tube and the pump sits on your head disconnected, but the principle remains the same as you’re in a positive pressure chamber. Your head is in a positive pressure chamber that has a filter to prevent viral particles entering [Sami]What’s it like walking around with it. [Kareem]Which one? The Oh the PAPRs? [Sami] Yeah. [Kareem] So it really depends on the PAPR, right? Like some of them are really, really super industrial, super bulky, and have space inside. Of course, what you notice is that sound is a little bit more muffled. Communication is more difficult. You can’t get close to things because you know you’ve got this distance between you and and the respirator itself so it can be challenging. To be honest with you, there’s the ones that have, that sit on top of the head. They have advantages because they use a disposable visor. Okay, so the hood itself is disposable, but the pump is not and the pumps, it’s inside that disposable hood, and you do have a buzz that’s sat on top of your head a little bit of a hum that’s constantly there, but you get used to it after a while. But listen, end of the day, it’s nothing is as comfortable as having nothing on your face or your head. Right? You ideally don’t want to wear a mask, you ideally don’t want to wear a hood, but you’ve got to protect yourselves and and if you can’t fit a mask, then you’ve got a try hood. [Jaz]Well, I’m glad you answer that. So yeah, if the mask is no good and tried a few then maybe the next step will be a hood. But until I guess we know what the standard operating procedures will be that we really don’t know which direction there’s going to head in. So I We respect that none of us know the answer to that. But one thing we do know is that Irish guidance was released and they’re advocating FFP2. Now this FFP2 need to be fit tested. And I also want to know, what if the, the ability to for the fit testers and I believe there’s a limited number of fit testing kits as well to these many bottlenecks in the system that may prevent everyone getting access to fit testing, and then maybe we’ll further delay who can get to work. So please, can you talk about that? [Tarik]So if I can take your first question first of all, when we do our teaching, we, the first principle is a surgical mask is a surgical mask, it’s a barrier protection, that offers some filtration, which is not standardized, whereas a respirator is a filtering device that also offers some protection, but most of the time, that’s not fluid resistant. So FFP2 is a FFP stands for a filtering facepiece. Yep, with P1 capability, P2 capability, P3 capability. So essentially, an FFP2 is a filtering device. Yeah. And any filtering device, any respirator requires a seal for it to optimally perform. Yeah, because it’s a respirator, you want it to filter, you don’t want air to escape in from the sides, you wanted to have a seal. The only standardized way and recognized way to test that seal on a person’s face is through a fit test, which couldn’t be qualitative or quantitative. So if a an employer or a wearer wants to know the performance of that filtering facepiece, regardless of its being FFP1, FFP2, FFP3, they do a fit test, if they pass a fit test, that tells them that there is a fit factor of at least 100, which means that if there is 100 aerosols outside, there is less, there’s one aerosol will get one particle, various 100 particles outside one particle will get in. And that’s a, what we call a fixed factor of 100. [Jaz]Can I just saidyou understand that point that even though you get a positive fit test, and you’re happy with a brand, and then the Fit Test to say goodbye, and everyone continues. If you just on one day, changes position slightly, you don’t put it on properly, then that may again be ineffective, right? [Tarik]Yes [Sami]Part of the program. And part of the products that we do is people will say to us, oh, come and fit test us, we can kind of do the fit testing. But that’s not half of it, we need to train you on how to wear it and how to don it and how to doff it, how to put it on safely, and how to take it off safely. And how to take care of it with the reusable ones, how to inspect it, how to clean it. So you’re quite right, if the wearer hasn’t had adequate training, in how to use it, it could be ineffective. [Kareem]I think it was one way that I like to compare it to is driving, right? So getting your fit test done. And, you know, passing the Fit Test for a certain mask is like getting a license for that vehicle. Okay? For that type of vehicle, it means that you can drive that car, so you get an automatic license, it means you can drive an automatic car, great. But having that license doesn’t mean that you know how to drive and it doesn’t mean that you’re going to be driving safety, you still have to adhere to the principles of safe driving. So if you get that license, that’s the same as passing your Fit Test. But if you drive with your window, with the door open, with no seat belt above the speed limit, then the driving license is effectively meaningless. It’s a package right? It’s about training and implementing safe practice, which includes part of that safe practice includes getting that license or passing that fit test. [Sami]So Kareem I think that’s a really important message that you just said, because I’m getting the impression that people just want to be fitted and say, Oh, can you come over? Measure me up? Tell me which mask is aware so that I can get on, I can book a patient in next week. And it’s actually so not like that. What’s just as important as you selecting a mask to fit your face is actually you knowing how to use it. And so, I would, I just, I want to express to colleagues to take with severe caution. Any form of Fit testing that they may be looking for, which is just a better come and measure me up and certainly out. It’s just so not like that. [Jaz]So thanks so much, gentlemen, my question I have for you now is, until the standard operating procedures are released for England and certainly UK, obviously Irish guidelines have been released. Your advices, for example, I’m a private dentist, should I be rushing out to get fit tested? Is there any reason I should be now? Or should I get try and get ahead of the curve? What’s your current advice to a dentist in my situation? [Sami]Can I answer that from the ethics point of view? So although we are being providing fit testing and we are responsive to people’s requests, I think there is a an ethical angle to this, in that PPE is limited as you’re seeing in the media. And I would think it’s particularly, a little bit particularly unethical if dentists who are currently shut down in effect by the CDO are getting fit tested and stocking up their respirators to sit in a cupboard inside a closed dental practice. But saying that, I’m also aware that we need to get ourselves prepared. So I think when it looks eminence that we’re going to be opening up, then gradually, we as a professional, as a team, should be preparing ourselves. Let’s start with our take, to take away from the frontline who are, of course, a very valid point anyone in need. [Tarik]On a technical point, most PPE that I see or RPE that I see available on the marketplace. Or when we go to UDC, whereas to so at the moment, we have official supply that has gone been procured through NHS England, and Public Health England to the end of the session, once we’ve empowered them with all the information, there is some supply that came not from that official supply and they don’t perform in the same way. So most of what’s available now in the marketplace, especially KN95. Other nasty emarkets, there is fake respirators, there are earloop designs, the ones that are not basically used on the front line, they don’t perform as well. So fit testing should be done on a RPE that you know that is likely to fit you. It’s on an RPE that it’s likely that you will get more of it in the future. And an RPE that you’re not taking away from an operational site because there is shortage of supply, we’re likely to be in phase returned to dentistry, I don’t think it’s going to be chaotic returned to dentistry. There are so many other ways that we know that we can prepare ourselves. I wouldn’t though ignore the topic and not engaged, I would engage with a testing team, I would engage and raise awareness on respiratory protection as a whole. Because knowledge is you know, it’s never, you can never waste getting more knowledge. But buying unofficial PPE from unofficial sources, and buying it in bulk without engaging a fit testing team, I think is definitely the wrong approach. Having a sample of some RPE that are likely to be available later on aan engaging a fit testing team that will empower you with knowledge and how to do it properly. I think is the right way forward, personally. And that might change next week, if the guidance change if the supply chain changes, if what we’re being asked to do s different from our experience, returning to work should be a coordinated, professional step. Shouldn’t be done on an individual basis. There are communities of practice, you have a network of colleagues around you and doing it as part of a coordinated approach with your local professional network, I think is the right way forward. No matter what what that step is. And no matter what the preparation is. I think if this time taught us anything, we need to come closer as a profession. We need to come closer as different professions and different workforce and help each other out in a time of need. But Also we should carry it on and use expertise in different sectors and help each other out. [Jaz]Brilliant. So, gents, next question I have is sent in by one of the listeners who I encouraged to, you know, send any questions we have for the group today. And when I borrow your knowledge here, is with the antibody test being more widely available now. And certainly I’ve been looking online, I’m very keen to get one ASAP. So that hopefully I won’t have to wear a hood , it’s my thinking. Now, can I go back like how it used to be? Can I go commando if I’m antibody positive? [Kareem]Yeah, I mean, firstly, I don’t like the idea of going commando, ever anyways. But there’s two points here, I think firstly, is you’ve got to make sure that the kit that you’re using to test yourself is validated, right? Because there’s lots of kits that are out there that you can buy. But one of the reasons why it’s taken so long for the government to approve something is because the validation processes are quite rigorous. And if you’re using something that’s not validated, then you may get a result which either will be also reassuring, or falsely concerning that may not be accurate. So that’s the first thing. So the second point is, we’re still learning so much about this disease right now. Okay? Sohaving antibodies to SARS COVID2, doesn’t, firstly, you can have asymptomatic zero converters. Okay? So there’s a large population of people that some studies have now suggested up to 44% of healthcare workers are asymptomatic zero converters, which means that you’ve got the antibodies without having declared any symptoms. But having the antibody does not necessarily mean you will have lifelong immunity. We do not know how long the antibodies will last, we do not know how the virus will adapt and change. So at the moment, I don’t think that it’s a wise idea for us to say, you know, I’m all good, I’ve had it, I’m immune, it’s done. We still don’t know. And I work very, very closely with our virology and infectious diseases department. And we’ve done several studies, and we’re working on lots of studies on at the moment, and certainly, directly from them, they categorically say, you cannot assume that if you’ve got the antibodies that you’re going to be in the clear, I’ll give you an example, we intubate patients with COVID, all the time, and about a 10th of clinicians who are involved in intubation patients have gotten COVID. Okay? I have several colleagues who have had COVID, swab confirmed COVID. And despite that, when they returned to work, there were in full RPE and PPE. So I think that it would be playing with fire if you think that having the antibodies on a test means that you’re immune forever, because we really don’t know enough yet. [Jaz]Okay, fine. I think that’s an answer categorically that No, you shouldn’t go commando. So if your antibody positive until the research is out there to suggest otherwise that we should still go with whatever the SOPs will be once they come out. That’s a fair summary. [Kareem]Yeah. And we need to be we need to be guided by the evidence. And the evidence is still it’s way too early for us to draw any definitive conclusions on anything and to take any risks. So until we have definitive evidence, let’s play safe. And let’s do the right thing. [Jaz]As talking as someone with a beard, I’m sure obviously, you know, the issues well. You’ve been subjected to many people you’ve tested, or you’ve probably declined to test, if someone’s got a beard, you’re probably not going to test them, you can have that conversation about shaving. Now putting religion even inside because I know I’m a Sikh today, but my listeners are not all Sikh. So let’s talk about the hoods, because that is one way to get around the beard. Or the fact that let’s imagine any type of mask facial mask does not fit you, for example. And therefore we’re now looking at a hood. But for those people who have been tested some hoods and I’ve got some colleagues who are testing some hoods, they find it that the type of and Doctor Sami, you know, being a periodontist, the type of fine work that we used to do perio plastic work, resin work, things that need good vision and clarity may not be as easy to do and it’s very cumbersome, like we said about the weight as well. The fact that you may have to use a saddle chair and a normal chair with a backrest will not be able to use that. So there’s lots of issues. I’m personally really looking for any solution that will not involve a hood. So I don’t really know I didn’t really finish with a question there. But what I mean to say is, hopefully we’re not going to need to all use hoods, but what advice can you give to those who may need to use the hood and how to do good quality dentistry is even possible? [Sami]So I think we’re going to have to readapt in many respects, and I think the clinical environment itself needs to be adjusted for the new era that we are now in. I agree with you, for those that are wearing a beard. If the respirators are clearly are not an option for them. So it has to be in the hood. So then you can work backwards from how you’re going to adjust the surroundings to the hood, much more space around the dental chair. I think you see, when I’m operating as an oral surgeon, I stand up. When I’m operating as a periodontist, I sit down. You make a very good point about the chair, I’m in the chair with the back on it, may be something that he might not be able to use anymore. So you think about using the saddle or standing up. The house was mentioned earlier that hood is this there’s an element of distance created. And that distance is a physical distance. And it’s also a psychological distance. We can’t communicate with our patients as well, that badly affects the elements of empathy that we can provide to our patients as we give them a more holistic chairside manner to our approach. And, you know, these are all things that we’re going to have to change the loupes is an issue of the moment and I know that as the leading suppliers in microscopes or loupes are looking at ways to adapt into the to the new needs [Jaz]And even the scopes are difficult. So I tend to doubt but even the microscope, my colleagues who are testing all this sort of stuff, hoods mostly You know, we’ve got a group of of Sikh people with beards and turbans who are trying to preempt a solution that will allow us to do good dentistry, but also be protected. And there’s a firm that loupes are difficult and microscopes are also finding difficult. Yes, Tarik? [Tarik]Jaz, we are testing now and working now with industrial products that are designed for industrial applications and trying to adapt them to the healthcare workplace. The marketplace is dictated by demand and need. So already we are as a group working with a couple of respirator manufacturers to evolve and develop some solutions. And that’s been driven by the demand. So if it is going to be, as you say, are likely SOP, and it’s going to be needed within the healthcare industry. Rest assured there will be developments, by dentists, for dentists, by healthcare providers, for healthcare providers. We are innovators we are we have a lot of creativity within our professional industry. And rest assured that there will be some new designs that everyone will be protected, if need be through a respirator, they will have the right solution for them. And most likely it will be developed by a dentist, or at least the development will be, there is contribution by a dental professional within that or a healthcare professional at least. [Jaz]Fine, but it’s just a lot of concern people thinking about, you know, we know that dentistry will never be the same again, but even to do the types of procedures we used to do for some period of time. We don’t know how long but for some period of time, we may be limited to doing extractions and very basic stuff. What I’m trying to say is that the techniques and the treatments that involve finesse may be difficult to do so early on until as you say, Tarik market responds and comes up with some RPE equipment that makes it conducive to excellent dentistry. [Sami]We also adapt in our techniques, though, Jaz I mean, you know, as time has gone on, in dentistry, even equipment has changed. And, you know, we ended up trying out new things, learning new techniques, and I think we’ll be forced, if you’d like to do that in this era as well. We have to come together and accept that what we’ve always been doing all along is has to be ready to be re adapted. It’s very difficult for a golfer to change a swing. But we are going to have to learn new techniques. And you know, you’re quite right to mention, you know, a particular group says the Sikhs and Muslims and Jews have a problem with the beards. But it’s you know, previously we’ve had concerns where women wearing Hijab and long sleeves haven’t been able to scrub up in [inaudible], some innovative research response to this, have a thinking outside the box to accommodate their own wishes, but also an element of just being a little bit more fluid to the approach of saying that maybe I will have to just change the way I stand, maybe I will have to change the way I look into the patient’s mouth, maybe there will be different lighting systems, we will have to we have to think about this together. [Tarik]We’re living in an era where digital scanning and custom made devices are more readily available. So creating a seal around the face, there may be other ways of achieving it. And all you need is, for a close fitting so there are two developments that need to happen. Ways of achieving a seal around the face and working around the restrictions of a person to make it personalizable. And maybe a loose fitting solution, where it is more, it’s conducive for the fine work and the what we need as healthcare providers. [Jaz]Thank you. I’ve been speaking to some people who’ve been trained to do fit testing up north in New York Region. And they’re covering a huge area. I mean, they’re covering from, let’s say, Yorkshire, Sheffield, all the way up to Newcastle. And they’re driving in between these areas. So with the lack of let’s say, fit testers to fit test, let’s say minimum 60,000 people that’s like 30,000 are dentists and there’s far more than 30,000 nurses. Let’s assume a conservative figure of 60,000, looking to come back to work. And I appreciate that you think there’ll be a phase returned to work. But certainly I think there’ll be some bottlenecks in being able to get fit tested. And let’s say one brand of mask runs out. And then suddenly, we need to get fit tested again for another brand says there’s lots of issues. And I don’t want to get too much into the intricacies of all this. But people will try and get around it and get to work as fast as possible. So this all this preamble is basically, one of my listeners, who really wants to crack on as you know, as we all do, as quickly as possible, asked, Is it possible to or advisable to wear FFP2 that you may not have had an opportunity to get fit tested? Because they’re thinking pragmatically that it might be difficult to. And then on top of that were a face shield, do you think that will give an adequate level of protection, is the question from the listener? [Sami]Well, I mean, it depends what the personal definition of adequate is. I think we’re all in it together that we want to minimize risk. Of course, a one bit of protection is more or less compared to another bit of protection. Our job here or what where we see our role is to help educate the individual to make their own risk assessments. Indeed, there have been those that advocate not fit testing and FFP2. I’ve seen it. And I think it’s a personal choice. I mean, if somebody wants to know if whatever they’re wearing on their face, be a kitchen towel is it allowing some virus to go down the side. If you want to know the answer, then you need a fit test, except that maybe we might be taking more risks to start with, because of the bottleneck. But the mindset to think that Let’s relax our safety measures is something that I wouldn’t advocate. [Jaz]Thank you and Kareem, I think I believe you with your vast experience of being on the end of wearing all these PPEs RPEs, Is there anything that you’d like to add to that? [Kareem]Yeah. Firstly, I also I just want to give just a slightly different perspective on FFP2 and FFP 3, where people are thinking that FFP2 means you know, you can be a little bit more loose with applying it. What people need to bear in mind is that in North America, for example, But they don’t use FFP3s. Okay, so the standard there is FFP2 or N95. That’s their standard. So, forget the thinking that FFP2 is different FFP3, it’s just about the viral filtration efficiency, that’s sort of, that’s the only difference. It still needs to be on to use a respirator to protect yourself from a potential viral exposure, it must be fit tested, if you want to take some potential risks, as we talked about already, okay? So at least a fifth in published studies, and, and third in our data from the people that we fot tested, between 20 to 30% of people, they do not have an adequate protection, if they have not been fit tested. Okay? So it’s up to you to decide if you’re prepared to take that risk. I know, I probably wouldn’t take that risk. Okay. But if you’re prepared to take that risk of not being protected from exposure, potentially, from a patient with COVID, or I should say, at least carrying SARS COVID2, then that’s up to you, but I would be guided by the evidence and by the data, and the evidence currently suggests that’s not a wise idea. [Tarik]Okay, can I turn, I take a third perspective if that’s okay? [Jaz]Yeah, please, this was all about [Tarik]Let’s understand the principle. Right? You don’t have to wear [inaudible], it’s not illegal to practice without respiratory protection. It’s not illegal not to do a fit test. Fit Test is a method to show you what CM you have from the respirator if you’ve made the choice to use one. If you use a respirator, you probably are more protected than using just a surgical mask if there is aerosol with particles, if that particles carries a viable virus, we don’t know the risks. We don’t know what’s in those particles. And we don’t know what’s the consequences of being fit tested or not. All the principles are is or the principle is, if you’re choosing to use a respirator, which means you’re choosing to protect yourself from the particles around you. If you’re one to do that, to the optimum way, a fit test is the way to demonstrate [Jaz]The next question I have is I’ve heard reports that in the urgent dental care centers, that because of the lack of a PPE in some centers, dentists are being encouraged to wear one FFP3 masks or whatever they using per session. So a morning and an afternoon, and then between patients changing the surgical mask that will go over the FFP3. That may be a pragmatic and practical solution in a moment. Is that something that you think can work for practice that may want to be saving money in the future? Because if the if that’s the current standard of play, can we not continue it like that? Is anything bad about doing that? [Tarik]If I can highlight a few issues, we’re in unprecedented times, and we’re dealing with a large a large problem of not being having the constant supply, and we’re having to deal with that and care for our patients. They need urgent care. So they need urgent care. We’re on a high peak pandemic with no limited supply at the moment. The Public Health England and maybe that’s I may be incorrect but my interpretation is a respirator should be used for single use in primary care settings. In secondary care settings, if there is a shortage, then it may be and it’s an appropriate setting, then it may be used as a sessional use. I haven’t seen any official document to say that you can use a surgical mask on top from a Public Health England point of view. It is thinking outside the box and it is extending the use of it and I believe that the latest guidance from BAOMS, the British Journal of Oral and Maxillofacial Surgery, advocates that. The problem that we have is the FFP3 is currently in supply are not fluid resistant, and we don’t have many of them. So adding a surgical mask on top offers you that extension, but we also use a face shield on top which offers some protection. Respirators should not be modified in any way. Because the whole point of having a fit test and checking with the respirator is that you wear it correctly consistently every time like you said earlier Right? So if putting a surgical mask does that, does that affect the threat? Or not? I don’t know. does it increase the chance of you when you’re removing the surgical mask for it to dislodge the respirator and break the seal? I don’t know. Does it offer any protection for fluid? On top of having a face shield on top? I don’t know. Does it offer some filtration for the FFP3 masks that have an exit valve and potentially the wearer maybe an asymptomatic carrier, and working with a vulnerable patient or a shielded person and coughs during, does that surgical mask offer some filtration or not? I don’t know. The ideal gold standard going forward would be to have a disposable FFP3, that is fluid resistant. That is not valved. And that is cheap and widely available on the same model that you can get every day with adjustable straps that comes in different sizes, then we would have solved the problem in dentistry and healthcare and manufactured in the UK. And comfort. Yes, and manufactured in the UK. And conforms to the quality standards of the British Standards of 149 or whatever standard. So if we have a UK made solution that passes a test that is cheap for us to use per patient, per procedure that’s easy for us to wear, comfortable for us to wear that we can adjust the straps, that comes in small, medium and large. That is fluid resistant, then I would buy that and wear that. And probably I’ll be, whether I wear and I need it or not. I probably now choose to wear it if it is readily available and economically makes sense to me. [Jaz]Should we be switching to reusable PPE? So some of the masks that looks like one of the main ones, I believe that’s what they tend to look like. Is that something that we should be thinking about instead of having to constantly worry about supply demands and whatnot, Kareem, I believe you may be well positioned to talk about that. [Kareem]Yeah, I mean, listen, there’s obvious advantages. There’s obvious disadvantages as well. But there’s obviously advantages to having a reusable one, actually, in the long run, it’s more cost effective. So if you’re thinking of one of the reusables, it costs anywhere between 30 and 50 pounds, without having to replace the filter, of course, because there’s an additional cost of having to replace the filter intermittently. And if you compare that cost to a single disposable FFP3 masks that we commonly use in the NHS, they’re in the range of five to seven pounds. So immediately, you can see that there is a cost benefit there. Okay?o there’s a cost benefit number two, because it’s reusable, you do not risk running out of supplies and needed to be fit tested in the next type of RPE that your employer provides you, okay? So you’ve got it, you fit test on it, you know it works, you use it thereafter, okay? And number three, it’s you can keep it for one individual or it can be shared amongst individuals if it’s clean. So for us and certainly with what I do, we have reusable RPEs, that I keep my own one, I have my own one that I’ve been fit tested on that I look after, that I care for, that I check the filter on regularly. I have an idea. I’m not worried that I’m going to run out of supplies, I’m not worried that I’m going to need to be refit tested again. So there’s obvious benefits to them. There’s some drawbacks, of course. The drawbacks are, they’re bulky, they’re large, they need to be cleaned. And of course, you must remember that the whole process of doffing these is a much more challenging process than doffing a disposable because a disposable, you carefully take it off your face with your eyes closed and drop it into the bin. But with these, you’ve got to be very, very careful because you’re not dropping it into the bin, you’re going to be grabbing it there’s two straps that need to be pulled out. You’re going to be grabbing it and then you need to be cleaning it. The cleaning process itself poses potential theoretical risks. There’s no data to support this, but it’s all theoretical risks that you may be dispersing any virus that’s on the RPE itself. So you’ve got to clean it. And what we do is we clean ours. I clean mine myself, just because my my own peace of mind once a day by disassembling it and cleaning it properly as per manufacturer’s instructions, different manufacturers have different instructions, and you’ve really got to adhere to those instructions. So there’s pros and cons of using reusable versus single use, to my mind, having the, you know, the benefits of having the reusable, for me, personally, at least, outweigh the risks and the end of the drawbacks of the bulkiness and the cleaning. [Jaz]Sami and Tarik, as dentists, Do you think reusable is the way forward? [Sami]Well, I think that all that Kareem just elaborated on is equally applicable to us. The one thing I would add about the bulkiness is this thing is like stuck to your face. And dentists in particular. We’re working a good What is it 6, 7, 8 hours a day at least with this thing stuck to our face, I don’t know how many patients we’re going to be seeing in the post COVID area compared to how many patients we used to schedule in our dairies before. But that in itself is going to be a challenge and they’ll undoubtedly be you know, facial markings, marks on your face after you don it could possibly cause scarring I don’t know. It’s something that we’re going to have to consider when we’re selecting which type of protection that we’re going to use and, and in dentistry also, certainly, for oral surgery, for example, I sometimes hear patients every 20 minutes for goodness sake, but I don’t think I’m going to do that again. But incorporating in that schedule now is the donning and doffing and the inspection and cleaning. So it’s so many factors now to put into the melting pot that we previously didn’t consider. [Tarik]I have access to both. And I’m fortunate to have access to both. Certain procedures, I would wear the reusable respirator, certain scenarios, I will use the disposable. For example, yesterday I had an anxious that lady that needed an impacted third molar removed, so it’s likely to be an AGP. And I chose to put a disposable one. Because I didn’t want to add another fear factor. It is probably the way forward. And as a fit tester, a variety of sizes, for a variety of scenarios is probably the way forward, both all clothes fitting respirators are designed for a short period of time. And the Health Safety Executive expects a wearer to wear it comfortably for less than an hour. So after an hour, you’re probably more likely touch it, you’re more likely adjust it. So they’re not designed for extended use both of them. And as part of our fit testing. The first thing we check, can you put it correctly consistently yourself? Yes. Can you comfortably wear it? and work with it? Yes. And then we did a fit test. And we’ve had people that put on our disposable and think No, this is too much for me. We’ve had people that stay on the whole training session with one. We’ve had people try on the reusable and say, yeah, that’s fine. I don’t see any problem with this. I actually do this when I do my DIY work, or DIY, DIY work at home and I’m used to it, and some people put it on and say no, I’m never gonna wear this. I hate the look of this. That’s not for me. And we have to be prepared for that. And respirator is a way of controlling the hazard. There are other ways of controlling the hazard. There is, dare I say not doing AGPs, dare I say controlling the hazard in another way. And don’t forget that respirator is the last resort in the [puzzle]. So all other things that we do is the right thing to do. Respirators should be considered as the last resort in protection, controlling the hazard. [Jaz]Sami with your ethics. background, I want to ask you who should be paying for this? Private practice, who should pay for let’s say all these FFP3s because I’m increasingly seeing some principals, trying to plan the future charge of this to make the associates buy their own PPE. Where do you see this? [Sami]I might have a law and ethics education that’s certainly far bit for me to give an opinion on how people should be running their own businesses, but I’m a principal as well. So I understand the issues here. I mean, it’s a minefield, I think the law states that employers need to be providing a safe working environment for their employees. And sadly, in this new era, that means providing them safe air to breathe. That’s a really, really sobering thought. But then equally, you know, principals haven’t traditionally provided loupes for dentists, they haven’t. Some provide them with uniforms, some don’t. It’s something that’s going to have to be an internal decision. [Jaz]Your opinion? [Sami]I haven’t even answered that question for myself and my own staff yet, it’s going to be a really tough one, [Tarik]No matter who pays for it, we need to make sure that we’re protected. And we have the right equipment that is, if it is a respirator, then ideally should be fit tested. And we need to and then if the dentist pays for it, then does the nurse pay for it? And if they pay for it themselves, do you quality assurance? Do you make sure that it’s working? Do you make sure that’s fit tested? So quality is I think what’s important. Paying for it, And who pays for it is obviously an important question as well. But for me the quality and the safety of everyone involved And I’m sure we will have a professional guidance on this from the people that are experts in this. [Jaz]Okay, fine. So gentlemen, the final question I have is, with us potentially Fingers crossed, hopefully getting back to work. And the inevitable increased demand for Fit Test is because based on what you’re saying, it sounds like for your safety, for the safety of our staff, it’s really important because we don’t know exactly what we’re dealing with just yet we need more research. So for the time being, I think that what I’m sensing is that it’s something that we should be getting done proactively once the decision is made about SOPs. So, should there be more people getting trained for fit testing, was it involved? And just give us a flavor about that? [Tarik]So I think yes, knowledge is key. We need, if we need fit testers, we need professional fiy testers, not industry fit tester. Training in becoming a fit tester, there are two methods qualitative or quantitative. It is both a it’s a skill, it’s an art and it’s a science. So with that, any skill, art and science need just not that you can’t just grab it by reading a book, you can’t grab it by just watching a video, you need to be trained, educated, you need to practice that skill, you need to have it observed, you need to reflect on your performance and be supervised to gain that competency in a safe manner. And that’s what we’ve been doing thus far. Not just training, but reflecting, supervising, mentoring, and ensuring that the competency is gained safely whoever provides a fit testing, it’s a legal requirement for them to be competent in doing so. There is a British safety. There is a accreditation scheme and being accredited as a fit tester is that gold standard of fit testing, but that’s for industry. In healthcare, we need well trained professionals that are able to do it within our context, understand our environment, understand what is needed, and I think we are as dental professionals, not just dentist but all of the dental professionals are ideally suited to be our own fit testers if we need it in the future. [Jaz]Brilliant. Sami, did you want to? [Sami]I would sort of agree with that so much in that you know and the time gone by firemen and construction workers have had to receive an element of training and the level of fit testing that’s appropriate to their environment, and the world and healthcare has just changed overnight now. So whilst a great majority of what they have overlaps into our environment, there’s a substantial amount that doesn’t, and therefore what is missed by generic training, I think targeted and focused training that is relevant specifically to our professional and we’ve just talked about. So when we were talking about sitting in the chair or a saddle, we’ve talked about the loupes, we’ve talked about the empathy of chairside and communication with the patient, when you’re appearing differently than when you did in the last appointment, but then six months ago, these are all things that the construction workers haven’t needed to address in their field of work. So model has brought all that into one basket, in order to make it more focused and relevant. [Jaz]Kareem any anything you’d like to add? [Kareem]Can I add, I wanted to add something Jaz, if I may. There are some personality traits that suit or qualities of a person suited to become a fit tester, you need to be pay attention to detail, you need to be conscientious, you need to give confidence to the person that you’re fit testing. And you need to not just want to tick the box. I have attended about six training courses, all of them accredited, and I’ve had different experiences. We all know training can be different and can be, the same content can be given by different people but the result can be different. Also, we know that six people can attend the course and their competency after the course can be different. So not everybody that is trained to be attend the course, to become a fit tester is a good fit tester. At the end of it, you need to have a process to ensure that the person at the end of that training journey is competent. [Jaz]So gentleman, What’s the difference between a fit test and a fit check. [Kareem]So a fit test is, as we discussed earlier, an employer’s responsibility. And it’s a way of assessing the performance of a respirator. And whether it’s adapt, does it conform, or create a seal with that person’s facial features that lasts for two years and it’s only for that particular model of respirator. And it’s not valid if the person loses weight, or gain weight, or anything that affects the scene area, including significant dental work, that makes it invalid. A fit check is the responsibility of the wearer. And that’s something that they should do every time they don the respirator. And it gives them confidence that they’ve don it correctly consistently. And they’re trained to do it for each type of respirator, it’s a different technique. [Jaz]So everyone who gets fit tested and starts wearing and FFP2and FFP3 for example, needs also to everyone needs to be a fit checker, a proficient fit checker? [Kareem]Yes. [Tarik]Part of the training part of the your fit testing is to be trained to fit check. So that’s why that’s one of the reasons why fit testing is so important. Because it teaches you to fit check, there are some people that think that I can fit check without having fit testing. So a fit check is effectively you put the mask on, you suck in, and if it sucks in effectively, and if it feels like there’s a seal, then then you should have confidence in that. But that’s, to my mind, that’s probably insufficient. Because you need to have quantitative, not just qualitative, but quantitative and objective measures to demonstrate that, that you have an effective seal whereas fit checking is purely subjective. And it carries significant user error. [Sami]So we were setting the standards, I hope, in dentistry, fit testing, should be the required risk management strategy. But it’s not the case in hospitals? Kareem? [Kareem]Well, I think that there has been some some institutions across the UK who have effectively said that you should that fit checking is sufficient. And that probably comes down to the fact that there’s probably too many clinicians or health care workers that need fit testing, but they do not have the capacity to fit test everyone and so therefore they’ve made pragmatic decisions to meet healthcare demand. People should just fit to test- fit check, sorry. And I think that if you have, if you’re taking responsibility for your own health and well being, then I don’t think personally that that would suffice. And I would encourage employers to really consider the, you know, doing what’s best for their employees as well [Sami]We’re quite fortunate, I think, in primary care dentistry, that we do have much more of a level of autonomy to make our own decisions in this regard. So it’s not going to be as sort of victims of a departmental policy of a large organization or in dental practices can make their own risk analysis in this regard. [Jaz]Brilliant. And can I just get some rough dates? Sammy, when do you think I’ll be able to do some composites again? [Sami]Well, the last time I did a composite was about 25 years ago. And I certainly hope I’m not going to be doing one anytime soon. But let’s look, let’s be positive about this. Let’s be positive about this, I know there’s lots of politics involved. And I know, there’s questions as to which advice we should be following. As Tarik has alluded to, I think it’s going to be a phased re entry back into the profession. And I think we’ll probably be doing more of non AGP procedures to start with. I’m not going to put a label on anything. I would hope, I would hope that we’re practicing dentistry in July. [Tarik]Can I add we, first of all, when it is safe for you, when it is safe for the nurse, when it is safe for the patient, when it’s safe for other patients in the practice to do so. Or also perhaps when we have the evidence that it is safe for you, for the nurse, for the patient, for other patients in the workplace for you to do so. Also, I hope or last message is for us to go back to work. We need confidence from the profession. We need guidance from the profession, we need that coordinated approach from the profession, we need the patients to have confidence in us. We need the CQC to have confidence in us and our workplaces. We need our workforce to be confident in their ability to do everything safely, that they are protected, that they’re their patients are protected, and that their loved ones are home or protected. I have resistance from my loved one saying no, don’t go to work. Because with all this fear around, I don’t want you to bring it home. How would you feel if I felt ill? So I think two ways. One, we should already be working out we should be preventing disease, we should be reaching out to our patients, we should be engaging with them. And we should be helping the national response and taking the burden out of the 111 triage. I know I spoke to a GDB this morning. And that was taking calls, despite his normal hours not being open on a Saturday just to take that burden off 111. So that little, the as much effort that we all do as a profession, the quicker we will get to normal, whatever what that normal might be. [Jaz]Well, I’m here is hoping that it will be ASAP. Gentlemen, it’s been great to have you on the podcast today. Lots of facts. So much needed, because there’s lots of speculation going on. Thank you for all the hard work that you guys doing behind the scenes, and of course on the front line as well, really on behalf of the nation. Thank you guys. [Sami]You’re welcome, Jaz, thank you very much for having us. It’s great for us to get together and chat and to be thought provoking in this way. We see ourselves as just a very, very small piece of the jigsaw puzzle. And we’re happy to help anybody that reaches out to us. I’m happy to put our email address out there, which is info@dakatra.co.uk. So that’s spelt info, I-N-F-O @dakatra, which D-A-K-A-T-R-A .co.uk. Any one that has any questions, by all means we are, our doors remain open. [Jaz]Brilliant. Well, thanks very much, Gents. [Kareem]Thank you for having us. [Sami]Thank you. [Tarik]Thank you.

Many Dentists still believe that caries in to dentine on a radiograph automatically means they need to start drilling – why might they be wrong? https://www.facebook.com/watch/?v=564343240902780 Remember that case I posted on my FB and IG page some months ago? It had SPLIT our profession down the middle as to whether you should drill those carious lesions or not. Need to Read it? Check out the Full Episode Transcript below! https://www.facebook.com/protrusive/posts/670960430338941 Well, I asked Louis McKenzie about this case, as well as about caries detections systems and WHEN we should be picking up the drill? Why should use a caries detection system (such as ICDAS)? Which is the best system? We share THAT case – the one that split the opinions of THOUSANDS of Dentists – find out what Louis would have done! Find out what I DID end up doing! What about cracks? Does that count as a ‘cavitation’ and therefore warrant restoration? We discuss a classification to describe radiographic caries. Pearl: when you place immediate resin bonded bridges, consider a split pontic technique! www.rbbmasterclass.com for the full online course – use MAY2020 before 31st May 2020 to get a discount! Click below for full episode transcript: Opening Snippet: If there's just one IGtv or YouTube episode that you watch on this podcast, in all of your existence, make it this one. This is all about to drill or not to drill, because frankly, I believe that many, many dentists all over the world on drilling caries too much, too often, and they should stop now... Jaz’s Introduction: Hi, guys I’m Jaz Gulati, I will not keep you or bore you any longer. I won’t go straight to the episode with the legend that is Louis McKenzie. The story behind this episode is that some months ago, I posted on the two main UK dentist Facebook groups as a UK Dentist and For Dentist, By Dentist and I post some photos of anterior caries. And I got around about I think 5000 dentists in total to actually view it according to stats I have, and 1500 or thereabouts engagement, so people actually clicking on several comments, and it split the nation down the middle. Half of you wanted to drill the life out of these legions, half of you want to slap on some fluoride and review it. So we’ll find out what Louis McKenzie wanted to do was because he was anti lesions, approximately the crack line there. A lot of you are itching to get your handpiece out right now while you’re watching this. But you know, it’s a fun. It’s a fascinating topic really is. So I’m really happy to have Louis on. Please join us for this full episode on to drill or not to drill. The answer is around about somewhere halfway, if you want to skip straight to that, but why would you? There’s so much useful stuff that Louis McKenzie shares with us for caries detection process, and so much more insight and into the complexity of when or when we shouldn’t be drilling into teeth. The Protrusive Dental Pearl I have for you is something that I borrowed from Louis McKenzie, and it’s on my course, the resin bonded bridge masterclass, which, by the way, on the 31st of May, is going up to $90, or after the 31st of May, before 31st of May if you use the code may2020, it’ll give you $68 off so it’s $22 only, I’m doing this a lot for charity because a lot of the money is going to charity and the rest of its fees, ads I’m doing basically it’s my way of contributing for lockeddown. And I’ve already had some great feedback people who said it’s perfect for E-learning people who have messaged me to say that it’s made RBBs very clear for them. I’m so pleased to hear it. I personally do think after spending weeks on creating this course that it is the best value CPD you will do the entire lockdown period. So if I’m wrong, I’ll give you a money back. That’s how confident I am. So please join me on the RBB masterclass The website is rbbmasterclass.com And the pearl I have for you is that sometimes if you’re doing an immediate resin bonded bridge, I’ll just show you a few slides from from the course itself. When you’re doing an immediate, you’re taking a few risks, you’re taking a few aesthetic risks, and a few technical risks, so what if your lab work doesn’t quite come back as you want it? And you’re going to be removing a tooth that day and placing the bridge there. So your lab work needs to be on point. So that communication aspect comes in. And the other aspect is the aesthetics. What if the aesthetics are not ideal, and then you’re going ahead and placing this bridge? Well to overcome the risk of the aesthetics, ie the shade match of the bridge pontic not being ideal, or the shape or morphology not being ideal for the day that you’re going to fit the immediate resin bonded bridge, you can do a split pontic. So here are some photos that Louis gave to me, to as part of my online lecture on resin bonded bridges, on the split Pontic technique. And basically what you do is you request a laboratory to make the framework as normal. And on top of the framework, there has been some composite placed as a core, and then you get a separate Pontic, ceramic Pontic that actually can bond on to the composite core. And the benefit here is that you can check the fit of the framework and obviously bond that on and then you can check whether you’re happy and the patient’s happy with the shade and aesthetics of the Pontic. Because if the patient is not happy, then all you need to do is cement the Pontic in with a temporary cement. But if you’re happy you’re going to go ahead and follow your adhesive protocol which we discussed on the course. So the split Pontic technique is really good for immediate resin bonded bridges on patients with high expectations and high smile lines. So that’s one of the pearl I’m gonna share with you today. So let’s jump straight to the episode now with Louis McKenzie all about to drill or not to drill caries, when and why? Main Interview: [Jaz] Today is not I mean, today is not about sexy composite, veneers aesthetics. This is something that needs to be more Instagram rather than that sort of stuff. Because on the social media platforms in dentistry, this is a massive, huge daily topic. [Louis]You’re right. It doesn’t lend itself to Instagram. But for me, it is a sexy subject that says probably too much about me. [Jaz]To have you within the podcast, it’s an absolute honor to have you. [Louis]Thank you, Jaz and nice to meet you as well. [Jaz]Thanks so much. I mean, it’s your first time sort of you’re virtually meeting me but I’ve been to quite a few of your lectures. And the reason I thought of you to bring you on, on this topic of of caries management in primary care, which is such a huge topic is you really had a massive influence on me in about I think was 2011 2012 BDA conference, you were at the mainstage, about 400 people, you had this massive widescreen. And it was not only a very informative educational lecture, it was very funny as well. And I really liked your teaching style. So I then came on to future courses as well. But at that lecture, the way you had managed caries, was like a paradigm shift for me, it really was. So you’d always stuck in my mind. And, you know, now and again, and I see a bitewing. And I sometimes think, what would Loius do? Honestly? 100%. So when this podcast came to be I’d already earmarked he was one of the people I really want to have on the show to talk about this. So just for the listeners out there who are small minority who don’t know who you already, just tell us about about, you know, your daily life and work and whereabouts you’re working at the moment. [Louis]Okay, so yeah, I’ve been qualified for 30 years this year, I’ve worked continuously in the same practice, which I think immediately makes you more minimally invasive anyway, because you see, all your failures come back to haunt you. And, you know, the big stuff, sometimes there’s no plan B. So yeah, I still consider myself to be a GDP but as a small part of what I do now. And so my main job is sort of teaching, undergraduate teaching at Birmingham, dental school and post grad teaching, mainly post grad courses, sort of private post grad courses, but also I do plenty of work with young graduates FDs and my sort of latest sort of roll around the MSc in restorative dentistry at a Birmingham dental school that’s just in its third year now. So I’m certainly enjoying that [Jaz]Is that with our Professor Buck? [Louis]Yep, that’s with Trevor. Yep. It’s the new course, Trevor’s run the has the longest running MSc in advanced general dental practice. And now that has been sort of evolved into an MSc in restorative dentistry, which is a two year blended learning program. Also do a bit down at Kings as well in the post grad department there with the two Banerjis, Abby Banerji, on the MI masters and Subir Banerji on the esthetics masters as well. So a real range of things, lots of different bosses to keep happy. [Jaz]Brilliant, and I’m a big fan of Dipesh Parmar, his work, his philosophy, and I believe you were his inspiration, his mentor. I mean, that’s certainly at least he credits you for that. So that speaks volumes about you as an educator I think [Louis]That’s kind of switched roles now. Because he [Jaz]has become the master. [Louis]Jedi. So he’s [Jaz] You must be really proud. [Louis] Oh, extremely. Yeah, absolutely. I mean, right, from the word go, I think over the years, one thing I think I have become pretty good at is actually spotting talent. And right from the word go, there’s just something different about Dipesh, you just got this natural eye for stuff. And, yeah, it’s been an absolute delight to watch him go from strength to strength, sort of an internationally famous, famous lecturer, and the stuff that he’s doing with composite is just off the scale. And so yeah, it’s fantastic. As often say, to the behind, you need to be as good as me. I’m trying to be much, much better, and they are, every year. But Dipesh is one of the first a real sort of innovator. And there’s lots of people snapping at his heels. But he’s moving fast. [Jaz]Certainly is but today is not I mean, it today is not about sexy composite, veneers aesthetics. This is something that needs to be more on Instagram, rather than that sort of stuff. Because on the social media platforms in dentistry, this is a massive, huge daily topic, daily controversies that we face, caries. And I want to just dive right in and ask you some really pertinent questions about caries, and I might start straightaway with the following one. So I think most gdps are not using a caries assessment system. Would you agree with that, in your experience to talking to GDP in the field and when you educate about this stuff, and what is your advice to the GPS about the caries systems out there? Because it can it can get very confusing, especially if you haven’t been taught that at undergraduate level. [Louis]Yeah, I think probably most dental schools do teach it but I don’t know how strong the focus is on at King’s with Avi Banerji. It’s literally front and foremost, I teach those particular subjects at Birmingham. But, you know, certainly from your question. Yeah, I think what you’re implying is that the majority of people don’t use a caries assessment system. And many from unfortunately, people I’ve also taught, don’t even know that one exists. [Jaz]From my experience of reading people’s notes, working main practices, internationally, Singapore, here, also working alongside American US trained, Harvard, you name it, dentist in Singapore when I was there, doing I’ll check their notes, no one would mention anything in their diagnoses, that would suggest that they were A) aware or B) happy to utilize that system. So this seems to be an international issue and hoping that we’ll change it, if you think it has a place. And that’s what I’m going to lead this conversation about, you know, have they got a place in contemporary dentistry? [Louis]I think definitely. Not just, Well, for a number of reasons. Just to sort of recap, I mean, the system that sort of internationally recognized is the ICDAS system, International Caries Detection and Assessment System originally dreamed up by some cariologists in a dark room over many days, and so the actual system itself is actually quite a complicated system. But a simplified version of it is something that’s really really easily put into clinical practice. Because basically, caries as we know, every single lesion is different. And it is difficult to detect, it’s difficult to monitor. But having a system, which is literally just a one to six numbering system actually makes you think about the disease and helps monitor it. And also most, you know, very importantly, from a sort of a dental legal point of view, just literally by writing sort of one digit. It demonstrates that you’ve detected it, and you’ve diagnosed it, and you know that it’s there. So certainly in this sort of increasingly litigious environment, I think the system works well. [Jaz]Where can one go to if there’s a dentist listening to this and thinking, whoa, I didn’t know systems exists, or you know what, I really should be using a system, Where is the best resource for them to learn? Because I think it’s a bit beyond this podcast episode to go through that all I mean, if you want to do a quick summary, if that’s even possible in audio format, but where can one go to learn more about that if they want to implement it in their workflow and diagnosis? [Louis]And there’s just loads of stuff out there, don’t go to the sort of the super complicated sort of documents, which are sort of multi page which are all about sort of epidemiological studies on caries, which is obviously incredibly important to base our caries management protocols are. But the basic system literally just click on anything. Click on google images, and you’ll find hundreds of sort of nicely illustrated guides, the basic system is quite simple. It’s sort of zero to six, zero basic, you look at the tooth, looks normal, you don’t have to write a zero. And a code one is one of those lesions that you got to dry the tooth to see it, you know, when you dry the fissures or your dry, smooth surface, and you get that sort of opaque whiteness, that’s the earliest visible sign of of caries. So that’d be a code one, then a code two is a lesion, wherever it might be, which is visible, wet or dry. Three is when you start to get a little bit of cavitation so there’s some enamel breakdown as well. So obviously, by putting these numbers you can actually record their caries lesions getting staying the same or or getting worse. So it’s good for monitoring for I think, is quite an important one because those lesions that we’re quite familiar with, where you’ve got a lot of shadowing under the dentine, no obvious cavity, but you just know that something’s cooking underneath there. And then five is a lesion, which is got obvious denting exposure, so a cavity, you might need to remove some food debris to visualize it. So that’s a five and then six basically is just a big lesion that sort of is covering about half of the tooth. So over 50% would be a classified as a six And so that’s a really, really simple system to show that you’ve detected the lesion. And the thinking about it. And also from monitoring point of view because you know what it’s like if you look at two different you look at the same lesion every six months, you know, if you haven’t got photos, very difficult with the number of patients we see to actually work out has it stayed the same? Has it got worse? But if you’ve got a number they can think Oh, right. Yeah, that was a one last time is still a one now, let’s just keep a watchful eye on it. The good thing about caries of course, is it doesn’t move fast. You know, you’re not going to go from a you know, an early enamel lesion to in the pulp in six months. [Chris Deary], the Dean of your [Jaz]He taught me the ICDAS system. So yeah, shout out to him. Of course [Louis]I mean, internationally. I think I had the same sort of experience as you did when I saw him lecture at the BDA conference. And it was an absolute revelation. The blogs are fantastic lecture, as well, and lots of things that I remember from that lecture. But one of the things that stood out was I remember, he said, caries isn’t cancer. And you know, it was a fairly [Jaz]Can say that again? In his accent? [Louis]Scottish surname, but I can’t do that. Too Scottish. So obviously, it was making, you know, quite a blunt point, that, you know, if we miss a leukoplakia, that then turns into something nasty, six months later, that patient, you know, it may be game over, you may have an inoperable lesion. So obviously, from a soft tissue point of view, we’ve got to pounce on those and take a, you know, a very, you know, cautious, very cautious approach. But with caries, because it is moving so slowly, I mean, talking about sort of three years to get through the enamel. In certain patient groups, you can adopt a much more watch and wait, and sort of protocol. But as long as you recording things well, from a dental legal point of view, again, what we don’t want to do is put a lot of, you know, watch a lot of lesions not recorded well, and patient goes down the road to see another dentist. And then even though a minimally invasive strategy has been employed, it just hasn’t been. It just hasn’t been documented. And so yeah, it’s a slow moving disease. That, you know, again, we need to keep a watchful eye on it, especially with class two lesions, because sometimes those sort of D1 lesions can certainly take off. With no sort of obvious change in the environmental conditions, patients still brushing the same, diet’s similar. And so yeah, real sort of watch and wait. But from an occlusal point of view, you know, it’s so easy to watch the occlusal surfaces, and, of course, to seal lesions as well. You know, if you’re worried, you don’t have to drill into it. If you don’t think it’s one for monitoring, just seal it. [Jaz]Well, you touched on it just there in your answer that is that if the patient goes down the road, that’s one of the big worries, I think, young Dentists have in monitoring lesions that maybe code three, for example, and you can see it radiographically. And you sort of get this feeling that if you do not treat it and the patient goes down the road, then another dentist would be a different mindset different, no pair of goggles would say, Whoa, whoa, whoa, you’ve got really bad decay, this needs to be treated. So what you know, not only does need to be documented, but I do try and have a very explicit conversation of my patients so that they can really remember this conversation I’m about to have with them. So I say you have got decay. And I’m sorry, to all Americans out there who listen to my podcast, but I say, if we were in America, you’d be having all these fillings on, but you’re not, you’re in Europe and that this is my line, and they seem to remember it right. So again, very sorry to Americans, I really apologize for that being the hot water there. But yeah, I don’t generally make a point to have a conversation on patient and I think that’s the only way tha we can address this without worrying about the patient going down the road to the other dentist, right? I mean, how do you tackle that? [Louis]Totally 100% agreed. The patient’s got to know where their lesions are, you know, I will give them photos. You know, email the photos of them so they know exactly where the lesions are. So when the dentist detects something, when they do go to another practice, yeah, it’s not a surprise at all. Yep, I’ve been watching that lesion there. You know, I’m keeping it nice and clean, it hasn’t, you know, it hasn’t changed. It’s been like that, you know, in some cases for 10 years. So yeah, there should be no surprises, patients certainly shouldn’t be surprised, because it is, you know, it is their disease that they’re carrying around. But if it’s arrested, nobody wants an operation, you know, anywhere in the body on something that didn’t need it. So and of course, a good way of looking at it is if you do drill into a tooth, say you make a mistake, and the lesion was active, it progressws, six months down the line, that cavity you actually drill is going to be no bigger than the one that you would have drilled on day one. So and then once the restoration goes in, you know, a patient with a carious lesion is high caries risk by definition. So then you’ve got, once you’ve done the restoration, that high caries risk patient because they’re not high caries risk until they’re proven otherwise, as then go the whole margin of the restoration to look after, as well. And so a non cavitated lesion, compared to say, a class two composite restoration or something like that, is much easier to maintain, than, you know, the material that literally from day one is experiencing sort of nano leakage and micro leakage. So yeah, drilling into teeth, it might feel sort of comfortable to do that, and a safe thing to do that just in case. You know, from a biological point of view. It’s, you know, you could argue it’s not far off butchery to drill into something that doesn’t, that is arrested and isn’t progressing. But your point about patient knowing exactly what’s going on in their mouths is absolutely essential. [Jaz]I like the fact that you send the photos, I try and do that where I can as well, the intraoral camera photos so that they have a record that this has been discussed, but also that I think that motivates them, and they they really understand what’s happening in their own mouths. On that note, just a side question. How big of an influence does it have on your treatment plan? If the patient with the same mouth but one is a regular attender, and one is an irregular attender? I mean, there’s so many factors that contribute to your treatment planning and caries, but whether that attendance pattern is one of them, so I tend to be a little bit more aggressive in my treatment with someone who is irregular attender. So if there’s going to be a restoration, I’d rather watch it on the regular attender. But if someone is the only comment, there’s a problem, and I diagnose all this caries, which is borderline, I’m more inclined to treat that person than not, but maybe that’s not the right way to do it. [Louis]No, no, I totally agreed. And I think, you know, the evidence base would agree with that as well, if you can’t be sure they know if they’re zipping off and you might not see him for another five years. Classic situation if we’ve, if you’ve got this sort of, I don’t know same sort of code two lesion you just wondering, should I seal this or should I drill and again, you know, the sealants so if you think they’re not going to come back for another five years or something like that, and I along with you be much more likely to just drill into that and just open it up because you can keep it super small. You know, just see how far it goes. Whether you know the difference between a conventional filling and a PRR it’s you know, it’s very difficult to sort of actually define one from the other but you could just keep it super small just give put a nice self cleansing restoration in there and Yeah, you’ve stopped the disease and then you haven’t got to worry about them sort of yeah the not caring for it or getting even worse and also you know for patients got a mouthful of them obviously attack the worst ones first. Because you know, you can be really surprised things that you think oh, you know, this is going to be a decent cavity is a tiny and equally, especially working where I work in in Birmingham, you can be surprised the other way where you know, loads of fluoride in the water, the enamel is, you know, very strong, very fracture resistance. So you can get some serious sort of a cult caries, as it used to be called, occurring under there so there’s a massive lesions when you look at the surface, you think they don’t look too bad. I mean, this is one of the things you know, you said at the start that, you know, it’s not a sexy subject, and it probably, you’re right, it doesn’t lend itself to Instagram, but for me, it is a sexy subject that says probably too much about me, because it is actually the core of what we’re here for. And it’s why dentistry exists. At and it is almost a sort of the importance of it is almost a forgotten subject. Or, obviously not forgotten, but it is subject that probably does. It’s never you’re never gonna have much, many Instagram followers with pictures of caries lesions, but [Jaz]we’re hoping to change that we’re hoping change that and the way we’re going to change. The way we’re gonna change it now is I said, Now that we’re talking about a, what we mean, you agree is a sexy subject, let’s pull out some photos. Why don’t you share the PowerPoint and we can discuss the case. And I’ll give everyone a background while you’re sharing the screen. So this is a 54 year old male patient of mine, who attended for an examination with me, has been to the practice for over eight years. And one of the great things about the practice I working [Loius] Is that it, Jaz? [Jaz] Yes, perfectly. We do plaque scores and bleeding scores for every hygiene visit. This is someone who’s got quite impeccable oral hygiene, regular attender and first time I was seeing him and that’s what I found, I was like, Whoa, okay, and I had a look at the chart. And nothing was documented for those of you who are driving right now and listening or chopping their onions, and then they can’t see the photos, I urge you to check this out on YouTube to check out you know, how many minutes to see in to podcast, to see the photos, because this is a clinical scenario that you may encounter or may have encountered many times. So this is like as a 54 year old male, regular attender and I really struggled internally, to decide whether I pick up the handpiece or not, and I almost treatment plan it to come back to start some treatment. But I remembered we agreed to have this podcast episode. And like you said, cariess not cancer. So I was totally comfortable to send him with fluoride and say, No, I’m speaking with someone who in my opinion, is very experienced and knowledgeable far more than I am. Let me speak to him. And I’ll tell you what he says. So I’ll be reporting back to the patient after this. But in this scenario, let’s start with the ICDAS, can you tell the ICDAS just from the photos and radiograph? Or do you need some clinical input as well? [Louis]No, I mean, they’re clearly fours, aren’t they? So you know, we’ve got shadows, we’ve got no obvious cavities. But we’ve got shadowing under the enamel. Obviously, we got some cracks as well. Yeah, it’s an interesting case that you’ve chosen there. Great photos as well, by the way. [Jaz]And I forgot to mention, actually, the background information, this post had around about 5000 UK dentists look at it and 1600 engagements. So what that means that someone’s actually clicked on and actually read more about it and flick through and 169 comments, and they will literally split in half. And some of their responses were Oh, yeah, who would have thought dentists’ saying? And some of the responses were not only very polarized, but some were really passionate. I mean, some people you are extremely negligent. If you monitor this. To others, they they propose the daughter test or the mother test, they say, you know, I wouldn’t have this on my daughter, I’d watch it. So you had really, you know, real polar response and reading these comments has been quite entertaining for me. And one thing that I could just ask you straight off the bat, that is was our right to take a radiograph? Because some someone said that actually, why do you take a radiograph? Didn’t you tell us caries is there? Is that really show anything? Not the air respect. But for me to help me decide whether I want to drill or not the radiograph for me was important. So what do you think about the radiograph adding benefit, does it or did I not? Why should I not have? [Louis]In this situation? Well, certainly from a dental legal point of view, you definitely justified so that’s the first thing to say. So there’s no question about it from a dental legal point of view. But equally, obviously, any radiographic investigation should improve the quality of your diagnosis or improve the outcome to the patient’s treatment. But now, we’re all looking at this lesion there and we’ve got the radiograph. And we’re probably none the wiser. [Jaz] That’s true [Louis] because of course, unfortunately, early lesions do show up terribly on x rays, particularly with an anterior views as well. So I think there’s a good argument. There’s a good argument both ways there. So I’m, so many would say yeah, it’s not justified because it’s not going to give us any more information. But of course, until you’ve got the radiography, you don’t actually know that it’s not [Jaz]Yeah, I was kind of hoping that it’d be really clear out for me, and I’m like, okay, I definitely tend to intervene now. But no, you’re right. We’re none the wiser. So what would Louis do? [Louis]Well, I’m delighted. [Jaz]Is there any more information that you want, I mean, I can give you any information. [Louis]I think the key to this one would be I mean, we could use transillumination, that’s probably going to make it look even more horrible. And probably going to push you towards restoring it. I think really, the only way you can be certain is to put a tooth separator in. So orthodontics separator. Now obviously, they’re a bit uncomfortable. And leave that in, sort of, I mean, you can leave it in for a few days. But after a couple of days, you’re going to get tooth separation. And so then you can basically take the separator out and can actually see if the surface is cavitating. If the surface is cavitated, then the decision is made for you, a cavitated lesion cannot arrest, the biofilm can’t be removed, even this patient becomes an Olympic standard flosser. There’s no way that the lesion can not progress, albeit very, very slowly. So if there’s a cavity, the job’s kind of done for us. [Jaz]So can I tell you what I did? [Louis] yeah [Jaz] I placed a wedge And I was able to just about feel my probe to confirm there wasn’t a cavity, but that crack that you see, on upper right one, distal, and upper right two, I can just feel the sort of the the crack almost that’s what I was feeling my probe just gently, no cavitation. So to me, that was the crack that was swaying me towards treating because the crack is in, in some ways. It is a cavitation in a way. [Louis]Yeah, absolutely. It’s a way for bacteria in there. We know there are bacteria in there, you know millions of them, in fact. And the crack really is a tricky one. Because now, the crack has probably been caused by the lesion. The demineralized enamel from a mechanical point of view is weaker. This patient’s in his 50s is been biting and protruding on these teeth. So it’s cracked because it’s unsupported by the demineralized dentine underneath. But obviously, that crack is not an actual cavity. It’s a wave of bacteria. And but you know, they’ve really got to queue up to get into that lesion. So it I mean, it’s a very good case that you’ve chosen because it is very different, because there is no, if you separate the teeth, and there is no cavity, obviously the crack still there. You know, you can see that. And also from a class two point of view, you often see these cracks, early caries lesions, been there for a while. And then you get a crack right from the center of the marginal ridge all the way down into the lesion. You’ll see these quite often when you extract a tooth, and there’s been a carious lesion on the adjacent tooth, you’ll see these vertical cracks going right down to the lesion there. And so you know, it’s a really, really tricky one to, Because if we drill into that, we go from a crack to a massive hole in the tooth, which is then going to have to be replaced. Patient’s in his 50s. So you know, I’m sure your composites are amazing. So but again, 10 years down the line, great. 20 years down the line, fantastic, let’s get the balloons out. But the likelihood is that that restoration isn’t going to last forever. And then when he’s taken out, as we all know, the coverage is going to get bigger. And of course, the average competition doesn’t last that long. So you know, six to seven years, class three is difficult to do as well. You know, regardless of rubber dam or not. Difficult restorations to get a perfect finish. So then we’ve got excess composite beyond the margins, probably. We’ve got microleakage, nanoleakage. We’ve got polymerization, shrinkage stress, we’ve got expansion and contraction of the material, which is going to be different to the tooth tissue itself. So are we actually creating a worse environment than the environment that was there before? So yeah, it’s a tricky one. Now obviously we all know some of our colleagues won’t be having this argument. The only argument be, which porcelain you’re going to use for the crown onlays. [Jaz]Hello, USA. I’m just kidding. I’m just kidding, guys. I’m just kidding. I don’t know if I’m getting or not. Okay, let’s just, that’s a different debate. [Louis]So yeah, it is a really tricky one. I think that I mean, the nice thing is, you know, you know your patient well, you’re seeing them regularly. And the other thing in this particular situation, it’s dead easy to remove the biofilm. Caries lesions are driven from the surface, if you can remove the biofilm, kind of doesn’t matter what it looks like. Because if that does progress, it’s going to be so glacial, that the patient is going to be 200 years old before you’ve got anything to worry about, at all, certainly thinking this particular case, I would adopt a watch and wait policy, if you’re making a decision. And to be honest, we’ve got all the information that we would have, I mean, you’ve got great photos, you’ve got a radiograph as well there, we’re going to get no, we’re going to get no more information, if we had the patient actually in the chair, other than the tooth separation. So for me, the patient can look after this lesion, and you can review it regularly. And see what happens. Give you the Deary test. [Jaz]The Deary test. Brilliant. I love it. [Louis]There we go. you know, and if it moves, you’ve got great pictures there. And so, [Jaz]So let’s talk about something that would change my management in this. So if it was an irregular attender, and the surfaces were covered in plaque, and the bleeding sort of came in, the plaque scores were consistently in there, you know, 30s and 40s. And maybe you know, the quality slider wasn’t so good, then my protocol, a call or decision making here would not only be to pick up the handpiece, but I’d actually treat them all even because of the patient going to have an anesthetic procedure rubberdam. And that moment, I just get even the smaller ones, I just restored it. That’s it for me, it’s all or nothing. And now it is my all or nothing approach, just fireball in that sense, if I’m going to do, if I going to drill one, I’m a drill them all. I sometimes do that [Louis]I keep an open mind, keep an open mind do the finishing, I think in dentistry, we should always have that, you know that flexibility to just keep all of our options open. And the nice thing about sort of lesions sort of opposite each other is treat the worse, you know, so you decide for whatever reason to drill into it, or do test drill or whatever. And then the nice thing is, once you’ve done that, you can actually look directly at the adjacent tooth. Quite often you will see, especially on posterior class twos all the time, and you prep one, you will always see some demineralization of the opposing teeth, just because they’ve been living opposite a carious lesion for ages. So it’s demineralized, no coverage at all. And as soon as you put the restoration in, that tooth is going to fix itself. Tooth are very, very good at repairing themselves. You know, we, you know, we know that the odontoblasts are working day and night against a carious lesions, if we can give teeth a chance to actually remove the environmental factors, then they’re going to fix themselves. So yeah, if you sort of have prepped one, and then just have a really good look with magnification, ideally, at the adjacent tooth, you can actually feel the surface carefully with the probe, obviously, you know, not probing into the lesion, but coming across the lesion, you can see if that surface is broken. And then if not, again, take a nice photo of that. You let the patient know, we’ve got this lesion here. You know, you mentioned the daughter test, which I think is an excellent benchmark for any operative procedure. You know, would you drill into it on your daughter and if you wouldn’t leave it alone, because you’re only going to make a massive hole and fill it with something where really you’ve just got to you know, either no defect or little crack. [Jaz]Brilliant. So now we know what Louis would do and I feel I can sleep well tonight knowing I did exactly that. But now I’ll email the patient as well and say, okay, it was split opinion. But here’s what we think, there’s no right or wrong answer, you know, because this one is a bit borderline, you know if it was way less in terms of size of these lesions, then maybe we’ll be having a different conversation but I picked a borderline one on purpose obviously. So for those of you on the pages on Facebook who said that I would definitely treat it. You know, don’t I wouldn’t be you know too hard on yourself, whatever. Because, [Louis]Yeah, there’s no right or wrong answer. Of course, if you drill into that lesion, again, you’d say, Oh, yeah, I did the right thing there’s caries there. Because you just [Jaz] you justify it to yourself. Yeah [Louis] it’s not the same. But unfortunately, you drill into almost any fissure in the mouth. You will find the process of demineralization knocking around, you could argue that every human has got the caries process going on all the time. The world’s most common disease, but it’s only if it’s progressing at that it’s an issue, but yeah, it’s a great case that you’ve chosen there because, I mean, you mentioned about it being 50-50 I remember a good quote from one of my friends, Professor Giles Perryer who said that there’s only one thing that two dentists will agree on. And that is that a third dentist is wrong. As it were, you know, that’s one thing nice thing about there isn’t a unified theory of dentistry and you know, that’s what I like about it, that it is a subject whether it’s sexy or not that it is easy to discuss one lesion for what 10 minutes or 15 minutes like we just have [Jaz]Certainly is. So what will I ask you, Louis is just switch off the screen share now? If that’s okay? [Louis]What’s cooking on the toward the apices of those incisors? [Jaz]You know, I haven’t even looked at before. Yeah, so it looks like canine but it can’t be, surely not because this person has a canines, but yeah, there is an opacity there isn’t it? On the above the upper left one. [Louis]There’s another one for you to investigate next time another podcast coming up. [Jaz]Yes. That’s it for part two, just we can use to part two. But thank you so much for sharing that. Thank you for laying those images out. So neatly there. So you’ve answered actually a lot of the other questions that I was gonna get into. So the final question want to ask is, many dentists believe that a radiographic lesion that’s into dentine is automatically pick up the handpiece. What message do you want to send to these dentists? [Louis]Well, that, again, it’s a good one. And I don’t know whether I’m actually changing my personal opinion on this subject. And so just to sort of refresh, we’ve got the ICDAS system, which is the proper ICDAS system is actually a two digit system. And the first digit describes whether it’s a tooth surface or it’s the margin of a restoration or margin of a sealant. So it’s actually a two digit system. So but the just the basic ICDAS system is that you could just use your simple one digit. A different system, not to be confused with the ICDAS system is the radiographic grading of the carious lesions. Because the radiographic appearances is something very different. The radiographic appearance we know is, you know, on average, six months behind what’s actually going on inside the tooth from a histological point of view. So that, the recognized system is through the system that basically says two digit system, so two so basically an E1 lesion so if you’re looking at a bite wing, and you’ve got a lesion that’s less than halfway through the enamel, radiolucency, then that’s an E1 lesion. When the lesion then extends beyond the center of the enamel, wherever it might be, then that’s an E2 lesion, but it’s still short of the denting, no obvious dentine changes, then a D1 lesion is one of those lesions where you see some radiolucency in the outer third of the dentin. Sorry, I meant D. So a D1 lesion is the outer third of denting, a D2 lesion is where you’ve got radiolucency in the middle third of dentin. And then a D3 lesion is when you’ve got deep caries sort of inner third of dentine. You know, even if you’ve got sort of pulpal exposure to the system doesn’t really go beyon D 3. So it’s a useful system again, for assessment as Professor Banerji I’m quoting all the legends today. Professor Banerji or Professor Kidd that, you know, a single radiograph in time, you could argue is you know, it’s important information, but it’s actually meaningless when it comes to carious activity, the only way you can show from a radiograph that a lesion is active is if you’ve got two radiographs taken a minimum of six months apart, if the lesions got worse, then that’s by definition, an active lesion. So that’s going to be sway you more towards operative management. But equally, if you’ve got a series of radiographs showing a lesion, even if it is a D1 lesion, and it’s not changing, and then, you know, you can basically say from all the evidence that you’ve got, and especially from a dental legal point of view, that is an arrested lesion. The only thing that it’s, and again, this is quite sort of anecdotal, I did a lecture once, too. I did a lecture not just on one tooth, I did a lecture on one surface, an hour lecture on one surface of one tooth. And this exact scenario happened. And it was a lesion that I followed, it was a D1 lesion for a six years, no change at all. Bitewings looked exactly the same. It was one of those lesions where you look at it and you think day one drill, this patient had a number of these lesions, a lot of them about 20 of them. So the deeper ones were treated. But then I adopted a sort of watch and wait policy, and was really surprised that because the patient completely transformed his diet, and oral hygiene lifestyle, and that the lesions just stopped. Now he was one of them not dissimilar to your patient that you just showed us where the lesions are not just interproximal, you can see the old demineralization coming around onto the buccal surfaces, and the palatal surfaces. And so these lesions Do you know, can be quite deceiving when you look at them radiographically. But anyway, I saw I’d watched this lesion quite comfortably for six years. And then six years, after six years, patient just came in for a checkup. And I noticed that a marginal ridge and actually fractured. Occlusal load, so that actually fractured I’m still there. But now the lesion had progressed. So it’s one of those tricky ones with these, the demineralisation, are they sort of slowly, slowly, slowly weakening the tooth? So that under occlusal loads one day, the marginal ridge might give up and the lesion might progress. I mean, the nice thing is, after six years, the cavity was no bigger than it would have been if I steamed in on day one. But again, it comes back to your point that that patient was a regular attender really well motivated, and this is the patient that would have got 20 MODs, if you know, if we’ve taken a transatlantic view, possibly not telling you which direction but so yeah, it’s easy to drill into tooth. But once it’s done, it’s done forever. And you know, you can’t, put the cork back in the bottle. Once a tooth has been drilled a restorative patient is a restorative patient forever and that old, that old saying so but equally, I think, you know, all these D1 lesions just slowly creeping, they separated the teeth on multiple occasions, there was no cavitation of the [Jaz]Louis, you’re the first person I ever saw who has ever taken a light body PVS impression of the interproximal surfaces between molars. [Louis]Yeah, you don’t get many shadows. You know, that is in you know, that is sort of proper level OCD, it was actually my Prof Perryer, I mentioned before, shared an office with him for 10 years, a real innovator, one of the world’s leading experts on blended learning in dentistry, and yeah, so he showed me that trick that wasn’t. But really, you’ve got to separate the teeth to do that. As ideally, unless it’s an obvious cavity, then it’ll show but if you separate the teeth, then you can just squeeze the impression material in there. Of course, you’ve got other ways of doing the look, you know, radiographic point of view, these various different scanning, scanning procedures that you can use in between the teeth, as well but I think the this, when if it’s an enamel lesion, yeah. And it’s non cavitated on the surface, yeah, again, surely none of us would ever want that done in our own, to our own teeth. But I think when it’s getting into the dentine, I think we’ve definitely got to get away from that sort of that trigger response that dentine caries equals drill. Because that’s just not sophisticated enough for, you know, for the modern clinician, [Jaz]Louis, do you watch, Do you watch D2 lesions as well? In the right patient? Radiographically Or is that I mean, that’s such an open question, because it’s so many variables, I suppose. But [Louis]Yeah, if it’s a cavity, on the surface, again, the you know, separate the teeth, ortho separator, if it’s a cavity, the decision is made for you. [Jaz]But it’s really non cavitated D2 occasionally you know, you find one [Louis]You do see them and again, you know, that is real, you know, that is really pushing the boundary, you know, many people would call that, you know, abject negligence, supervised neglect, whatever you like to call it. But the textbooks would tell us that the lesion is driven from the surface, from the biofilm and, you know, and if the patient is cleaning that surface, that even in a D2 lesion. So, yeah, that’s a tricky one. And, of course, most D2 lesions, in my experience, you know, when you actually drill into the marginal ridge to begin with, you make your access cavity, you see straightaway from the inside that there’s you know, there’s a cavity there. And so it’s the right, you know, you’ve made the right decision. Again, tunnel preps, they kind of went out of fashion. [Jaz]So are they back in fashion now? [Louis]Well, they went out of fashion, originally, because they were a glass ionomer was used to do the restoration. And glass ionomer is not strong enough to support the marginal ridge over time. So you tend to find, you know, they worked, they stopped the lesion. But then what happened is that the marginal ridges on average, tend to fracture because the glass ionomer was a bit too bouncy on the underneath. But now of course, you’ve got bulk fill composite materials that we can inject into these cavities. And really quite radiopaque materials as well, always tricky, you know, even with magnification to be certain that you removed all of the caries from the tunnel prep. But I’ve done a few in fairly recent years, because the nice thing is there is you preserve the marginal ridge. And you sort of attack the lesion sort of directly. But tunnel prep’s tricky sort of thing, especially without magnification. You know, obviously, you’ve got a scope, fantastic. Go for it. But both of materials is just so good now that you know, you can just inject them nice, thin canula, very radiopaque, low polymerization, shrinkage stress, obviously, put a matrix band in anyway, so you should get a really good contour because you’re literally filling up from the inside. And you’re not involving the proximal surfaces at all, [Jaz]because you’ve got the marginal ridge guiding the matrix that should get quite close to an activity in that scenario. [Louis]And you can optimize your wedge, we’ve got a good tip from you mentioned Jason Smithson. Good tip from him, you know, if you’re not getting a great wedge with your matrix band, just modify that with some ptfe tape either round the wedge or stuff in on top of the wedge, or a little bit of flowable composite outside the matrix as well to just optimize your seal. Yeah, restorative dentistry, you know, got lots of tricks, lots of tricks to fill really quite sort of dry, quite tricky, cavity shapes. [Jaz]Cavities are something that you know, like I said on social media, you see all these smile makeovers, I tend to post quite a few restorations, just past restoration I think class two is real art to get the correct matricing, the correct wedging, the correct gingival removal in some cases to actually allow the correct emergence profile of your matrix so I it’s an aspect dentistry I enjoy a lot and I think it takes a lot of care and attention to do correctly and it can’t be rushed these things, that’s just the point I made but the question I want to finish on Louis if you don’t mind is DO restoration on a five for example comosite and just see like a discolored margin all around and dentists are drilling this out and I’ve seen it a lot you think “oh yeah, you got leakage, you didn’t any restoration?” Is that just the biggest baloney ever? Is that a robin hood dentistry? [Louis]Again, I think Edwina Kidd published Professor Kidd at King’s, Guys, King’s down in London. You know published a lot of the work on this and just showed that will we remove way too many restorations and that most of them are functioning absolutely fine. The correlation between marginal stain and secondary caries is almost zero. And I’m glad that you made this point to end with because we’ve mainly been talking about primary carious lesions, which are difficult enough. But when you add secondary caries into the mix, you know, you take a lighter shade, you’ve got a stain around the margin, you take a radiograph, there’s a radiolucency, cervically. What is it? Is it caries? Is it some sort of lining? Is it bonding resin? Is it polymerization shrinkage? Is it a void? So incredibly difficult. But we do take out way too many fillings that’s been proved beyond doubt. A good, I’m coming out with all the old quotes is that, you know, composites can look you know, can look better than they are. And amalgam can look worse than it actually is. So, you know, these materials can sort of caries, will move more slowly, under an amalgam restoration, that’s for sure. Because the breakdown products of the corrosion, and, you know, bacteria just don’t like those. But it is tricky caries around, work stain around composite restoration is a super tricky one to do. Obviously, if there’s aesthetics that tips the balance, in favor of maybe localized repair, or maybe even restoration replacement. But yeah, if we replaced every single composite with a stain margin, we would never, ever do have time to do anything else. Because you know that the materials do develop positive negative edges over time, even the best restoration, you know, it is going to show up some marginal stain with time. And obviously, when that restorations removed, that cavity is getting bigger. So if we can adopt a more conservative approach to restoration replacement, and let’s face it, more than 50% of everything that you may, every GDP listening to this around the world does involve the replacement of existing restorations, not the management of primary disease. But the more restorations we put in, the more problems we create for ourselves actually diagnosing have they failed or not? The, again, the diagnosis of restoration failure is a complete science, separate science and classification system all on its own very, very tricky And just so subjective. You know, from clinician to clinician, depending on, you know, the clinical experience, the material has been used and what they were taught to replace restoration, but, you know, to think about, does it actually need to be replaced. You know, I think you know that’s why five years of dental school, exactly makes us think about these things, rather than just if it was just knee jerk stain equals replace, then anybody could do it. [Jaz]Absolutely. It’s just a point I made because I you know, it’s something that happens still. And you really have to sort of challenge that, I think. And it’s been great having you on the show today, you’ve given some great, what the kids are calling knowledge bombs nowadays. So you really shared. So that’s great. So thanks so much for coming on and talking about a really important topic, and mentioning some great legends in cariology and operative dentistry. And it’s been great chatting to you. [Louis]Pleasure to chat to you, Jaz. [Jaz]Thank you very much. [Louis]Thanks for everyone who listened. Jaz’s Outro: Thank you so much for watching all the way to the end, please do support the rbbmasterclass.com course I really appreciate to have you on. Subscribe on the YouTube or the IGtv. If you’re watching an either those platforms, or if you’re listening, you might want to go back and check the video part to see what the lesions look like that we’re talking about. Anyway, catch you in the next episode. Thanks again. Thank you so much for listening.

I was so happy to get feedback from ‘Finding An Associate Position‘ interference cast episode. What you asked for was some more direction on Portfolios, and that’s exactly what this episode sets out to do! https://www.youtube.com/watch?v=1URCtgQdczo Need to Read it? Check out the Full Episode Transcript below! As well as showing my own CV (it does not need to be too fancy!) and Portfolio, I tap in to Barry Oulton’s experience of hiring – what does he look for in an applicant? Alan Burgin (@the.cornish.dentist) and I also chat about our journey and the gradual process of organically building your portfolio (it was a snippet from an episode yet to be released). I echo in the episode that all these things are just to secure your interview – really what matters most is your emotional intelligence and your attitude. If you know a DF1 that would benefit form this advice, help them out by sharing this podcast with them! Click below for full episode transcript:  Opening Snippet: Don't think that you're the bee's knees, and the be all and end all, what you're doing is you're reflecting back, because, you know, we do need to reflect. And so demonstrate the reflection, demonstrate that there's the humble and that you are looking to improve things... Jaz’s Introduction: Hi, guys, and welcome to another interference cast. This time I’ll be talking about portfolios and their relevance. I’ve got a couple of guests, but a few snippets from a few other episodes, actually new content that will hopefully help in the decision of how to actually make a portfolio, the relevance of it and what principals are looking for, and the journeys of some successful associates and what advice they can impart. I’m going to be sharing with you my own portfolio and my own CV. And that’s not to say that my CV is the best CV by any stretch of imagination. I know far more skilled dentist, young dentists who have brilliant, glowing CVS and portfolios. But I’m going to show you mine just warts and all because who does that right? So I’m going to try and be as helpful as I can be. Maybe they’ll give you some ideas, some inspiration. And ultimately, I just want to remind you that none of this matters, essentially, as much as your emotional intelligence, your personality, how likable you are, your communication skills. Are you a team player? Everyone I know who is a principal that you really want to work for someone who is really forward thinking, they all have one thing in common, I think from what i’ve deduced, and that’s they’ll really hire for personality, rather than the credentials. I think the credentials play a role. And they’re important. And that’s where I’ll show a little bit about portfolios, and what mistakes that I share in my portfolio as part of reflective learning. But ultimately, remember that your personality and your people skills are far far far more important than what’s on any piece of paper. Also, making some cameo appearances in this podcast will be Barry Oulton, who will be talking about as someone who’s hired lots of dentists before, what is he looking for. And I’ve also got Alan Burgin, who is such a fantastic guy to speak to, very successful young associate, who I think shares a few gems. If you’re a young dentist, that journey that you take into finding your first job or the right job, and he’s got a few gems to share. They all both have their own episodes coming up, but I took a few snippets, so they have a few cameo appearances in this episode. Okay, guys, so this is my CV, I’ve redacted some of my personal details. So it starts off with about me, but even before then, funny story, I used to have like a really stupid funny logo. And then a dentist who I really admire Tommy “Jaz, this a really stupid logo, get rid of it, it really ruins your sort of the hard work that you do and it’s lovely, all the lovely things that you’ve done, you sort of, discrediting it by having this stupid logo.” I won’t share that stupid logo with you. However, a I think it begs the question, are logos important? I don’t think they’re important. But I know some dentists that will actually think of another young dentist with less experience in lower regard, if they’ve got a logo, because they think you know, Who the hell is this young dentist one year qualified to have a logo. However, even though I don’t have a logo on my CV, at the moment, I think times have change, you know, I think the world is a completely different place. It’s the world of social media, social presence, and to have a branding associated with you is not a bad thing. Some people, maybe some of the oldies, I don’t know, maybe I’ll get shot for saying that. I don’t know. But some of the oldies made me think that it’s not a good idea to have a logo. But I think it’s part of personal branding. So maybe I might ask someone who I really admire and respect what they think about that. And they’ll probably think, who cares. It’s not the make or break deal. But that’s just something aside about a logo. So I start off writing a little bit about myself, then I dive straight in into education. So fairly standard two page CV, nothing fancy, nothing different. Some people do all sorts of crazy, different things. Mine is pretty boring and plain. And then my work history, what I learned, I also describe the types of work that carried out, for example, in my restorative DCT position, the type of work that I did that’s written on the bottom there as well. Some published work some prizes, like I said, we made an app once I stuck that in there, does it really matter? No, I don’t think so. I don’t think that’s what you know, makes or breaks your, you gain the position. It is sometimes when there’s hundreds of applicants for position, then these little things may give you a bonus. Debatable. None of these are important as your personality, but I’ll just show you a few examples of leadership management, personal interest, CPD. Now I’ve seen some CVS which are like seven pages of just a listing every single course you have done that, when I first saw that I was like, wow, I was actually quite impressed. But then again, it becomes quite long. So I don’t know if you want to do that. Certainly, it’s good to have a log of every single CPD you’ve done. But I wouldn’t like put every single half an hour, section 63 course you’ve done, just the big courses. So I put a few, a few select ones that I’ve got on there. But you may follow that approach of having every single course on there. If you’ve done some big ones, if you like any, why don’t you feel proud of them and want to stick them on there. Some people have done that. I’ve just kept bit to a few. And I keep a little PDP very small, just a sentence at the end. So that’s my CV part. But then what I’ve got is lots and lots and lots of cases, this is my portfolio. So I start off with my finals case, you know, this has been on my CV since like, day one. So I was very proud of my finals case. So I’ve got that on there. A crown prep using verti prep approach, some composites I did in the earlier years, it’s me as a first year dental school, then some dahl composites I’ve done in hospital training, internal bleaching, just a range of different things. I’ve done some crown and thing once upon a time, treating brown spots, white spots, composite bonding, just a selection. Now, when you start out, you may leave, you may only have like two cases as a composite and maybe a denture, that’s totally fine. You know, it’s just some evidence that you know, you can carry out some good dentistries, i’ts fine. I think it shows some discipline about you. And the fact that you’ve actually gone through the effort of documenting cases. That’s partly why I think a portfolio shows as well that you are, you’ve got that in you to actually be disciplined to, you know, save your photos, crop them, flip them, and reflect on them. So that’s why I think that it shows as well. I’m happy to show some blood, I’m happy to show a torn rubberdam, I really struggle with that composite you see there, but I still stuck it on because it shows my human side. So I am perfectly fine to show that I’m not perfect. And yeah, I just basically you could see the volume of cases, I have my portfolio. And these are, like I said, been building up over time, I did not have a portfolio this large when I started out. And just all sorts of cases that I have, not all of them are 10 out of 10 standards, some are just average or slightly below average. But I’ve just stuck it in there. Sometimes they make for good conversation, if you get to the interview stage. Some Dahl work, so you get the idea. And I’ve also got some OPGs of wisdom teeth that I’ve removed surgically. So if you, you know, if you think you’re proud of some of the extractions, you’ve done wisdom teeth, a good skill to show and the end of what my references in a paper that I wrote. So that’s essentially what my portfolio is and what my CV is, nothing crazy. Now, sometimes people do all sorts of funky things with their CV, if I can think of an example. So I’m on a website called Canva, canva.com. Now, and they’ve got some pretty cool like templates you can use. So for example, you can use this template, add your name on, I think these look pretty funky, pretty nice. I wish I had access to this, when I was first making my CV, I could still change it. But I’m sort of kind of dropping out. So I’m not needing to. But certainly, I will use canva.com to find a relevant template that you can use. So here we are another sort of template you can see on your screen there. So these are pretty cool, I’d say. You know what this one reminds me of the sort of logo that I had, the stupid logo I told you about. So you get gives you a clue as to what I had. But, I mean, this is this is pretty good. Canva templates, I think are they look nice. But again, this is not as important as the soft skills that you have. Everything about a portfolio and CV, the purpose is to get that into. It’s that interview that you’re going to wow them with your beautiful personality and charisma and giving them confidence that you’re going to treat their patients really, really well. So hope that was useful to see. I’m not sure if it was, please hit me up and let me know if it was or it wasn’t. And let’s see what Barry Oulton has to say and what Alan Burgin and have say. Main Interview: [Jaz]So Barry, I want to have you on to speak about something that follows on from a recent episode I posted about finding your first associate position and how people can go about doing that. And I’ve been flooded with questions from I mean, it’s a sorry situation for everyone involved at the moment in the world, you know, but in dentistry, we like to sometimes reflect on the people who may have been hit very hard and that is DF ones, their first year out of dental school. Six months into it or the or there abouts. They’ve now completely out of clinical practice something that they’re starved of, they’re only just about to get into a position we’re about to you know, advance out of their comfort zone to do the bigger cases they’ve only just got the the grasp of general dental care in the real world. And now everything’s come to hold and they’re in this position where They have to now apply for their first potential associate position. I want to know from you is what should, what should they be thinking right now? And I want you then tell us about because I know you are, you’re hiring dentist now and again. And I’ve been through that procedure many times before. What do you look for in a CV? To what can make you stand out? and partly what do you look for in a portfolio? Because I think about 10 years ago, no one, I mean, at least is why my perception 10 years ago, we didn’t have portfolios. We didn’t need portfolios. But every young dentist, I know now who’s applying and rightfully so, they’ve got a portfolio, what do you think, would be in a portfolio that impresses you and what doesn’t? [Barry]Okay, so firstly, huge subjects, right? The first thing is, if they’re coming at it, let me let me tell you about an experience when I was a VT trainer. People would just send kind of generic letters. Dear Sir, dear, I’ve got a couple of dear dentist I got. I mean, honestly, mate, I was like, so that came through, like, Ben, if you can’t be asked to find out my name. Then on you go. The ones that I have been impressed with, and thought about hiring are the ones that have demonstrated in their covering letter, that they have done a bit of research about the practice, you know, I’ve just recently hired a new associate, primarily, because I want to mentor and he wants mentoring, I’ve got a lot to share. His covering letter really was about the fact that, you know, I noticed that you do this, Barry and you do this, that and I’ve seen you do this and and I’m like, Okay, this kid is has made an effort to find out about me, and find out about the area and the patients. I had one applicant that I contacted. And I said, so where do you live? And it was a London, I said, so do you know how long it would take to get to the practice? And he went no, not yet. And I thought, [inaudible], mate. If you haven’t even researched, how you gonna get here, you’ve clearly don’t give us stuff. You’re just pepper spray. So I like somebody’s covering letter that demonstrates that they’ve made an effort. I really liked recently, somebody applied and then followed it up with a phone call. I just wanted to check I’ve sent [inaudible] a covering letter and my CV, I just wanted to check that you received it. And if you would like to have a chat or anything like that I’m available.” And I’m just like, right. This is somebody that’s demonstrating that they give two hoots about this job, and they want it. [Jaz]Barry, I think that’s really good. I think a lot of young dentist may feel shy or reserved, or as if they are not in a position to do that. But I think it’s great. You mentioned that actually we send out it’s completely okay to follow up with a phone call. And that’s a really good point. [Barry]I think you need to have a USP, what is your unique selling point? You know, why would I want you at my practice. And it’s not about bragging, it’s not about going because I’m awesome, because we’re not going to know that for three to six months, to be perfectly honest. You know, what I want to know is that you’re going to care for my patients and look after my patients. And I’m different from some of the principlas. Other principlas might be focusing on gross revenue, whereas my focus of attention is on quality and care. And, you know, looking after the patients, so I think that you, you need to be aware of what sort of practice you’re applying to, what sort of dentistry you want to do. And it’s worth mentioning a few bits in that. I think it’s quite hard. I like I mentioned to you earlier on, I suggested, I’m about I’m writing at the moment, currently writing, training an online training course. And I’ll send you the logo, but it is get that dream job and it’s not bespoke to dentistry. It’s generic, because if I was to and when you go on and have a look at it, you know, if you go on, there’s nothing available right now, but there will be. And I give you three descriptions of three different of three houses. Do you remember when we did predicates on the two day training? The other day? [Jaz]Yeah, right. [Barry]So some of us are highly visual, we process our information visually. Some of us are auditory where we process most of our world through our hearing and sounds and we describe our world through that. And others of us are kinesthetic we, we like to touch and feel things, and we process through our feelings and describe our world through our feelings. So I start off with a document that gives you three choices of houses. And each one of them is written in one of those predicates visual, auditory, and kinesthetic. And so which house would you prefer? You generally pick one. And then I say, right, well, they’re all the same house, they’re just described in somebody’s predicate. Now, when each applicant describes themselves, they will describe themselves through the words that they represent their world with. So they might describe themselves through highly visual language. If myself as the deciding factor of whether I interview you are highly kinesthetic, I am going to be drawn to a covering letter that is more written by somebody who’s kinesthetic than I am to somebody who’s visual. Does that make sense? [Jaz]Yeah, so their own predicate will, the type of predicate will appeal to a certain type of principal? [Barry]Absolutely. So what’s the secret, the secret is to write covering letters that make sure that we’re covering all of the predicates, because you don’t know what that principle is going to be. You don’t know what their preferences. So by wording carefully, the opening paragraph increases the likelihood that the principal is going to go, I’m going to take a look at this, this person, rather than going oh, I really like this group, because this group will be the ones that rose purely in his predicate. But, you know, he might be pushing aside others that aren’t including some of the language. So I can’t go into it too deeply right now. Suffice to say that there is there are ways of writing carefully with some words that speak to more people. And give the vision of what you’ve got, and actually give them a better feeling about you, based on the words that you put in. That being said, from broad strokes, use names, you know, show interest. And because the idea is to get your foot in the door and get an interview. [Jaz]So the CV, the portfolio, the cover letter is a vehicle to get the interview. Once you have the interview, that’s a whole different beast. But gives, you know, once they can see you and meet you, and maybe through Zoom meeting nowadays, but you know, it’s all about getting your foot in the door for an interview. So they’ve got a cover letter that is personalized, that’s been well researched, that’s in the name of the principal and is about their town. It’s using the correct predicate if you’d like that it’s gonna, you know, very.. [Barry]It’s gonna use the all three predicates. Okay? Because you don’t know. There are no typos. [Jaz]Absolutely. [Barry]Get somebody to read it. You know, get your punctuation right. You know, we’re scientists, right? I haven’t really written anything since I was at uni. At uni you’re used to writing alone. I mean, nowadays, you probably know, right, you probably type. And we got Grammarly and stuff like that. So goddamn use that it’s really not acceptable to have a load of mistakes in a letter now. [Jaz]I’m just mindful of time because I really want to push that. What about the portfolio? Because that’s the new thing are relatively new portfolios. I mean, I’m going to talk a little bit in the video about what’s in so I’m going to just show my portfolio and what that involves. But what are you looking for in a portfolio nowadays, hey, you know, you might listen, imagine you’ve got 100 CVS, cover letters, portfolios. Half of them you can dismiss because they’re just they say, dear dentist or whatever, the others you don’t get a good feel for, but a lot of these are going to be identical. They’re all qualified in you know, 2019 2020, for example, in take this batch of DF1 dentists, they’ve all got the same MFDS or whatever. What are you looking for in a portfolio that’s going to speak to you. [Barry]So if I’m looking to recruit somebody of that age, of that experience group, age is irrelevant, but the experiences they’re just completing DFT what I don’t expect is a portfolio that’s full of full mouth rehab and this that the other because, quite honestly, you know, I anybody that is overreaching or effectively bragging, I’m like, I’m mindful of that. You can’t be that good after a year, right? You can have the right mindset of, I’m the best that I can be at the moment and I want to be better. That’s what I’m looking for. I’m looking for somebody that I can, at that, that level of experience. I’m looking for somebody that I can work with a mentor and help and be there for. I’m not expecting somebody to come in. I wouldn’t personally be expected somebody just to come in and hit the ground running. I think that for me personally, that’s unrealistic for somebody that is effectively a year qualified. And you can’t possibly have been exposed to all of it in a year. So I want a portfolio that demonstrates what they’ve done. But also, I quite like it when you tell me what you could do better. Because the whole thing about dentistry, The other thing about life is it’s a constant, never ending journey of learning and improving. I’m of the mindset, there’s no such thing as failure, only feedback. And if you say, you know, this is a case that I did, on my next case, I would like to improve this by doing this, this this, I’m thinking, you know, well, that’s great. You don’t think that you’re the bee’s knees, and the be all and end all, what you’re doing is you’re reflecting back, because, you know, we do need to reflect. And so demonstrate the reflection, demonstrate that there’s the humble and that you are looking to improve things because we all should be even 25 years qualified, I should still be and I am reflecting back. how could have I have improved that? What areas would I like to grow? I like a portfolio that demonstrates a range of skills, but also does give me an idea of their limitations. You know, I don’t want I did hire an apprentice. And one of the applicants failed to disclose that he or she had never done a molar endo, had never done a crown prep, this is even after DFT. And they’d had quite a restriction on certain things. Well, that’s quite important for me to know. Because it would be better for me to know that and go great, you know, we can introduce you, slowly, I can hold your hand, I can, you know, take you through that. So I think it’s showing some of your best stuff. It’s been honest, it’s been reflective. And it would be useful if you can, that your portfolio reflects your personality. So make it neat, make it smart, make it professional, make it slightly different, you know, whether it’s on a USB or whether it’s, you know, hard bound or whatever, you know, if there’s one job you’re going for, and you really want it, I mean, put some effort into that, that communication, that folder, that book, whatever it is. [Jaz]Brilliant. Thank you very much, Barry. I think that’s very useful. I’m going to add on a few things, showing my portfolio and or basic testimonials. I’ve got like a coloring that this is some years ago, I had a coloring done by my five year old patients that, you know, we got along really well. And they made a little coloring, a little drawing of me. And I’ve always kept that as like, my proudest testimonials from a patient and I think principals like to see that, show your human side, you’re good with kids that sort of stuff. [Barry]Yeah, testimonials, brilliant, you know, include some testimonials where and make them short. Because, you know, people like me don’t want to read long ones. But you know, short, punchy, or even screenshots, a couple of screenshots from Google of five star review. “My God, he was fantastic. Oh she was really gentle and amazing.” It’s like, because that’s what we’re in the game of, we’re in the game of caring for patients. And the quality the dentistry, don’t get me wrong, right. It’s important. The most important thing is how you care for the patients, how you look after the patients. And if you interact well, because without patients, it doesn’t no one’s know, I’ve never had a patient thank me for a tertiary Fisher. But they have complimented me on how gentle I was and how lovely I was. That gets more patients. Thanks for having me, mate. It’s an absolute pleasure to speak to you. [Jaz]Thank you, Barry, as always, it’s been great cheers. [Jaz]What your path was? And now I want to say what what can you you know, for those listening and watching right now, young dentists, what advice would you want to give them above and beyond what we’ve already talked about? [Alan]So I think really, it’s something useful would be, Don’t rush to get to the end. Because you again, I think you can be influenced and see cases online that you think that’s what I want to recreate. But there’s a lot of steps along the way to get to that. And if you just focus on that end goal. It’s you know, people will say that, you know, got to enjoy the journey as much as the end point. And by setting those small goals, you can really appreciate every little bit and achievement that you make. So, yeah, don’t set this end achievement. And you know, once I do that then I’ll be happy or then I’ll be doing well because really, it’s got to be smaller than that. And the second thing I would say is in kind of links on to that is just try and take enjoyment out of your work. I genuinely enjoy doing the work that I do. And my poor wife when I come home and say, so some photos I took today, usually, very politely obliges, but you know, she does not want to see another occlusal composite. [Jaz]How long you married? [Alan]Just so two years. [Jaz]When you get to five years, she doesn’t even listen to my own, plus she’s a dentists, just miss my podcast. She can’t give a shit about why do, man. I come home and I share the photos. And she’s like, Listen, I really don’t care. [Alan]Yeah, I think when the baby comes, that’s gonna be [inaudible] Poor kid. So enjoy what you’re doing and so on the same thing is the first point, I suppose is. I think when I was in mixed practice, you sometimes hear people saying, Yeah, I wanted to get into private practice, because then you get you can book more time and all this. And you’re sitting there going, well, doesn’t help me. And it just practice. But actually, you don’t have, it comes back to the small goals idea, you can just pick one case to say someone comes in, and you have a look in the mouth and you go, Oh, it’s just an composite occlusal. And you could think, Okay, get that, get that done, move on. Or you could think, Okay, I’m going to actually designate some time next week. And, yes, I’m not going to make much money out of that case, I might even make a loss, but it’s not going to affect your yearly take home. So learn something from it. And you can, if you making the big change, from doing what you’re doing to Okay, I’m going to do the perfect crown preps and I’m going to do the perfect dentures, I’m going to be the perfect everything. It’s not gonna happen. So just pick one case, enjoy it. And don’t worry 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 repeat that over and over. So everyone’s different in how they’re going to, how much time they’d be able to dedicate to that. But I when I was in [inaudible], I was working, I had no part time positions initially when we moved there. And they were all very, very different practices. One was private one was high need NHS practice, and a couple in between. And so I used my private practice time to try and do that but you can do it within your own normal day list. It doesn’t really matter. [Jaz]What you’re given there is really real world advice. Now it’s gonna help a lot of people. It’s a mindset thing, isn’t it? And I think Yeah, you can’t go to doing everything perfect gold standard, because you know, you have to be realistic about the time. If you all had three hours to do a couple of composites for every case, our density would be you know, our contact points will be tighter, our fishes would be on point. Our occlusion would not be as bad. A lot of things will be in our favor if we had all that time but to actually balance out especially if you’re in mixed practice or NHS practice. It’s a great little tip that you get, great little nugget I want emphasize that too. I would call that protective time. Give yourself and I think the way you said it was was great, pick a case and say you know this is my protected patient or protected case. And the rest of it you have to work smart and work well but still deliver as best case as you can. But then that one case where he’s going to fall in love with dentistry. In that fall in love with all the other dentistry but i think you know what I mean like that one case you can really put the cherry on top and get it perfect and slowly build your portfolio like that.

In this interview I discuss with Harmeet Grewal about Rubber Dam Isolation: https://www.youtube.com/watch?v=AEQ7bAuPWZQ Need to Read it? Check out the Full Episode Transcript below! How to get started with rubber dam isolation We discuss our undergraduate experience of rubber dam isolation How rubber dam reduces stress and improves the quality of your work Reduce ballistic droplet spread of viruses AKA the cough How to talk to patients about rubber dam – your mindset about rubber dam will affect your success rate and the patient experience of rubber dam! Are we rubber dam police? NO – sometimes rubber dam can be a hindrance! Me and Harmeet both love the mantra: Start now, get perfect later! Which rubber dam to use? Our views on IsoVac vs Rubber Dam Harmeet shows some useful clamps for molars and top hacks for Rubber Dam Check out Harmeet on Instagram @dr_harmeet_grewal Click below for full episode transcript:  Opening Snippet: Hello everyone and welcome to another episode of Protrusive Dental podcast. I'm your host Jaz Gulanti. Today we'll be talking with Harmeet Grewal, all about rubberdam isolation, which is so topical and so pertinent with the COVID-19. And how will we get back to work? Might there be a need for those dentists who are not routinely using rubber dam isolation to start using it? Obviously, we're worried about the aerosols, but also worried about the ballistic events IE when someone coughs and that's one mode that the virus can transmit. So it's very topical episode if you like... Jaz’s Introduction: Thanks for everyone who voted on the social media channels. But what you voted was for Harmeet Grewal episode and rubberdam isolation. And the next episode will be to drill or not to drill caries with Louis McKenzie, so I’m looking forward to that one. I won’t blab on for too long. I hope everyone out there. I hope you are doing really well. And I hope you’re getting to spend time with family. And I hope you are thinking about the day that we come back into practice. How can we come back bigger, better, stronger. And of course I hope we can use this opportunity so when we head back to work we can be fresh. My Protrusive Dental pearl is that some episodes ago I shared my customer screen. Now since then, Richard McIndoe shoutout to him, has modified it and added the goals, the patient goals section, which I think is so important. But I had a lot of messages from a lot of people saying, Look, I’ve got this CSV file, the which is the customer screen, but I have no idea what to do with it. So I’ve gone ahead and made a video on YouTube about how to actually install a custom screen, and then also how to pre load the custom screen with text in there. So not having to always type the same thing. So for example, if you take a bite wing, usually 9 times out of 10, the justification for bite wing is to check bone levels and for interproximal caries. And that can be written there within the customer screen. So it’s almost like a template within the custom screen. So if you’re one of my email subscribers to the newsletter, and episodes, you will receive an email already with that. If you’re not, then when you go to protrusive.co.uk pop up box will come up, sign up for the newsletter and the first email you’ll get, the welcome email will have the custom screen and the YouTube link of how to install a custom screen. So that’s all there for you. So that’s getting you to think about when we head back to work. How can we make our note taking better, more efficient? How can we work smarter. So I hope that’s useful to you. Now let’s jump in with Harmeet Grewal and rubber dam isolation. Main Interview: [Jaz]Right, Harmeet, thanks so much for coming on the Protrusive Dental podcast. Great to have you. [Harmeet]Thank you. [Jaz]You are someone who’s now redoing great things in education with rubberdam, which is such an important thing. But just before we get into that, we’re here in sunny counties, is it Cheshire? [Harmeet]I’m not sure. I don’t know where we are just up north. [Jaz]We’re in a private area. We could have pretended we’re in a five star hotel, but we’re being very real with you. And we’re here for the Dawson Academy at the moment, we thought be a great opportunity to learn from homie. So yeah, thanks for waking up in the early hours to record this before an intense session with Ian Buckle. For those who’ve done Dawson Academy, you’ll know exactly what I mean. So Harmeet, how did you get started with your journey in sort of getting using more and more rubberdam and getting to a point where you think you’ve been quite proficient with it? [Harmeet]It’s just trial and error really, I mean, I was kind of, I started using it as a time where I felt like I needed to use it not necessarily knowing why. So the reason I was using was thinking, I’ve been doing these composite courses. I think that I’ve just done Jason Smithson’s a lot, okay, he’s using rubber dam, I’ll see the logic of this. But there’s no courses out there. It’s kind of for me, it was a trial and error. It was going in and just doing it day in day out making the mistakes, and then learning from them. And then over time, it’s just like anything, isn’t it? You’d more you do something, the better you get at it. And then he kind of got to a point in terms of where the teaching led to. It was literally a conversation with a therapist. So I was working in Hitchin at the time and she said Harmeet Listen, I’ve got group of friends ladies and composite staff but can you teach us like rubber dam as well like a good day on competent rubber dam? So All right, let me put something together. So I started putting something together and I thought actually like a lecture on rubber dam. People think it’s like a quick topic actually, if all the bay, easily. [Jaz]Especially if you have a hands on component. [Harmeet]Exactly. So we started talking and I set up a course and then the funny thing was I was like I need to price this now. Okay because you know You listen, everyone knows you do a course, there is a charge for it. Okay, so, but then I said, Alright guys, this is what I’m gonna do this how much it costs? suddenly everyone just went quiet. You know what, I’ll put the effort? I made this presentation, I’ve got this idea. So let me just try it. Yeah, let’s roll it out on online and see if there’s any legs in this. And I just put it out there. And I think it was within 30 hours it is sold out the first course. And then I rolled another day out and the same thing. 24 hours, it just sold out again. [Jaz]It’s the demand is there. And then that’s exactly what we’re the one the first question want to ask you with that, at least be nicely is. Why is the demand out there? And why should we be using and learning rubberdam? [Harmeet]Okay, so two questions. The demands out there because I think it’s one of those things rubberdam that I think it’s not, it’s, it’s poorly taught, if it’s taught at all. Okay, because it’s something that’s skimmed over, why it skimmed over, who knows, it’s, it could be that when people are at uni, there’s people have biases that, you know, some people justify not doing things, that could be a tutor, you know, just saying, Well, I don’t think you need it, therefore, I’m not going to teach it or it couldn’t be someone saying, Well, actually, I don’t know how to use it myself. So therefore, I can’t teach it. So it could be [Jaz]I 100% agree with that. So my experience with that was the gdps, who were also part time tutors at the dental hospital. They weren’t using isolation day in day out. You know, I probably even say that, having seen some of their root canals on outreach. They weren’t even let’s not even get into the topic of endodontics. But so if the tutor themselves were not proficient in doing it themselves, how can they teach it to a student? So I think a large part of that is depends on where you were taught and whether the tutor was doing it with them. [Harmeet]100%. And then I think the other thing is Why? I think as dentists we always want some evidence, don’t we? We always want some evidence because it.. [Jaz]We love the nitty gritty. [Harmeet]We think it’ll help us sleep at night. Actually, there’s always evidence for, always evidence against. [Jaz]Why do you use them? [Harmeet]So I always always base my decision on logic. Alright, logic is one thing. And that’s logic around the decent dentistry. Actually, even more important is for me is reduce stress, and improve clinical practice. Now, if you say to any dentist, can I reduce your stress and improve the quality of work? He’s gonna say, No, no, no. The first that’s always stress. Stress is sometimes up because patients are difficult. We’re working in a difficult environment. Patients don’t want to be difficult first of all, you know, they know that they’ve got an awkward mouth and they apologize profusely, don’t they? Often they do. It’s not their fault. But actually, the process of putting a rubber dam on you’re kind of eliminating that patient for a while on you. It’s just you and their teeth. Tongue’s gone. Everything else is gone. [Jaz]Everything’s out of the way and quite often they fall asleep. [Harmeet]Exactly. And then but that stress element, then I was laughter in my lectures about the situation where you have a matrix band on and about 15 cotton rolls, and your hand cramp. And you remember that? You can’t see your composite and we laugh about it. But we’ve all been there. So now you can put rubber dam and breathe for a minute. [Jaz]That’s the main reason I use it. I feel so much more relaxed as a dentist when it’s on. I don’t have to constantly watch everything. Okay. One of my patients I’ve been if that ever happens to you, he probably has because I see it so much is when our patients in the middle of a root canal. I think she was diabetic. And she just had to use a loo. That she had to use. That’s fine. Yeah, go come back. Okay, I am no, no fear that she’s going to look at things like this is a total peace of mind. Yeah, has happened to you? [Harmeet]It has but then I kind of I guess I’d normally forewarn people in terms of like, you’re going to be in the chair for while this is how much, it’s longer it’s going to be. So they kind of caught up on that. I need to pay for parking. I probably need to go to bathroom. I need to probably do this. But there’s times I need to go. [Jaz]or they need to cough. And they can just go cough into your hand. Mess up anything. Whereas if you’re not using isolation, yeah, to that degree. You’re always stressing about the cough. You’re always stressing about the tongue. You always think about the anatomy. [Harmeet]Yeah. I think patients cough because sometimes they don’t know what to do. So a tip for everyone is just your communication with the patient. Actually, for a lot of patients they might have rubberdam, I’m actually explaining before you do the treatment. So examination stage, what you’re going to do, pictures, films, and then obviously in the day, just reiterating what you said. [Jaz]Do you use an analogy to explain to patients what you doing with rubberdam? [Harmeet]I kind of explain it at least it was one of the reasons actually for using it was on the logic of adhesive dentistry. So when I was talking about you know those questions why to use it, it was I always think of Firstly, let’s look all the guys we look up to Magne, Dietschi. I mean, that does that two in the world, but there’s always a common theme amongst these dentists isn’t it, any work they display, always done on the rubber dam, must be a reason. But I’ll bring it back to like, what are we doing essentially if we kind of being crude with just glueing something to something else aren’t we? So if you’re broke something at home For example, I wouldn’t you know, if I broke a plate, I wouldn’t just pick it up and just try and stick it back together and probably want to clean it, make sure it’s dry. That’s the kind, when you pick up a packet of glue that’s what it says clean dry surfaces. And that’s why think about teeth. So that’s then how I explain it to the patient. Why am I using this? [Jaz]I always mentioned every and every episode, and I’m mentioning quote from Zak Kara. But Zak always says it’s like painting in the rain. And that’s how we know he said,. [Harmeet]He said, it’s painting the corridor through the letterbox. [Jaz][inaudible] brilliant analogies, I always. And I always often say it’s like an umbrella and everything is gonna be protected. And also, you don’t need that horrible feeling that you have when you’ve water at the back your throat and you’re sort of flooding. You don’t have that anymore. Yeah. And patients bind to us,. [Harmeet]You know, you can say things in a nice way. And then even just think the explanation is like, actually, once it’s on, I can concentrate on doing really nice work for you. Which patients gonna say, I don’t want you to do nice work for me. So don’t use it. [Jaz]They won’t say that. But what they will say afterwards is that oh, my God, this is such a new technology. [Harmeet]Yeah. It’s funny, isn’t it? It’s have been around since the 1870s. [Harmeet]Well, yeah. 1860. And it’s, it’s crazy that you say is taking us this long, but like I said, it’s just because it’s poorly taught, but back to the communication to the patient is purely, I then put it on, explain to them how they can swallow and breathe, you know, so they feel in control. And then give them a few minutes before we start. And that’s probably the best way to communication actually becomes important in this place. Important in everything, isn’t it communication? So yeah, but that’s a different topic. [Jaz]Absolutely. Are you part of the rubber dam police? [Harmeet]No. I, you know, it’s, I don’t want to be that person who breaks people for not using rubber dam because I think that’s unfair. Because there are some instances where, you know, actually, you’ve got to think, is this gonna be a help or hindrance? [Jaz]Let’s get, Well, that was one of my questions. Let’s go into that. So when does rubberdam actually become a hindrance? Rather than a benefit. Any specific scenario for you? I have a few in my mind. But when you recommend? [Harmeet]It depends on personal comfort. So some people might say I composite veneers at the moment seems to be the buzzword, doesn’t it? Now, having a rubberdam on with gloss ties, and then you getting resin composite in there. It’s messy, isn’t it? Sometimes it’s not that you don’t use rubber down, but sometimes I apply split dam, might be a different option. It could be that you’ve got a wire retainer. Well, it could just be you’ve got heavily broken down teeth that you might not be able to clamp, you know, then therefore you if you can’t get a clamp on it. So how you’re going to get rubberdam on the teeth. Or it could just be emergency situation. [Jaz]Yep. In the real world [Harmeet]Real world is like you know, you’ve got small chip on upper incosors. And let’s be honest, easy enough to isolate. Exactly. You could just cotton rolls in the access. It’s why not? I’ve done it. You could have a really good patient with good mouth opening. You’re doing a really small occlusal cavity on the six. I’ve done it without it. [Jaz]Stress factor is way less on there. [Harmeet]Yeah, exactly. [Jaz]Class fives, either. I don’t use rubberdam. Because I feel like it’s just in the way. [Harmeet]Yeah. Again, you don’t need to again, maybe on the lowers. It’s a little bit again, I sometimes prefer a split dam. It’s still a little bit of isolate. Yeah. But it’s something but yeah, I don’t like to because I understand that people, you know, we all have different working environments. And you know, it’s, I don’t think that just because you haven’t used rubber dam, therefore, you’re a bad dentist. And yeah, so I don’t really agree. And, and also, you know, I guess another thing this is going social media, I think people think this is been using rubber dam. People think the rubber dam needs to be perfect. You know, if it’s not inverted, or.. [Jaz]I’m so proud of the rolls on my rubberdam and I’m like, you know, fine as isolated I’m happy. Then you go and make it neat and nice. It’s good. It’s really good for your dentist OCD. It’s good for your stuff. But it doesn’t doesn’t have to be perfect. I love it. [Harmeet]And I always say like, you know, if you’re just starting, start now get perfect later. That’s a phrase from a guy called Rob Moore. [Jaz]Absulutely. Rob Moore. His podcast is called the Disruptive Entrepreneur. [Harmeet]Exactly. So he’s brilliant. And it’s just, yeah, people just, that’s admirable, we all want to be perfect. Okay, but like, you know, sometimes just make a start. And at the end of the day, always realize what we’re doing it for. It’s not for social media, which is nice, because I do think social media is brilliant. But there’s, it’s for the patient, isn’t it? Then it’s going to benefit us in terms of our clinical work, but then the afterthought is Alright, this could be a good tool that I use, whether that’s to teach people, teach patients or the dentist, but that should be an afterthought not, you know, the forethought? [Jaz]Well, if you’re getting started in rubberdam, then I think like you said, start now and get perfect later. So book in that extra 10, 15 minutes for your first case, for example, talking therapists, young dentist to fit I know plenty of not so young dentists who don’t use rubberdam actually now clocking on that they want to do rubberdam just book in some extra time, right? Take it slow. It might be embarrassing first few times as your nurses trying to floss and that sort of stuff. And you’re struggling. Yeah, it’s just like you said, start now get perfect later. [Harmeet]Well, that’s it, it’s just giving yourself that time. I think sometimes as dentists, we’re guilty, we don’t give ourselves time we go and try and implement something in the times that we would, you know, doing it in previously, if that makes sense. You know, might have do Michael Melkers and not be booking 45 minutes for the composite, and then still expect to do their rubberdamn now, in addition, I say, just give yourself time, you know, like you need to,. [Jaz]And your nurse needs to be in, you know if your nurses never used rubberdam before and you’re suddenly going to rubberdam course and you come back and say, right, we use rubber dam, and you just start using it. And the nurses, you know, finding this dusty pack of rubberdam. Everyone needs to be in on it. [Harmeet]Yeah, you’ve got to train your nurse and you know, what? Would you want to be sat there all day, not doing anything? It’s, you know, I just think sometimes we underutilized on nurses, and we don’t give them the credit that they do. Because one, they have to deal with a lot of us and we’re not easy personalities. And, you know, it’s not an easy job. It is a funny thing. Actually, I want to give it my best joke on the course I’m giving it away now. But there’s a video I do like some pre film videos of techniques. And then my nurses and often asked people I was like, You must think my nurses inherently really good. And I must have trained phenomenally. And people are kind of like Well, yeah, she must be, you must have trained her you know? And then I kind of say well, actually in that video, it’s not my nurses, that my mother in law. My wife’s in the chair as the patient and it was just literally a case I needed to film these videos. I said are you free? Can you help me? Yeah, like somebody’s got no nursing background actually just the act of me saying that can you just hold this and do this? It was easy. [Jaz]If a non nurse can do it and you know you can train your own nurses. [Harmeet]But then I always say to everyone we always quick as dentists we blame everything else but actually it’s often starts with us. And what we need to do is we haven’t communicated often dentist we communicate in eyebrow raises. Weird eye looks Huff’s and puffs. And Grandpa, but not words. Yeah, if we just use our words, we probably think you know, life would be a lot easier. So that’s another tip. You know, just talk to your nurse, get her involved and get I guarantee you there’s.. [Jaz]Get the practice involved. Get the whole practice, you know, it treatment coordinator reception, you know, so that in the future when they say, Oh, you know, what’s that dentist like? What’s the treatment like? And I want people to have reception is that Oh, by the way, he used something called rubberdam It’s amazing. You’ll be very comfortable. So yeah, that’s maybe a far fetched example. But you know, with any treatment modality that you’re offering that you’ve changed your practice, the whole team should be in on it. [Jaz]That’s it treat your staff with it. I do any work my nurses needed, done it for free, done it on the rubber dam you know, she now she came from a practice and never use rubber dam we use is to the point I don’t have to. It used to be when she first started working for me “Harmeet, do you need rubber dam? [inaudible] Even for stuff I don’t need it for. she’s got the rubber dam out. I was like “Jesse won’t need it.” [Jaz]In fact she’s probably surprised. Oh, you’re not using rubber dam in this case? [Harmeet]She rarely surprised. She’s disappointed? When you say “Jesse, we don’t need rubber dam today.” Because it makes her life easier as well. [Jaz]Which the opposite of that is when you ask the rubber dam and then your nurse raises like, again rolls her eyes. That’s when you haven’t had that sort of session beforehand, whatnot. [Harmeet]It’s not because they’re closed off. You just need to spend some time maybe just kind of you know with them and training them [Jaz]Using the right rubber dam. In my experience in the past and want to hear what you are recommending now. But when I started from dental school, I hate rubber dam. We use a horrible green latex one that kept tearing. Alright, then I moved to that horrible purple one that it’s impossible to tear but it’s just in the it’s the ribbed one. It’s I think it’s latex free? Hated that as well. Then I found the Unodent one with the latex free. And that’s been phenomenal for me. Is that what you’re recommending? Is there something better? And how important is it to use the right rubber dam for the experience as a dentist and maybe even as a patient? [Harmeet]I yeah, you you always have your preference towards materials. So I use I mean the two that kind of seem to be go to, the Unodent or Nic Tone and I like the Unodent. It just works in my hands. I mean, all rubber dams can tear but then that’s based on often it’s maybe not punching the hole clean enough, maybe leaving too little distance between hole punches and then even sometimes it’s often the way people manipulate it between teeth, often not being patient and sometimes being a bit too aggressive with floss which pulls tears that can often be the biggest problem. So first it’s learning how to use it and then after that is preference. Now I like Unodent purely in the basis I use a heavy gauge. Benefit of a heavy gauges you get quite nice soft tissue retraction, easy to invert and everything but then also from but I guess photography of things. It gives quite nice contrast when you’re taking Your images and things. So I like that side of things. But again, it’s preference. I mean, if you speak to endodontist, I think some of them suggest that Roeko down the ribbed one because I think, [Jaz]I think the single tooth isolation, I can definitely see advantage. Very quick, easy, it’s got a lot of given it. For multi teeth quadrants and stuff, I found that a nightmare personally because he is quite thick and to flush it through is not as nice. So free from trial and error. I’m glad we reached that same illusion about rubberdam choices, but you know, us wherever you want to. I think sometimes you have to go through the difficult periods to realize what.. [Harmeet]You’ve got give everything a try. But I’d say you know, if you want to start a good place try the Unodent, heavy gauge. [Jaz]if you’re getting frustrated from the rubber dam is probably the rubber dam as well. Adding to the frustration, I just felt that way with a green one, I had a massive shift when I switched rubber dam and it became easier and quicker for me. [Harmeet]Some time you know, it’s the little, it’s a small little details of rubber dam, that actually make the biggest difference. For example, we talk about the size of the shape, people don’t realize they come in different sizes that can influence maybe how tightly you’re stretching over the frame, or how much material you have to play with. Because you can imagine if you’ve got something stretched quite tightly, because it’s like an elastic band, I always say. So that then makes it more difficult to manipulate. Because if you’ve got something with a little bit of give, it’s easy to manipulate around clamps through. So it’s just little things like that the nuances I guess that make the rubber dam placement then a lot easier. [Jaz]It just get up everyone start using more more rubberdam to get that sort of hand skill. Yeah, that’s necessary along with your nurse who, do you get your nurse to floss? Or do you floss? [Harmeet]My nurse esentially what she’ll do is I’ll once I’ve got it in place, she’ll kind of stretch it over the contact area, some contacts, it has dropped through some areas it doesn’t but she’ll stretch it. So essentially, by stretching it, she’s thinning it out, holding it there while I gently pass the floss. Again, it’s teamwork. And, you know, it’s you can in terms of learning it, you can do it yourself. I did it myself, you know, you don’t have to go on a course, you know. But I always think the way I’ve kind of got better at dentistry is like why sit there and make a million mistakes? Why not go to the guy who’s already made those mistakes, you can fast forward that process. Hence, the course is. [Jaz]Down on the shoulders of giants. And I mean that in your case, your isolation I see is absolutely phenomenal. I messaged Harmeet sometimes I’ve got this clamp, can I modify this clamp in this way? And instantly he responded that Yeah, go for it. So you know, I trust me up to disable that. And it’s Yeah, like I say, instead of wasting that time, that embarrassment with a patient, you get a head start. And when you feel more confident that patient can detect that. So my next question Harmeet is, Oh, so a lot of dentists advocate using the Isovac or the Isolite, which is for those who don’t know, it is a it’s like a mouth prop. But it’s also has a something that sort of pushes the cheek out of the way, pushes the tongue out of the way. Yeah, it’s good. I’ve used it. My bias is still towards rubberdam even financially is a better thing to use rubberdam than Isovac unit per pouch has single use. But What’s your view on that? Someone who’s like very pro on Isovac who never use rubberdam because of it. [Harmeet]I’ve used isovac I’m, you know, I kind of got it in the last practice. And it was good. But again, expensive. And actually I just found sometimes they’re a little bit faffy to put in. I don’t think they’re always that comfortable. People think like, oh, they’re going to be very comfortable. But actually there’s a lot going on. Sometimes it’s just easier to use rubber dam and issue I found that I still found access wasn’t that easy with the Isovac in. Because you’re kind of limited to the angle of the approach, if you know what I mean. You know, it kind of makes it slightly narrower working corridor for you. So you can only really approach arch in in one direction. So early time I found it useful was for like kids. Okay, you know, if you’re doing like fissure seals and things. Yeah, that’s good. That’s the only time I find it useful. But otherwise, I just find rubberdam this easy, quick, deeper. [Jaz]See, that’s what Isovac people say they say, Oh, it’s so much easier than using rubber dam. But it’s what you’ve been exposed to and what you give an opportunity to. Yeah, I think if you I think for the complete beginner. Yeah. Isovac may be easier to you. Yeah, then the nuances of rubberdam. And going through the sort of the pain of the learning process. I can see the entry point into isolate. Yeah, but here’s my argument with those who use Isovac and Isolite is when you’ve got your Isovac in. Okay, and then you let’s say you’re doing a DO on a lower six. Yeah. And it’s getting close to gingiva. How many caries lesions are we restoring that I’m not near the gingiva? Very few probably, you know, often you’re doing the wedging and then there’s a bit of bleeding happening, right? And then you put your matrix in and you’re just having to whisk away some blood. If you just use rubber dam to compress that papilla. Yeah, that bleeding issue is gone. So I think as a macro isolation, Isovac is great, for the tongue and cheek, but on a micro level, the hemostasis it will be rubberdam. [Harmeet]I agree. Rubberdam definitely. Entry points. I mean, I guess entry points in terms of ease of use. But I guess financially, isn’t it? I mean, unless you’re going to actually put nice principlas you want to buy or if you’re prepared to fork out as an associate, but rubberdam is just yeah. [Jaz]I think my principal was happy that I’ve started, even though we had isovac that I stopped using it and just use rubber dam. I think Yeah, I would say it’s 250 a pop or something like that something something crazy. Right. So last couple of questions then. On when you teach your courses, yeah. And you have delegates of various experience levels. Sometimes as an educator, you realize something new that you didn’t know that your delegates either had a learning need that you didn’t realize maybe, or that in the real world, your delegates might be struggling with something that you maybe hadn’t considered? So what are the most common mistakes you see people make when they’re on your course, hands on the isolating that someone could be making Monday morning, or they listen his podcast? Oh, yeah, you know what Harmeet inspired me. I’m gonna start using rubberdam now in practice. What’s the most common mistakes to look out for that you see? [Harmeet]Okay. So in terms of delegates, I mean, I try and be quite good to the delegates in terms of one before they come on courses, I kind of email everyone and say, Listen, if you have any questions, specific questions, just send them to me, any struggles. Because it kind of gives me an opportunity to look through my lecture and say, I have is discovered, and to be honest, is it generally always is if there isn’t, I always say to people, you know, I will then add something in the slide. Okay? Or if it’s something on the day that they come up when I’m actually No, I haven’t thought of that. Let me look into that. And then I’ll get back to you. So I try and be helpful in that way. In terms of how I pitch that I always pitch today in terms of Listen, I don’t know what anyone knows, really. So we start really basic. And I think because I’m actually even in the basic of its people, actually, I actually didn’t think about that, to go through the basics and ramp it up towards the end of the day. But then, in terms of mistakes that I see people, it sometimes you know, it’s not the actual hands on is something I think flossing, sometimes actually flossing, the dam through contacts, actually, dentist, we can be a bit overly aggressive with it, we will be just trying to get this thing through. And sometimes we actually create more headache for ourselves. Because one, it can hurt the patient. Two, if you just forced the rubber dam down too quickly, all that rubber dam might not be through that contact point. So what essentially happens is you’ve got floss, and then you’ve got rubber dam wrapped around it. Yep. So what happens? You pull that floss out, rubber dam pulls with it. [Harmeet][Overlapping conversations] [Harmeet]Because I think most dentists would have that situation where they floss [Overlapping conversations] and you’ve hold it. And you think why is the rubber dam pulling with it? Well, you pull it hard, and then it’s just torn. It has tearing in. But often it’s more the rather than the actual hands on what mistake dentists make is rushing. We sometimes don’t, I talk about a checklist. So you know, Ian’s talked about the Checklist Manifesto is a good book, and having checklist for everything. Because they liken it to aviation, right? Yeah, a pilot might have flying for 30 years, they still go into their cockpit, and.. [Jaz]They have a co pilot with. [Harmeet]And they have a checklist before they take off. And it’s not exhaustive list, it’s the main points. That’s the reason why it’s the most successful industry. You know, if a plane crashes, we hear about it because it’s so rare, then they find a black box, they want to figure out what went wrong. Why not apply that to dentistry, you know, actually having a checklist, again, not exhaustive. Like they say, five to seven point list, with the main points, you’ve got some structure for yourself, you’ve got some structure for your nurse, you know, as you all know what you’re doing, actually makes you more efficient. But sometimes you can give people that checklist and we do during the course. But then sometimes they start skipping.. [Jaz]That’s when you run into in trouble. [Jaz]And that’s when you run into trouble. Because you realize, actually, I haven’t completed that first step. But I’m jumping on to the second and then you jump on the second and you realize the first steps coming undone. Actually, I say if you actually spent a little bit time making sure you’ve achieved each goal, actually, the process does becomes a lot more streamlined. [Jaz]When you become slick, then you can do it intuitively. But I think when you’re learning out having a checklist that that would be I think, [Harmeet]even even though actually when you’re slick at it, you still need a checklist, because the other thing that happens with human beings is we sometimes just go on autopilot. You know, we can have all have a bad day.. [Jaz]Unconscious competence. [Harmeet]Exactly. We all have a bad days, or sometimes you need that kick up the backside, just to remind you. [Jaz]So we’re gonna start wrapping up now in terms of all the tips are giving, I’m going to ask you two things now. One, I’m going to ask you maybe a more experienced question, okay, and how we can get around that. And then, I’m gonna ask you for your, the best tip you want to give us to our listeners in terms of a little hack you can share with us. The first question is, when we’re isolating molars, and second molars, it’s one of those difficult things we can do. Or something I struggle with a lot. What advice do you have with that and also So in that situation whereby, when you put a clamp in, let’s say you put a clamp on the seven or even sometimes a wisdom tooth, but there’s no space because the coronoid process is in the way. And often I get the patient to move their jaw all the way to one side, okay? But it costs an arm just worried about, you know, causing pain problems, is that the only way? Is there a better way? And then generally on that topic of isolating molars, what nugget is going to give us? [Harmeet]So first is get a good clamp on the tooth first, because if your clamps not secure, it’s going to pop off and we don’t want that. So generally, for things like you know sevens and eights, you want one of the kind of auto metal clamps, I use these Coltene clamps they called gingival retractor. [Jaz]You’ve got a photo? [Harmeet]I’ve got a picture actually of a few. Let’s have a little look here. [Harmeet]Let’s share the screen with you. [Jaz]I think you’re sharing already. [Harmeet]Okay, brilliant. So here we go. So these are the kinds of Coltene clamps if you can kind of have a little look there. Okay. So generally, they come as a B1, B2, B3 there’s also a B4. B1s generally, lower molars, B2s upper left sevens, particularly. And then B3s generally, upper right sevens. Because you can see there’s like the difference in you know, the beats of the clamp, different widths. And that’s normally because sevens have that kind of triangular shape. Okay, so these are a bit, they clamp a bit more aggressively, so you get better grip on the teeth. So these are brilliant for that. [Jaz]So these are not your primary clamp, they are additional retraction or [ ? ] [Harmeet]That’s the primary clamp that goes on first and you always want to just put your clamp on first check it secure, right, then you know, you’re good start. Now then the next bit is just maneuvering over and like you said often it is. it’s like when you do an extraction, isn’t it? You get that patient to move their jaw slightly gives you this little bit of wiggle room, maybe even close slightly. That’s the second tip. The third thing is just having, like I said, not stretching the rubber dam sheet of your frame too much. [Jaz]Okay, [overlapping conversation] [Harmeet]Exactly, people stretch it over the frame so tightly that it’s quite like given, you know, they’re almost trying to pierce the rubber dam, actually, all you just need it to do is grip on, because then by having access, like having some given there enables you to get it over the bow of the clamp. I always use the analogy of like feeding paper through a printer, you know, you’re just feeding it over, and then you’ve actually got time to flick it over. If it’s too tight. Every time you try and get it on the bow it flips back on. [Jaz]Definitely been there. [Harmeet]And also, if you have the loose clamp and you’ve got that muscle, elastic energy in there, it’s going to ping the clamp off, isn’t it? So that’s Yeah, that’d be my tip for that one. [Jaz]Fine. And then what is your hack that you can share with the listeners about rubberdam? What’s the main one of your pro hacks. [Harmeet]Let’s give little hack from one of the lectures. Here we go. Because there’s so many. So people ask about you know stents when you’re using a [inaudible] free composite, rubber dam and my clamp gets in the way. So I say let’s start backwards. If you’ve got your model of your wax up, what I’ll do is decide, say your wax list for this example. So we did composite three to three. Okay, you always you know, you’re going to, obviously have your stent to encompass three to three, but you need something for your stent to sit on. You need your stops. So you think you know, I need to rest on the fives and the fours. So then you’ve got to think Alright, then need to put my clamps either on the sixes, or the fives. Okay? So what I’ll actually do is I’ll get my wax up model, I’ll put my clamps on to the model. [Jaz]Like you have done on the.. [Harmeet]That’s it, and then I’ll put them on I’ve done no, they’re the clamps I’m going to use. And then I’ll just make my putty over the top of that. And then I can see I’ve just cut that back then. So I then know, when I go and put my rubber dam and everything, I don’t have to mess about adjusting things, because I’ve already done it in advance [Jaz]That awkward scenario we were going on and then I’m going to backfill so I guess worked for me, whereas yours very predictable is that yeah, it gets through that. [Harmeet]It’s actually, you know, can do it quickly in your lunch break. You know, it’s just you’ve saved yourself like 5, 10 minutes of messing about in the mouth and you can actually just crack on and do the work that you need to do. [Jaz]Amazing. Well, I think we’ve covered a good few reasons to use rubberdam and a good few reasons not to use rubber dam, how to accelerate your sort of experience and learning rubberdam, which rubberdam to potentially use. Go out there Monday morning start using rubberdam, building the extra time, if you need a bit of help, Harmeet is always available. I’ll put on his link to his sort of event or whatever. [Harmeet]Yeah, well just contact me on social media if you want. We do obviously, we did the courses around the country but even you know, practice now we go and teach practices, teach teams so whatever you want. [Jaz]Brilliant. It’s a great thing of teaching. I think it’s so nice to see good isolation. I think the patient’s benefit it, I think we as dentists and the wider team benefits overall. So thank you for for coming on. [Harmeet]Thanks for this podcast as well. Actually. I really enjoyed it. I mean, yeah, listen to people like Tif and, you know, you’ve had some great guests, actually, I envy it. [Jaz]I’ve been very fortunate that people are sharing their, this over what you know what they do day in, day out. And I think it’s been good for learning points including this one. And thanks for doing in a video format so I can share a few snippets from your slides and appreciate that. Thank you. [Harmeet]I’m glad to put some makeup on. Jaz’s Outro: So as always a big thank you to our guest for today’s podcast. Harmeet Grewal, I’ll catch you the next one with Louis McKenzie but in between that episode, well between this episode and that episode, I’ll also have a little bit on what to include in your portfolio and your CV for those especially in DF1 in such difficult scenario for everyone, but especially you know, DF1s because you know, you’re the least experienced dentist in the country, technically right? And then now you’re having all this downtime, not having the ability to refine your hand skills, and then you’re potentially looking for either a DCT position or an associate position. So a competitive content for you in terms of all you know, I’ll show you my CV and my portfolio, which had landed me some good jobs before. So I’m hoping that’s gonna help you out in terms of ideas and thanks as always for listening all the way to the end.

I speak with a Musculoskeletal Physiotherapist (Ben Pollock) and a Physio-turned-Dentist (Samuel Cope) about back pain and Dentistry – I was left SHOCKED about the relationship (or lack of!) between bad posture and having pain as a Dentist, Therapist or Nurse. Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: check out my favourite (non-dental) books (my reading list) for self-development, social sciences and personal finance. https://www.youtube.com/watch?v=a7sdALEGp80 How can we prevent back pain becoming a problem for our profession Advice for dental professionals suffering from back pain Will saddle chairs work? Does magnification really help your back? (this one was surprising, too…) Back pain myths debunked – is there a role for massage? Pilates? Mobilisation and manipulation? Acupuncture? How to know if your Physiotherapist is evidence based? What can we do AT WORK to help our backs? Are you moving around while doing your Dentistry? Shout out to @Ian Dunn at 34 minutes Is stretching good for back pain? What relation does stress have with your back? I somehow manage to bring occlusion in this one…sorry not sorry! We draw parallels between the Physio world and Dental world If people want regular updates on back and neck pain in dentistry they should follow: Twitter: @Toothphysio and @Ben_FYS Instagram: thetoothphysio If you are looking for an evidenced based physiotherapist in your local area then find followers of @MSK-Reform on twitter and see if any of them can help. Message from Sam and Ben: We will also be starting a novel neck and back pain musculoskeletal pain programme later on in the year that will be advertised through the Toothphysio on twitter and Instagram. This will include dental specific: · Education on prevention · Management of neck and lower back pain · How to manage colleagues with back and neck pain · How to cope with acute back and neck pain and how to overcome it with pain relieving strategies · Case studies · Exercise class The course will be run by Sam and Ben, two qualified musculoskeletal specialist physiotherapists who will guide participants though exercises and education. Click below for full episode transcript: Opening Snippet: What do dentists, hygienists, therapists and nurses need to do to make sure we don't end up retiring with or due to back problems? Yeah, tell us tell us Ben about posture. So have we as a dental industry overplay the role of posture?... [Ben]Most definitely. If there’s one thing to take from this podcast, is that [Jaz]Surely being like this, like surely just like, you know, you when you see those photos on people on Phantom head courses, and they’re like, they’re like this, and they’re like, polishing something. And they’re like that. I mean, granted, we won’t be probably not like that for longer than a couple of minutes at a time, you know, when you’re doing the distal lingual of a six or a seven. And you just have to do it. I think after listening to today, and listen to you guys, I’m gonna feel less guilty about doing that. And I’m just gonna just move along afterwards. Jaz’s Introduction: Hi, guys, it’s Jaz, again. I want to ask you a question. How much money do we spend as a profession, on our practices, on our chairs, on the service and maintenance of our equipment, on scanners, hand pieces, and generally just making sure that we have our favorite kit available? What is the most valuable piece of equipment, or maybe not equipment, but most valuable asset in your practice? It is your health, your hands, your mental health, your physical health. And of course, when you consider that 94% of dentists will retire with backache. And apparently 100% of nurses will retire with backache, it makes you really wonder about our priorities do we actually look after our health as much as we should be? And combine that with a stressful position with a sort of confined environment and the different postures that we have to adapt? Now I mentioned postures but one of the most profound things about this podcast episode is that I learned that actually, the posture is really overrated in dentistry. I could not believe it. You hear my reactions through the podcast. This podcast episode is done with two physiotherapist, Sam and Ben. Sam is actually a physiotherapist turned dentist so he can give us the view from sort of both sides of profession, physio and dentistry. So this is a quite unique episode if you’d like I picked up quite a few nuggets about my own personal health. The Protrusive Dental pearl, I want to give you today is a reading list. Ben actually shared one of his favorite books in the episode and the book is called ‘Why we sleep?’ And so that got me thinking. And I had a few messages from people asking about my reading list after I’d mentioned those Brian Tracy books on a few episodes ago. So basically, I’ve put together a little book list, you can find that on the website, protrusive co.uk/books, and you can access that I’m going to stick it on the Protrusive Dental community Facebook group as well. So I’m gonna just my basic recommended books are read, I’m very much a disclaimer is that the books that I put on there are very much my own taste and the kind of books I’m into is self help, self development, productivity, social sciences, things, you know, things like Malcolm Gladwell, for example. So those kind of books I’m into also personal finance. I’ve got two personal finance books on there as well, which is you know, what time during COVID to consider things something reading into something like that, how to actually learn about looking after your personal finances something I’ve taken interest in last couple years. I’ve got that on the protrusive co.uk/books, and we’re going to jump straight to the episode. I’ll catch you in the outro. Main Interview: Guys, we’ll just dive right in, as I say, and we’ll start the Protrusive Dental podcast guys, for those of you who are listening. I haven’t met Sam and I certainly haven’t met or emailed Ben before, but we’re having the first ever Protrusive three way. [Ben]Excellent. Wow. Yeah. [Jaz]Let’s start with Sam. Sam, tell us about your, because we started connected by email you listen to podcasts, and I think you can add some great value to the listeners today. Tell the listeners about your background in terms of you know, your dentistry but before your dentistry which makes you in a position to be able to talk about the sort of things that we’ll be talking about today. [Sam]Yes, why I qualified from Kings in 2015. Then I worked as a locum physiotherapist in the Northwest and that’s where I got good interest in musculoskeletal physio. Then after that, I decided that I wanted to do dentistry so I was on the dentistry course and the four year program. And then while I was there, I was an associate for a private company where I saw NHS private patients. I was also the physiotherapist for Merseyside Fire and Rescue in the Philharmonic Orchestra. So lots of perks there. [Jaz] Wow. Very nice. [Sam] And then, but I found that when I was working, I was seeing a lot of dentists. And I was also seeing a lot of students as well. And that’s what kind of got me and me interested in you know why is dentistry such a high risk profession for lower back pain, neck pain, and that was what the majority of that was coming in was lower back neck pain, upper back pain. And it also found that when I was going on placements as well, I’d ask, you know, the principals, you know, why do you work, you know, why don’t you work four days a week? Why you work reduced hours? and most of them would say, Oh, it’s because of my back pain or because of my neck pain. So it does have quite large impacts on dentist life I found. [Jaz]Absolutely. And when you said so you qualified 2015 that was not in dentistry there right? What was it? [Sam]That was in physiotherapy so then I qualified dentistry last year. [Jaz]Amazing. And then when you were doing your locum that was a locum physiotherapist, right? [Sam] I was like in physiotherapy [Jaz] I’m about to say, you’re on this accelerated four year program, you’re able to practice dentistry as students of that year. Sam definitely was not doing that if anyone’s listening have that sort of nature. But no that’s pretty interesting story. And now you’ve developed an interest in that obviously, because of your very unique background, I think, do you know anyone else who’s had a physio / dental background like yourself? [Sam]Well, I was speaking to Ben about this before, but I actually know that well, it was a physiotherapist that had gone on to do dentistry that helped me get into into dentistry. [Jaz] Also at Kings? [Sam] Also at Kings Yeah. [Jaz]Cool. Very, very good. It’s good to have that four year program actually. Which helps, I think just to shorten the know, the five year degree. Ben, tell us about yourself. Your background, I believe is in musculoskeletal pain. [Ben]Yeah, absolutely. I mean, well, before I introduce so Jaz, I just want to say a huge thanks for having me on the podcast really. Also, I really appreciate what you’re doing for dentists. I think it’s really important to ask questions, you know, whether it’s dentists, physios, doctors, you know, it’s really important that we stay current that we stay evidence based and that and we’re learning all the time so yeah, kudos to you for putting this on really. I must say that, you know, I probably wouldn’t be the clinician I am today without podcasts. I mean, shout out to the physio podcast out there says choose health. There’s a NAF physio podcast, there’s Physio Edge, Strength Physio. And honestly, without that their input, I wouldn’t be the clinician I am today. Certainly. So [Jaz]I actually listened to one of the physio podcast says Sam. Oh, yeah, I think it was the physio edge. Right? You sent me an episode? [Sam]Yeah, [Ben]Yeah, it was with David Pope. [Jaz]I think it was, [Ben]Honestly, if I was a patient, I would want David Pope to be my physio. He just sounds like the nicest man. But you’d want to tell him about your pain, you’d want to because he’s got this really soft Australian accent. And as I say, if I could pick a physio I’d pm him every day. [Jaz]It was a very good and smooth listen. And it was great to open my eyes to that well, you know. So tell us about how do you two know each other? [Sam]So we qualified from Kings together? So we went through right the way through physio school, in the sense, and then we just kept in contact ever since. [Ben]Yeah. So I didn’t even introduce myself. Did I? Yeah, let’s go back to that bit. Sorry, I went off track. So I’m Ben. I’m a physio. I’ve been working in the NHS for a number of years. Currently, my role, I see a lot of GP referrals. So if we go to like, a GP with neck, back, shoulder, knee pain, you probably see someone like me. My, I’m doing work in pain management at the moment, which is slightly like a more specialist area. So essentially, it’s for patients that have had pain for longer than six months. So it’s become a little bit more ongoing, a bit more persistent. And the goal isn’t necessarily to reduce their pain, but in fact, be more functional and live better with it. So we it’s not just exercise, it’s stuff like sleep, stress, diet, medications, doing a setback plan, thoughts, feelings, emotions. So it involves a bit of psychology training as well. So yeah, that’s kind of my current area of work. I think that’s probably why Sam reached out to me because, you know, as I say, and what Sam said is dental practitioners seem to be a high risk group. [Jaz]Yeah, I mean, I had something like 94% of the dentist. I don’t know where I got this figure from, you know how they say 66% of all figures are made up. It could be one of those but 94% of dentists will retire with back problems, and 100% of nurses apparently will retire [All] 100% [Jaz] Yeah, apparently so that I don’t know where I got this from. But, tell us how prevalent is it? We’re, over the run both of you. And, you know, we’ll just dive right in in terms of making it valuable for the listener. What do dentists, hygienists, therapists, and nurses need to do to make sure we don’t end up retiring with or due to back problems? [Ben]He laid on that. [Sam]Yeah. So the prevalence is, it’s 60% to 94% of dentists will experience [Jaz] See! 94. [Sam] But they experienced some sort of musculoskeletal pain at some point in their life. That’s from a systematic review that one. Well, the prevalence of lower back pain is particular is massive. It’s the leading cause of long term disability. 7% of GP consultations as well are from lower back pain. For dentist, lower back pain is the most common, then it’s the neck and then shoulders. In terms of what causes it, I think, whenever I speak to dentists, if you say, oh, I’ve got lower back pain, they’ll instantly say, you know, what your posture like? How do you sit? Do you use loupes? And if you spoke to a physiotherapist, exactly the same thing, they’d be saying, how much exercise are you doing? You know, are you moving around a lot? And it is, it goes from, you know, almost like 1985 physiotherapist, we’re changing people’s postures and making sure that we’re sitting right. Whereas now on the most current things are just to keep you moving. So I think, the reason why I’ve got Ben on here as well, it’s because you’re like, whenever I have any physio questions, and [Ben] Thank you, mate, for saying that. [Sam] yeah, I like is one of the best things that Ben ever taught me or led me to was the best posture is the next posture. And that, [Jaz]Okay, tell me about that. And again, at the back. Oh, as in get you moving? I like that. [Sam]Yeah, exactly. So if you’re in one position for a long period of time, then you’re going to get pain regardless of its, you know, bolt upright, elbows at 90 degrees with loupes on if you’re in that position for a long period of time, eventually, you’ll get pain. [Jaz]We’re saying that is even though we’re using magnification, which is keeping our head away if we’re the problem is not necessarily the posture. The problem, are you trying to say is that the lack of movement? [Sam]Yeah, exactly. I mean, they did, there was a systematic review, very recent one that looked at saddle chairs and loupes. And they all agreed that loupes could improve your posture, that it would improve your dentistry, you do get better crown preps and things, but they never, not once did they say it will reduce your pain because no studies seem to look at it. And one of the reasons for that is because they never find that the posture, links to pain and I think Ben’s very good at talking about posture so [Jaz]Tell us Ben about posture. So have we as a dental industry over playing the role of posture. [Ben]Most definitely. If there’s one thing to take from this podcast, is that [Jaz]That is for me, I mean, that I think that’s going to send the shockwaves I think this is crazy to think that [Ben]I’m probably gonna upset a lot of loupe and scope companies with this. And I am aware of that, but yeah, so essentially, if you know, asked a physio, maybe 30 years ago, how important is posture they probably say you know this much. Now with thinking it’s probably this if that I mean, there was a paper came out 2011 it was a systematic reviews and there was an association, a link with posture and back pain, so and that’s the awkward postures, manual handling, prolonged setting, all those things I just simply not linked with back pain. It’s because back pain is essentially a medically unexplained symptom. It’s, you know, you can have all the scans under the sun and it’s going to show some change there but we’ve got absolutely no idea what is actually causing it. It is going to be multifactorial, when it’s gonna be individual. A lot of what we understand about pain now is that it’s about the tissues. It’s about the nervous system. We interpret the feedback from our tissue, if, you know if our nervous system is heightened somehow, which includes our brain, etc, then it’s going to be super sensitive to stimulus. So if you’re in an awkward posture at work say you’ve got a really busy clinic, you might be what running 15 minutes late. You know, I’m aware that I was gonna sweat and but if you mess it up, I’m not sure if I’m allowed to swear. So I call myself [Jaz]on Apple podcast, I put myself as explicit. So it’s fine. [Ben]Yey, I’m off the hook. But yeah, so I’m aware that if you guys mess it up, you know, you’ve got litigation and stuff. So that’s obviously presence, though, it’s almost, you’ve got a couple of things there that are kind of risk factors stuff like this [Jaz]So the fact that Yeah, the stress is heightened in our profession. It’s fast pace. So that’s messing with our sort of the neuroscience part, which, you know, I think I appreciate it. It changes your perhaps it changes, what in dentistry, we have something called adaptive capacity. Is that something that’s relevant in physio as well? [Ben]Mate 100%. You’ve nailed it there. So when pain has been going on for longer than six months, it’s not about the tissue. It’s about the nervous system. And so if you’ve got pain for like, longer than six months, your nervous system, it’s neuroplasticity? So [sign up to Genesis,] stuff like increased transmitters. You have more neurons. It’s a bit like if you have an amateur violinist, yeah, that their cortical mapping in their brain is going to be for that hands is going to be fairly small. But if you get an expert violinists, the cortical mapping is gonna be huge, right? If you remember, not sure if you guys go through like the homunculus in the brain and stuff like that in your training, but the mapping is a lot more so your nervous system changes to stimulus. So that’s the same thing happens with pain. Once you’ve had it for a long period of time. It’s not about the tissue. It’s about the nervous system. And that’s what that’s how we kind of want to target back pain. it’s not postural, it’s not tissue focused as such is more about looking after yourself, sleeping while, doing some form of exercise that you enjoy, eating well. Not worrying about things especially about posture. And yeah, I suppose I’ve listened to a couple of your podcasts, Jaz, as I say I think I like how you look for the Dental pearls you know, the the bits of wisdom to take away. Unfortunately, I can’t really give you like a big answer in terms of like a quick hack, but it’s simply is just looking after yourself, mate. Really. [Jaz]That’s fantastic. Sam, you probably listened to more episodes than what Ben has it being in obviously a dentist now. Do you, can you see the similarities in terms of what Ben is saying? And what Barry Glassman says in terms of the role of occlusion and parafunction because what everything you’re saying is very much echoed by what Barry, Barry Glassman, Ben if you don’t know is an oral facial pain specialist, right? [Ben]He’s the one you spoke about bruxism on your communication in bruxism was that? [Jaz]That was no, that was Episode 11. But he’s also similar count they prescribed the similar appliances these are you know anterior only appliances but what Barry Glassman also says that it’s very similar to you guys saying. So you guys’ saying okay, no, it’s not posture. It’s, andd you also mentioned about, you know, neuroplasticity, but in Barry and his over philosophy, which I very much agree with it, it’s not the bite, it’s not the fact that the bites messed up. It’s the fact that we’re parafunctioning, it’s our muscles, you know, contracting purposely, that leads to all the tissue damage, and then also that pain becomes chronic. And then that becomes, that changes the neuroplasticity. It was him who introduced me to that term neuroplasticity a few years ago. So I’m just drawing these parallels in what you’re saying. And I’m always apologetic, but yet not sorry. At the same time to bring it always back to occlusion, which is one of my favorite things to talk about. But it’s true. Sam, what do you think about that? [Sam]I think that’s really similar to TMJ pain and how you treat that and especially with bruxists, because you’ve always got to take Yes, you have the physical symptoms of bruxism which is the tooth damage and wear, but then you’ve also got the psychological factors of, you know, they’re not getting enough sleep at night or they’ve got children is really hard to look after or social problems where they’re having problems at work or they haven’t gotten back access to hobbies that they used to like to do and things and just building on the stress. So I think really the main thing is, you know, in terms of from that, but also linking it to back pain is that if you are feeling back pain, is it because, you know, don’t always think, Oh, it’s because of my posture is because of some sort of physical entity, think about the social things that are going on in your life. Now, whether you’re having lots of family problems, your girlfriend’s broken up with you, you’ve been then like Ben was saying before, you know, if you’re running late, and things like that, you know, all those things will impact on your back pain. And I think like the psychological and the social factors are probably, you know, probably the reason why you’re getting the back pain rather than, you’ll always find that the back pain or being the worst when, say, you know, you run in, you know, half an hour late, and then your crowns not fit, or you’ve got a screaming child in the chair that won’t take the fluoride varnish. [Ben]Yeah, but also is kind of always separate in mind and body there in the sense of, I call it [inaudible], where, you know, the tissues are here and the psychosocial was over here. But you know, in the day, when we’re treating a person here, you know, that they’re one on the same, if you’re having pain, you’re gonna have, you’re gonna probably be a bit irritable with your partner, you’re gonna be a little bit more stressed than normal. Pain is quite complex like that, you know, it kind of permeates into all facets of our lives. So kind of, unknowingly, or knowingly, but yeah, so apart [Jaz]As a much more profound effect, then at the surface level [Ben]100%. And patients tell me all the time, you know, it’s really frustrating, because it’s invisible, you can’t see it, you know, so, on the surface, I look like, I’m fine. But actually, I, you know, the secondary suffering as a result of this pain is quite profound. So yeah, that’s part of my role is talking about how to, how can people be more functional and live better with it. You know, okay, the pain’s there, it’s pissing, I’m sorry, I’m gonna swear, it’s pissing them off. And it’s permeating the facets of their life. But can they control stuff like sleep? Can they manage their stress? Can they get a little bit more active? Can we give them a plan for when they do have a setback of their pain? So it’s a fairly holistic and comprehensive approach to the management really, rather than just a tissue [Jaz]Well, both of you, if you can just cover a couple of scenarios then is that the dentist or hygienist or nurse who has not started maybe because they’re early in the career started to show signs of back problems? What advice can you give preventatively, and maybe a few minutes later, you can then give some advice to those who are now suffering, you know, dentists, nurses, therapists who are now suffering with pain. Is your advice essentially the same for both of them? Or can you tweak it to make it tailored to that individual under those circumstances? So please, who would like to touch on that first? [Sam]Yeah. So in terms of preventative advice, the best thing to do is to keep as active as possible, the NHS guidelines, say to do 150 minutes of moderate intensity exercise, or 75 minutes of vigorous intensity exercise. And, you know, a lot of people think, oh, I’ve got back pain, so I need to do planks or core or, but if you’re running, swimming, doing an any exercise that you enjoy, you’re going to be improving all of those structures anyway. And a famous Aristotle quote, is that ‘Excellence is not an act, it’s a habit.’ So you have to do the exercise that you like, because that’s the exercise that you’ll continue to do. And then you’ll keep yourself strong and enjoy a more fruitful career or on a longer career as well. And then in terms of if say, of a hygienist or a dentist would get in pain. I think Ben’s probably the best for this. [Jaz]Yeah, I think that’s a good way. So Sam, you’ve covered prevention, some tips about prevention, doing exercise and the importance of that. So Ben, now we have the dentists, hygienists, therapists, or whoever who is now suffering with lower back pain and they think, Oh, yes, because I’m a dentist. I’m like this all day long. They might then buy a microscope for their practice, and they might still say Actually, no, I’m still suffering. And they might come and see someone like you, what would you do? What would you advise? [Ben]Yeah, I think I suppose it kind of depends on the individual and how long they’ve had it. But I suppose it’s if you’ve been suffering for a long time. And I think the first thing is to get a good physio. There’s a lot of kind of non evidence based kind of care out there. And you want to be seen a physio that is evidence based, it’s current. There’s movement in the MSK professional at the moment called MSK Reform and the big Rs. And essentially, we’re trying to lobby like government and our governing body to improve the standard of practice, and to get us better regulated. But yeah, see a really good physio, because it’s really difficult to do on your own. Pain is a tough thing to manage. And it’s a tough obviously getting a good physio, probably a good start, but I think with back pain, neck pain, etc, that it’s doing some form of movement, and that’s going to be quite scary. Because when you’re in pain, you should rest, right? No, it’s actually the flip side, you need to move more and you’re not going to be making your back pain any worse by moving with pain, as long as you can tolerate it. Pain does not always mean damage. A good example is I’ll get my examples out here, but a hangnail, paper cut, stubbing your toe, you know, treading on Lego, all these things are super duper painful. And how much damage is there? [Jaz]It’s not proportional to the pain. [Ben]It’s not. It’s a very unreliable message of tissue damage. And people around you will say, No, you shouldn’t be doing that, because you’re in pain. But actually you should be because that’s going to desensitize your nervous system, it’s going to give you the confidence to move more, which is going to help you condition so yeah, pain doesn’t always mean damage. And so find a level of activity that you can do, that you can tolerate, and slowly, slowly, slowly build it up over a period of time. [Jaz]Is Pilates supposed to be a good one? Pilates? [Ben]It’s a very popular one. And the reason it’s popular is it’s quite low level when it’s very social. So I mean, you could do that in any class really, essentially, a paper came out in like the 80s. That suggest the link between core stability and back pain and physios at the time went absolutely bananas about it. And there’s and that’s why today you see so many Pilates classes, since it was only one paper. So since it has been debunked. And it’s also like, Sam was saying, it’s just important to do any form of exercise no matter whether it’s Pilates swimming, running classes, yoga, whatever, really. So yeah, it’s important to kind of realize that. Pilates, I mean, I’m not pooh poohing Pilates at all. I think it’s a really good start. Because, I mean, I’ve done Pilates classes and bloody hard work to be honest. But yeah, it’s not the be all and end all is what I’m saying. And it’s a great start to get people moving. And plus, with a class, it’s socials. I mean, we’re social animals. And today, and if you haven’t exercised before, I would say find something as simple as I’m saying that you’d like that social and is led by a professional because they’re going to be on it. Yeah, you know, do this, do that. And after a couple of weeks, you’re going to be seeing the same faces and you’re going to be chatting to your classmates. And as I say, we’re social animals, so and you’re not doing it on your own. Yeah, you know, another initiative is powerful run. I love powerful run at the moment. Get your local path and run for free in the community. What a great idea. [Jaz]Brilliant, so you’re all you’re saying is find a good physio who is evidence based and focus in that and I completely agree. No, I used to think many years ago that everyone qualifies in any profession when I was younger, like my teens, I think okay, all dentists are the same, or doctors are the same on any profession are the same. And I still, you know, you learn over time that actually no, not everyone is as evidence focus. Not you know, and I know some plenty, let’s not get into I’m not gonna give any examples, but yeah, I think you know, where I was heading there, but [Ben]Yeah, if I dive in with non evidence based stuff, I think that would probably be a good shout. So stuff like manual therapy. I mean, it does have some evidence, but it’s very short term. So stuff like, like massage, some are actually a really popular one. The way it works isn’t how people think, it doesn’t change your muscles at all, because there’s no friction, right? So when you rub the skin, I mean, you could rub it all day, every day, you know, you’re not going to change the muscles in terms of their health, but what it will do, because you get the massage is going to release the body’s natural painkillers, desensitizing that nervous system for, if it’s a crap massage a couple of hours, if a good massage, you know, week, two weeks. So yeah, that’s not going to be good for long term management of the back or neck pain. I probably put mobilizations and manipulations in there as well. So that they’re some people might have had those before where people were treating joints, getting a click that kind of thing. The effects of those are fairly short term as well. So okay, if you’re looking for short term relief, but not for long term relief, and stuff about like, biomechanics and getting in souls and stuff like that, you know, the evidence for that is kind of fairly low. Acupuncture is another one. And acupuncture has been taken off the back pain guidance for the NHS, the nice guidance, because versus placebo, it’s a [inaudible] It has equal effects, same with ultrasound. So, if any, if your physio starts getting those kind of treatments out, you probably want to question whether they’re the physio for you basically. [Jaz]That is really, really good, useful insight. Honestly, like, you know, you don’t get this sort of insight in terms of what’s a good physio, what’s not. And I think by getting that information that you did, it will help a lot of dentists who may already be seeing a physio thinking actually, is this really working or not? Sam, can I ask you a couple of questions in terms of, you know, obviously, you’re full time dentist at the moment? [Sam]Yeah, so I’m in my foundation year at the moment. Yeah. [Jaz]How do you finding it? We’re about to do it, man. [Sam]Good. I’m in the Meols actually at the moment, which is just near Liverpool. As you can probably tell from my accent. [Jaz]Yeah, I was in the Meols, actually, this weekend. I wish I’d known I would have invited you to do this in person. But and this is probably the best Coronavirus situation actually. [Sam]Yeah, even at the practice I’ve been, I’d say I’ve given advice or even treated every single person in the practice now say, [Jaz]Well, you know, you’ve got an added skill set. Well, what I want to ask you is, as a wet fingered dentist now, can you tell us some things that we could be doing at work? So obviously, Ben covered very nicely about physios and the role of movement? What can we do while we’re at work nine to five, to help the cause? And also one question, I really want to get that is there any evidence that we’re probably not any evidence because probably never been studied, but doing checkups while you’re standing up? I heard Oh, yeah, that’s supposed to be good. But then that’s really relating to the posture theory, right? But you tell me. [Sam]So what I use loupes all the time, and I do find that helps. But when I’m doing my examinations and things, I’m never in one position. So at university a lot of the time, they always tell you to, you know, to sit down and to make sure you know you’re in a good position, you stay in that one position. But I remember I’m going to name drop, but I remember Ian Dunn came around and he’s great. He’s one of the Perrier guys, and he was saying, you know, you got to keep moving around, your patient to be able to do the best dentistry and that’s really true. And that’s, you know, if you’re moving around the patient, even when you’re doing a checkup, or, or anything, that’s absolutely great. I’d say that to keep yourself moving rather than the nurse going to get the patient. You know, even just walking out to go and meet your patient and bring them back in is good. And that’s also good to help build rapport with your patient because you’d have a little bit of chitchat before you come in and you get your exercise and, or a better you know, getting your steps on your watch. And yeah, those are the two main things that that I say in terms of the sitting into standing. You know, if you find that sitting down when you do your dentistry is is good for you then that’s what you should continue doing. If you find that standing up, you find that the pain is less or you enjoy standing up more than, do that. To keep yourself moving, sometimes it’s good to have every other patient you could stand up because if you stand up, you end up putting more pressure on your back. Whereas when you sat down, you put more pressure on your upper back. But everybody sits different. And it’s really an individual approach that you have to take. This is why in terms of posture, and you know, it’s easy to prescribe posture because there’s just a one size fits all, when really, it’s a one size fits no one. [Jaz]That’s really interesting. One thing that reminds me of is that in every single practice I’ve ever been to, that everyone’s got that same poster, the BDA poster, and tells you about all the stretches you have to do in between your patients that might help. So the role of stretching? Is it overplayed? Or is it is stretching, good for preventing back pain? [Ben]I could go on that one time. All right. So yeah, stretching is an interesting one, actually. So there’s a bit of debate in the research in terms of what it does. We used to think it changes tissue length, right? So if you stretch, you know, the muscle, it increases in sarcomeres in series, so you get a longer muscle to then when you stretch it. You know, it’s Yeah, you get more range, basically. That’s still there. But that was quite a while ago, what they’re starting to learn now is it’s actually to do with stretch tolerance. So your muscle doesn’t really change. But actually your tolerance to that movement changes. Which is why you can get changes fairly quickly, you know, you probably might have noticed if you stretch every day, not that I would ever do that, because I’m not a fan of stretching. But if you do that everyday, you get changes fairly quickly. And that’s not necessarily because of changes in the tissue, which, you know, if you go to the gym, you know, you might get a buffer three months ahead. But with stretching, it happens in a very short space of time. And that’s because it changes in the nervous system rather than changes in the muscle. To answer your question directly Jaz, is it important that you do those stretches? I would say, you know if they help you then yes, but you’re probably far better off just doing something you’re like outside of work. [Sam]You have time to do what it is just between patients as well. [Ben]Yeah, God, you guys are busy enough. You don’t want to put like an extra thing on your plate, man. Don’t do that. [Jaz]That has been so enlightening. Honestly, learning about the power postures overplayed was crazy. And I actually really love how both of you have constantly every couple of minutes mentioned some evidence base as well. You know, massive respect for that. [Ben]No fair play. I think, as I said in the start, like it’s important, we are current an evidence based. Otherwise, that’s how we deliver the best care for our patients. I mean, you guys must notice it in dentistry, you know, it changes every five or 10 years. So if you’re not up to date, then you know, well, the stretch example is a great example. You know, we’ve kind of flipped it on its head completely there. And I’m [Jaz]I’m still mind blown about posture. Honestly, I was gonna, I don’t know, maybe Sam, do you think everyone’s gonna be surprised? Listen to this, or, am I just late to the party? And I didn’t know [Sam]Yeah, I’ve given some presentations at Liverpool University to all the lecturers and it was a shock to them. It just blew me like, I was speaking to like, some of the professors and like, even sometimes you hear, like, as I’m given the lecture, you hear people gasp. But it doesn’t matter. Because you see everybody looking at each other as you get into it, and they’re like, Oh, yeah, he’s gonna talk about I’m gonna sit right. And then the next minute, you say, oh, it doesn’t matter. And everybody’s shocked. [Jaz]That’s really cool. [Ben]It’s interesting, because there was a paper that me and Sam threw it was, they got this thing called biofeedback in English, it’s where they, it basically shocks you to put you in a good position. If you’re not in a good position. And it made people’s pain worse. So in fact, you know, there’s evidence that focusing on posture too much actually makes it worse. And it makes sense, right? So if pain is perceived in the nervous system, and you’re thinking about your posture all the time, you’re like, you’re in a position, whatever position you’re in and you’re like, Oh, shit, I need to. So you’re thinking about it, you’re re registering those messages, you get in those neurons firing by thinking about it. So actually, you just need to change you’re position for symptom relief and do all those bits I mentioned outside of work so [Jaz]I say the same thing to the people who overcomplicate and my patients who think much about their bite, or think too much about the position of their tongue, that you know, just relax. And you know, it’s the same thing with people who focus too much about their posture, people who focus too much on the position of their anatomy and their bite and stuff. I was drawing parallels in my head, as you said that [Sam]I think one of the one of the facts that I quite like getting in is that for the last 84,000 generations of homosapien, we’ve been walking or running for 10 miles a day. For the last few generations, the average amount of walking or running is less than a kilometer a day. And our genes are geared to move that amount. And then as soon as you’re moving so much less, you know, you can’t change your genetics, our bodies are meant to move. So as soon as you’re putting that static position, or if you’re not exercising outside work, that’s why you get in these problems, because we’re just not designed to be static and immobile. We’re designed to move. And that’s why Ben’s saying all the time, you know, the thing that’s gonna get, the better is movement, when you’re in pain, you need to move. And that’s because our body that’s what your body’s screaming out for. And also, when you do get back pain, you know it a lot. You know, we were saying before that it’s not due to physical injury, but a lot of the time feeling a bit of back pain is a preventative mechanism that your brain uses to tell you to move on as soon and and, you know, dentists will say oh, what position should I move in, but we even me and Ben speaking the other night, and we were saying that it’s okay to slouch. If you find that slouching is comfortable, then perform your dentistry in a slouched position. And then, eventually, over time, like we said, if you’re in one position for a long period of time, you’re most likely going to get pain. So if you’re in pain when you’re starting, then move to a different position. But don’t ever be afraid to slouch. And you’re fine. I mean, one of my friends is doing the FD. And their TPD was budging, and telling them not to slouch and to sit up straight. So yeah. [Jaz]Did you have to bite your tongue for that one? [Sam]Well, yeah, you’ve got too many. [Jaz]But surely being like this, like surely just like, you know you see those photos on people on Phantom head courses. And they’re like, they’re like this, and they’re like, polishing something. And they’re like, I mean, granted, you won’t be probably not like that for longer than a couple of minutes at a time, you know, when you’re doing the distal lingual of a six or a seven, and you have to do it. I think after listening to today, and listen to you guys, I’m gonna feel less guilty about doing that. And I’m just gonna just move along afterwards. [Sam]I think we know that, you know, if you put your arm out in front of you, for a small amount of time, it’s not painful. But if you look after there for like, you know, a couple of minutes, it would start to get tired and painful. And that’s the same with lean and over with the Phantom heads, you will only be able to physically be able to stay there for so long before you can’t bear and you have to bend change to the other side. So [Jaz]Listen to your body. [Ben]Yeah, I mean, we’ve talked a lot about moving here. And you know, I suppose that when we talk about movement, we refer to the tissues I think if we zoom out as well, like it’s important we look after ourselves, like, exercise is a component of that. But you got to also focus on stuff like sleep. I mean, if any of you guys are a science geek, so you’re definitely I mean, I know that Sam’s read it, but if you ever read ‘Why we sleep?’ by Matthew Walker, it’s an absolute blockbuster, honestly, it’s like the Forgotten pillar of medicine, in my opinion. So getting a good night’s sleep in is really important. You know, managing your stress, however, that’s a very tough thing to do, but try to mitigate that as best possible. Eating well. And yeah, just all those things that you might have come across. Dr. Rangan Chatterjee, he was on the tele GP at home, he talks about the four pillars of medicine, which are lifestyle medicine, and that is exercise, diet, sleep, and, and being more relaxed and less stressed, and most people are missing one or two of those. So if whatever the low hanging fruit is the one of those that you feel like you could probably address because at the end of the day, we’re healthcare professionals and clinicians and we need to look after ourselves and we can look after others, you know, question self care is quite a big thing at the moment. So yeah, just sometimes it’s, I mean, we’ve all done it. We just get caught up in worrying too much. And we take a lot on, we’ve got family, we got kids, we got all these responsibilities, and sometimes you got to kind of take a step back and think right, what can I do to look after myself, and that’s gonna motivate the nervous system, which is going to help your back pain. [Jaz]I’ll definitely download the book, the ‘Why we sleep?’ Obviously, I’m going to definitely download the book, the ‘Why we sleep?’ And I’m definitely gonna download it for another reasons because, Ben, you’ve got all these books behind you, but I am certain you’re someone who’s read these books. So that’s the message I got today. [Ben]I yeah, I mean, I don’t profess to be like a I don’t have any investment in Matthew Walker’s books or whatever by for like, at least 10 people buy things that are off the back of [Jaz]I think about 500 people will purchase this, now that you recommended it. So [Ben]I’ll let Matthew Walker know. I did tweet him. [Jaz]Sam, sorry, Sam, you’re gonna say something there? [Sam]Yeah, I was gonna say me and Ben was speaking the other day. And we were saying, you know, Why do you Dentists have such a high risk of guests in back pain, neck pain and all these other pains? No, we’ve already said that. It’s not to do with posture and things. So we were saying that the one thing that Dentists have that most of the, you know most of the professions don’t have is the map stress that we’re under. And I think a lot of dentists work, you know, work alone, which at the moment, I think it is changing, where dentists are talking to each other a lot more. And it’s great that like in foundation year, you every week here with colleagues, and you speak about different things that go on. And I think that’s probably the most important thing to prevent back pain. And general well being is to listen to things like headspace, calm, to even meditate and just try and stay stress free that way. But another way is, you know, keeping really social and joining things, I think you’ve gone on quite a few times about Dentinal Tubules, which I think is really good and connecting people and go into as many conferences and courses as possible so that you can interact with different dentists so that you know that you’re not alone when you get your first complaint letter or when that dreaded GDC letter comes through your door or if it ever comes through your door. [Jaz]It’s so true, man I was on. I know Ben had listened to Episode 11 Communicating with Bruxist. But Barry Oulton also done communication courses for Dentists. And when I went through this course, I learned that 17%, according to a survey of dentists had considered taking their life at one stage. So then that just reflects Yeah, it’s crazy, Ben. I mean, it just reflects the stress that we do have in our profession. But I think you two, the way you’ve covered it today have debunked a lot of myths that are out there, which really, really shocked me, honestly. And I’ve learned so much from that. Is there anything any final comments you’d like to add? [Ben]You first Sam? [Sam]Yeah. So Well, we’ve, we really want to promote kind of self help and strategies for dentists and we, me and Ben at the moment, currently putting forward something called the Tooth Physio, which is on Twitter, and Instagram at the moment. And we’re thinking or we’re going to see whether we can try and put a course together as well, where we can go through case studies and go through exercises and different things like that, that can help specifically aimed at dentists to help dentists. But I think the main things to take away from today would be that the back is really, really strong, tons of muscles, ligaments, fascia that are protected. The reason why it’s painful, won’t be to do with posture, it will be because of other psychosocial factors that are going on in life as well. And if you are in pain, that the road to recovery is never a positive correlation. It’s always got pitfalls and things. But if you are in any worry about your back pain, the best thing to do is to seek help from, like Ben said, and evidence based healthcare professional, and to go from it that way. And they’ll be able to give you self management strategies and help to manage the pain getting back to activity faster, and I’ll give you a paced exercise program that you can work with just to get you back to activity and get you back working as well. That’d be the messages I’d give. [Jaz]Can I just intervene, Ben, before you go is that on the last episode, I just published it the other day. One of my pearls I shared was to go on the ACP TMD website, which is the charted sort of physiotherapist in TMD. So those physiotherapists who have got a special interest in TMD. And I found that really helpful to connect with my local physiotherapist who has done further training in TMD. And I had lunch with him and I learned some stuff from him. Some, where can dentists go if they want to find a physio like you who’s obviously evidence based and cares very much to Give up an evenings Come on a podcast like this? Where can we find you? Obviously, I’ll put your contact details for those in London but if someone, somewhere is there like an association that you think are a bit more clued on than others? [Ben]Yeah, I would say if your area is under Connect health where I work for, and then you definitely get an evidence based care there. If you feel like you’re not I think as I say, see if you can find, if you go on Twitter and you go to MSK Reform, there’ll be a bunch of physios on there that have in high regard, they will guarantee you there’ll be able to recommend a good evidence based physio locally for you and anyone that follows #thebigrs which is also part of that movement so anything like that and I suppose I mean there’s obviously thousands of really good evidence base NHS physios on there so yeah, I think I think yeah, seeking there for MSKR, never seen the reform. But yeah, if not, [Jaz]I’ll put your details in there and anyone in London and I’ll put your [Ben]Our Twitter handle is at ben_FYS. Fys is spelt F-Y-S. There was a lot of Ben physios as you can probably imagine. So FYS that will do [Jaz]I like it. Guys, thank you so much for giving up your evenings come and teaching us so much. One thing I have to mention before we go though, is to do with you, Sam, is that it’s interesting, he said how having the loupes or the scope because of the change of posture will not necessarily mean that you have a better back. But I love the fact that you still have loupes because we both value the importance of magnification and dentistry, right? I mean, I don’t want people to get the wrong message. And they actually know people on the cusp who are about to purchase magnification, they should not then be put off by what you said they should still go ahead and buy the loupes. [Sam]Oh, 100% Yeah, and I use loupes not because it helps my back pain but just because you get you know, you get the magnification in your it’s, you know, the systematic review the set didn’t say anything about it helping back pain said that it does 100% improve your dentistry. And also the light is if you do get it with a light, the lights about four times stronger than the headlight. I use the headlight now and I can’t see a thing when I’m looking at the tooth whereas I put my light on and it’s literally like it. I feel like doing, me and Ben was speaking the other day and he said that dentistry is like he was on one of your podcasts when you talk when somebody was talking about. It’s like working for a letterbox in the dark. Well, why don’t you work for a letterbox with the lifetime? [Jaz]Absolutely. I’m just hoping to go through one episode with someone without having to mention some a gem from that Episode Episode 10 Zak, that was Zak Kara episode. Every bloody episode we’re having to refer back to that one episode. So Zak, I know, you listen to this. Bloody good you are, One more thing I forgot to ask which I can just cut in is foam rollers yay or nay? [Ben]Nice. So if it feels nice. Absolutely. I mean, I like a bit of foam rolling to be fair. But that’s what you’re doing it for is because it feels nice, it’s not going to, it’s going to give you that short term relief, just like the massage. It’s not going to change the health of your tissues. [Sam]And we will say in a good, like pain relieving strategies as well, or what we, what me and Ben used to do but still, it does still really help. So if you’re a dentist and you do have some back pain is getting, say a hot water bottle on it for 20 minutes to use a tennis ball against the wall and kind of rub around the back that can really help to relieve off that acute pain. But it won’t help to get you better, but it will help to reduce the pain. The only thing that will get you better is the exercise and the progressive exercise that you do. But [Jaz]I have never moved so much while recording a podcast because you guys [Ben]With ice and heat. So interestingly like again, it doesn’t change the tissues below. You’re a mammal. So it doesn’t matter whether you’re in Antarctica or in the Sahara, you’re going to maintain an internal homeostasis no matter what. So you’re doing it for that pain, that difference sensation and some people prefer heat some people for ice. Ice basically reduces the neuron firing. So that’s why it’s less painful. It doesn’t reduce inflammation and swelling because it doesn’t for it to do that. It has to be like your skin would have to, well your tissues, it has would have to be like 27 degrees, and there is no way you’re going to get your tissues below the skin to 27 degrees with ice, it’s just not going to get through. So that’s another myth with ice and heat as well. [Sam]That’s unless Rose doesn’t let you on the door. [Ben]And you gotta get a titanic reference in there if you can. Jaz, you’re talking about parallels? Right? So I so I had a little dive into your podcast, right? And I expected I expected like physio to be here and dentistry to be here. Right? And I was completely like, you were talking about stuff like communication, how important that is, like developing rapport. Trust, when you get in patients to self manage with like brushing their teeth, flossing, changing diet, stuff like that. I mean, that’s it. I’m basically an exercise salesman, right? So like I was quite amazed at how actually two different professions and working in different kinds of areas. Yeah, we’re providing the same kind of thing being being trustworthy, being honest, coming up with a shared decision with the patient, you know, informed consent, you know, going through their options and the risk versus benefit analysis of this, that and the other and blew me away. I just thought that actually, yeah, we’re actually very much the same. [Jaz]I think so. And I missed that physio edge when I also thought about that. I mean, that went in depth about some physio aspects, which I didn’t understand about certain techniques. But yeah, in terms of the overall themes, trying to be evidence base and trying to, you know, essentially it’s healthcare so yeah, it was it was very interesting. [Ben]Yeah. And, like Zak Kara Yeah. Like you say, you mentioned him. That was, some of the stuff he mentioned. And I think I took a couple of bits. I think you mentioned about a late patient about how to address that [Jaz]How to address, How the reception so cater. Yeah, that was a gem. Honestly, that episode is still one of the you know, the gem, the number of gems per sentence is phenomenal from that one. So it’s as quiet as that. But, guys, thank you so much for coming on. I’ll put all your Twitter handles and Instagram handles on so people can follow the advice that you’re giving. And yeah, really appreciate you coming on. [Sam] and [Ben] No worries, man. Jaz’s Outro: Thank you very much for watching all the way to the end. I really appreciate it and if there’s any other topics that you think I should cover, let me know I’ve got loads of episodes sort of edited already, including Complete Dentures with Mark Bishop, Cracked Teeth with Krina Patel, Composite versus Ceramic with none other than the legend Chris Orr. I’ve also got our one of the favorites, Protrusive favorite Zak Kara back on to discuss Presenting Treatment plans and communicating with patients yet again. Don’t forget to hit subscribe on the YouTube and if you also want to stay in tune with the email content that I’m sending out recently, I put a YouTube video up how I take occlusal photos, and only those on social media would have seen it. So if you want that something like that in your inbox, you head over to protrusive.co.uk type in your name and email stuff like that will be coming to your inbox as well. So keep in touch. So anyway, I’ll catch you in the next episode. Thank you so much for listening.

https://www.youtube.com/watch?v=yS6UAJmwz9A Need to Read it? Check out the Full Episode Transcript below! In this interference cast I discuss my opinions and experiences of finding associate positions and what strategies DF1s and Dentists looking for associate positions should consider. Is BDJ jobs obsolete? Can social media help? Is a dental portfolio over-rated? Surely, you need to know the right people? Questions and comments on the video welcome! Click below for full episode transcript: Opening Snippet: Hi, guys, and welcome to this interference cast today on a very important topic, something that I get asked about quite a bit from our younger colleagues... Main Podcast: And that is basically I’m in df one, how do I go about getting my first associate position? And actually, the things I’m going to share with you today are applicable to those if you’re looking for your second, and God forbid your 18th associate position. So there are some things that are parallel or similar between all those stages of your career. So basically, if you’re looking for an associate position. What’s the best way nowadays? While I’m recording this, we’re in lockdown. COVID-19. So yes, what I’m saying may not be applicable right this moment in time, because everything has been sort of disrupted by COVID-19. But the principles are hopefully apply for whenever you’re about to find or look for your next associate position. And if you’re in df one right now, this is probably something at the forefront of your mind right now, when we come out of COVID-19, you’re going to be probably looking for that associate position, your first associate position. And having said that, I’m someone who’s done DCT one and DCT two posts in Guys hospital and Charles Clifford Dental hospital respectively. And they’re very useful for me, but I’m very much and I’ve said this before, in a previous episode I recorded with Dhru Shah is make sure you’re doing a hospital job for the right reason, do it because you want to, because you enjoy that and not because you’re afraid to go into the real world of GDP land, if you like. So make sure you do it for the right reasons. I’ve said that before. However, nowadays with the COVID-19, and the fact that who knows how long it will take for practice and certainly private practice to get back to normal, it might be another year. So now more than ever, I have to say a hospital DCT position is looking quite favorable for this extra reason of COVID-19. And just job security, income security. So if you’re already on the fence about whether you should do a DCT post or go into an associate position, you know, it’s not a bad time to be considering doing a DCT position. Even if your ultimate goal is to become a general dental practitioner or a specialist or whatever. It’s not a bad thing to consider at this moment in time. So where do you go about looking for your job? Well, firstly, back when I was applying when we like, you know, seven years ago there about the BDJ Jobs was there and I used it. But what I found when I was applying on BDJ Jobs was that the principal would write back to me saying, sorry, we were inundated with applicants and we made our decision. And that’s generally why I’m fine, you know, with the with BDJ jobs, those who post a job on there, they’re quite often going to be swamped with hundreds of applications, especially if you’re in London and south east. So I don’t know how effective that is. Whether you’re actually posting a associate position in your practice or as an associate when you’re applying, you’re actually competing against a lot of people. And it’s difficult for principals to sort of go through and differentiate, especially if you’re only been one year qualified, two years qualified, then I think it’s very easy for the principal to say, Okay, I’m going to dismiss these 150 CVS, because these people don’t have at least three or four years experience, and then automatically, you’re not in the shortlist anymore. So BDJ jobs is I don’t know if it’s working that well for that many people at the moment. But certainly I know a lot of my colleagues who are looking for associate positions, they’re not really using BDJ jobs as much as we used to. So you can argue, it’s obsolete now. However, at the time of speaking on this, I have to applaud the BDA. It looks like Finally, the BDA is doing something I’m liking this direction in which is going I think the BDA is starting to show some of that leadership and unity that we’ve been all begging for over the last few years. So I’m watching this space. I’m liking what I’m seeing so far. I’m liking how proactive BDA is being on social media now whether they actually amount to something and actually help to make some changes and help dentists in a tangible way, is yet to be seen. I’m also commending the works of Jason Smithson, Luke Foley et al, from the British, newly formed, British association of private dentists. I think there’s some great work being done there. So while you guys are doing a great job representing our profession. So Facebook is a actually a pretty good way nowadays to find your associate position, I found an associate position that was very happy with some years on Facebook. And I can post a link or a graphic up to some of the Facebook groups that are, I think, are quite active and quite good. Some of the bigger groups like UK dentists, and For dentist, By dentists, often looking for good associates, but there are these dedicated groups on Facebook. So that’s good. And something I’ve seen, which is pretty cool is sometimes, you actually can get a good response where instead of waiting for the right job to come on and get posted there. For some people, what I’ve tried, what they’ve tried before is they advertise themselves saying, Hey, I’m a GDP, I have this many years experience, this is why I’m about hire me. And I’ve seen that. And that’s actually work for some people. So that’s a different approach that you could take on those groups. So being proactive, and advertising yourself. And having said that, another tip I want to share with you is back when I was looking for an associate position, I feel as though everyone in my professional circle was aware of it. So don’t be embarrassed that you’re looking for an associate position. Don’t be scared to tell the world that you’re looking and you know, through six degrees of separation, you never know who that information might end up with. And you might get a phone call one day saying, Hey, I heard that you’re looking certainly, I’ve been approached or headhunted, if you like, by some very eminent people before because the word got around to the right people that I was looking for a job. And that was potentially going to work out quite well. For me, I didn’t take that job in the end. But you know, the offer is coming are just amazing. So unless people actually know that you’re looking for an associate position, how do you expect for people to gain contact with you and offer you a position, things aren’t gonna magically appear, you have to put yourself out there. It goes with the saying that having connections in dentistry is so important. And if your net worth is your network. So a few examples of how that has benefited me in looking for associate positions is dentinal tubules. I’m very active part of dentinal tubules. And Dhru Shah himself was able to put in a good word for me a few times, I remember when a few other mentors of mine, were able to pull a few strings and get my CV or portfolio to the right person. And that was quite handy. So remember to, when COVID-19 ends and the restrictions are lifted. Make sure that you’re not just an online persona, make sure that you’re attending courses, Congress’s, affiliate yourself with a professional body like BDA, study clubs, for example, dentinal tubules, BARD, PACD, BES, whatever your interests are, I think if you connect yourself with like minded professionals, then that is going to exponentially increase your chance of finding not only an associate position, but the right associate position. So make sure that you’re active not only just online, but you’re active in the real world, you actually go into these section 63 events, which are usually like these free evenings or, or heavily discounted courses that you could go on, and you meet people, and you introduce yourself and you build your network. The other thing that which I’ve banged on about before is having a portfolio. Now I don’t know, any good principal worth their salt, who will not ask for a portfolio when you’re applying to work in their practice. I think portfolios don’t need to be too fancy, they don’t need to be full of full mouth rehabilitations. Not everyone is after a big cosmetic guy. It’s good to have a whole range of procedures in your portfolio, to show the principal that you care, that you’re a caring dentist, that you take the effort to actually document your work and reflect on it. I think that is so so powerful. If you can show evidence of reflection, then I think anyone who wants a ethical and good dentist will see that’s what’s being presented in front of them. It’s an interesting story, how I actually found one of my first associate positions, and my principal at the moment in the Richmond dentists I work on Fridays is Hap Gill, and Hap been a mentor for me for many years. In fact, our journey started on Twitter, believe it or not, many years ago when I was a dental student, I was tweeting, he was tweeting, we started tweeting each other I then learned that he’s also a Hounslow boy. And I learned a lot about his philosophy. He was also a Sheffield graduate as well. So we just sort of connected on that. And you know, fast forward Three years later, so it’s a slow burner, but connecting with the right people over Twitter helped me to find what I think is a dream associate position. I’m very happy where I work at the Richmond dentist and I love working with Hap, he’s a great mentor of mine. So sometimes just being out there, be yourself connect with others on social media, so Twitter worked well, for me, I don’t know how popular Twitter is nowadays, certainly my activity on Twitter has decreased a lot, but sometimes just saying hi, and connecting. So it was actually Hap who connected with me. So it’s very, you know, I still think, wow, you know, he’s such a time I was looking up to him, like, why would a bigshot dentist connecting with me, I’m just a poor student, you know. So I felt great. So there are some great people out there, great mentors out there, who will give young dentist a chance and listen to you and talk to you and mentor you. So just look out for them, watch out for them, connect with them. So that was a story of how I found one of my most fulfilling associate positions. Another technique, which I’ve successfully used is actually finding a practice potentially locally to you or, or a practice that you want to work at. And even though they may not be hiring, I actually walked in one day on a Saturday morning, because I knew they were open and Saturday, dress in my suit, with a CV in hand. And I just went and I introduced myself to the receptionist. And I said, Look, I’m not sure if you’re hiring at the moment or not. But I just like to tell you that I really admire your practice. I done a bit of research about this practice, I knew the principal works, I was already following the principal on social media. Does that make me a stalker? But I was able to build some rapport with a receptionist, and I was able to leave my CV then at the receptionist, she wasn’t a decision maker in the practice. So she just sort of file the CV away and said, Okay, I’ll do my bit, I’ll tell the principal, but Fast Forward three months, and someone was handing in their resignation at the practice. And, you know, the principal already knew that there is a keen young dentist who is practically begging to work at my practice. So why should I advertise his practice out when there’s already someone suitable, potentially out there. So he called me up, interviewed me and I started working there. So that is another technique, you know, you don’t have to wait for a vacancy to turn up to advertise yourself or hand in your CV and your portfolio. So that worked well for me. And that could potentially work well for you as well. And finally, I’m just gonna leave you with a few, with a quote. And that is that you may have to kiss a lot of frogs before you find your prince charming. So unfortunately, beggars can’t be choosers. And you know, the reality is, you are one of almost over 1000 df ones, for example, who suddenly need to find an associate position. And it may be a while before you find the right one. Now, some of the things I’ve told you like having a portfolio, being part of a community like tubules, or PACD, BARD, whatever, well, that will maximize the chance of you finding the right practice in the first go. But actually, most young dentist I speak to, I know most of it is great. If you’re still at that same practice, your first associate position has been 10 years and you’ve been there. Amazing. But that’s quite a rare story. So don’t be disheartened. That is not an all singing, all dancing practice. I think you have to remember, if you’re in DF one, when you’re just finishing, you’re still honing your skills, you’re still learning, then be in the practice that is going to help you learn and don’t forget about the earn. So don’t forget about earning money at your stage. It’s all about I was very much about learning, learning learning, I want to work in environments I could learn. And that was always a priority for me over earning. So just bear that in mind. When you’re looking for an associate position. Try and find a practice where you can see a hot, high volume of patients, that’s going to skill you up better and quicker than anything. And make sure that you have a good team behind you and a good principal and some good mentors. That’s essentially the secret formula. So I wish you all the best if I can be of any help message me on my social media channels. If you found this useful, send this to one of your colleagues. And as always, please subscribe to the YouTube channel and on my podcast, Protrusive Dental podcast. Thank you very much.