Protrusive Dental Podcast

Following on from the hugely successful Part 1 with Dr Libi – we present a very clinically focussed Part 2 where we discuss: A case of a deep cavity on a deciduous molar – how would YOU treat it? Stainless steel crowns and Hall crowns – lots of troubleshooting Brilliant analogies and communication pearls yet again LA vs No LA when treating Children? Management of Molar Incisor Hypo-mineralisation (MIH) in primary care When should you refer? https://www.youtube.com/watch?v=9bo85tC2s-o Need to Read it? Check out the Full Episode Transcript below! Downloadables for watchers/listeners in Protrusive Dental Community FB group: Guide to Hall crowns [PDF] Paeds Blog [Link] SDCEP guidelines [PDF] If you missed Part 1 – do check it out on YouTube, on the podcast, or on this site. Please Subscribe and share if you found this useful, it’s how my cast grows! Click below for full episode transcript: Opening Snippet: You can when you're saying something you know the truth. So taste your cement. See what it tastes like? Okay?... Jaz’s Introduction: Hello, everyone. And welcome back to part two with Dr Libi Almuzian after the first episode all about prevention, we’re going to follow on a little bit more about the clinical stuff. So for example, we’re going to discuss this type of cavity, this type of presentation, a deciduous molar with a cavity like that, how would a pediatric specialist manage that, we’re going to talk about the use of local anesthetic in children, is it always necessary? We’re going to have a big part of the podcast episode discussing about stainless steel crowns. And we’re gonna discuss why GDPs are not taking routine bitewings on children. As before, there’s gonna be quite a few downloadables and I’ll put them on the Protrusive Dental community. So it’s going to be the whole crown booklet by Dundee University, some more by SDCEP and a pediatric dental blog that I’ll put on there as well. So for those who are interested in this, they can follow up on that by joining the Protrusive Dental community on Facebook. I’m hoping that you’ve noticed that the audio is a bit cleaner for this part of the episode. When I switched to recording with a different software, it actually downgraded the quality of the audio. So I used to get a lot of messages in the initial episode saying ‘Jaz, how’s your audio so good, what kind of setup do you have?’, but I feel as though the audio quality has dipped in a little bit. So I apologize for that. But we’ve got a way around it. So I’m hoping this already sounds better in your headphones while you’re on your job while you’re cooking or in your car. So I’m hoping that in future episodes unfortunately got bit of a backlog of three or four episodes before this technology with improve sound. Hat tip to Dr. Zak Kara who helped me improve my sound. So in a future episodes, around three, four episodes time from now, the entire episode hopefully will have as crisp as audio as you can hear it now. Anyway, we’ll join Dr. Libi in just a moment. But I want to give you a Protrusive Dental pearl for this episode, which is basically this, during this lockdown period, it can be quite difficult to be your usual productive self because everything is now alien. It’s weird being at home, you know, the temptations of daytime television, daytime drinking, all these sorts of things are in the way and you may be feeling that you’re not as productive. So I certainly felt that way. So one thing I started to employ is a trick by someone called Brian Tracy, who has numerous books, which I read. And one of them I believe is called Eat That Frog. And the way he says is Eat That Frog. So what Eat That Frog philosophy means is when you wake up in the morning, do the most difficult thing and get it out of the way. So that thing that you really can’t be bothered with, can’t be asked with, you really don’t want to do, do that thing first. So that’s what I’ve started to do over the last week or so in terms of what I’ve been doing. And I think it’s made a huge difference by eating that frog first thing in the morning. It’s actually improved my day, I think so is that. His other book, Getting Things Done was really influential to me around about eight years ago when I read it or when I listened to it. And it’s all about getting things done. So checklists and whatnot. But the main tip I can share with you from that book is the philosophy of mind like water. Now what mind like water means is, I used to be someone who I used to have my to do list up here in my head at random points throughout the day, I might be thinking, right, I’ve got to do ABC, I’ve got to take the bins out, I’ve got to make sure I finish this project, I’ve got to make sure that I message that person send this email, oh, I am, I’ve got to pay that bill or whatever it is. But if you actually have a system so that your mind is like water, you don’t store anything like that in your mind. Instead, you have a system for example, for me, it was a robust to do lists. So every one of my thoughts, every one of my tasks is on a system. And I never have to worry about my tasks because my mind is like water. So I hope that made sense. So those two tips from Brian Tracy, I hope they help you during this lockdown period. And as always, I’ll join you in the outro of this episode. Main Interview: [Jaz] I want to talk about now, probably the most stressful thing for GDPs which is emergency child patient and I’m not talking trauma because trauma is always stressful because trauma is something we don’t see very often but when we see it’s really important and that could probably have its own five part episode of trauma but Let’s talk about something that really used to stress me out a lot when I was earlier qualified. And it still worries me when I see an emergency you know it’s like 1pm and suddenly it at 3pm, a child’s booked in with an emergency. It’s still something that stresses me out. So, you know, it’s difficult to manage a child when they’re in pain. And it’s difficult to manage a child in any way. But when they’re in pain, when they’re suffering, whether it’s an abscess, or whatever. So I want to hear some tips on managing childhood prevention. And let’s talk about, Can I share that clinical case with you? [Libi] Yes [Jaz] Let’s start with this. So that for those listening on the podcast, I’m going to describe the what we’re seeing. But for those obviously watching on YouTube right now, then you can see this. So what we’re seeing here is an upper left D, on a 10 to 10 1/2 year old girl. Can you see that okay, Libi? [Libi] Yeah. Okay, thank you. [Jaz] Brilliant. So the C was removed around about six months ago upon the recommendation of an orthodontist, because the three is that looking like they’re maybe ectopic. What I realized at this appointment was that having a look at the recalls, because I’d seen the patient remove the teeth, and I’d seen the patient because of some other issue, she’d actually had not been seen by any of the dentists of practice for routine checkups. So one little tip there is make sure that when you see a child for emergency, have they had their recalls? Because this should have been picked up at recall. But the patient never had a routine examination appointment. Anyway, she comes in complaining of a pain on chewing. And when I had a look, there was no signs of an abscess, the tooth wasn’t really that tender to percussion. But as you can see, there is some subgingival caries. And obviously, we know this cavity has been there for some time, because there’s gingival overgrowth into the cavity. I’ve had half an hour to manage this. And you know, I put my hand up, I’m slow dentist, half an hour to manage this in the way that I want to, in the style that I want to and you know, given the child lots of time, that’s not enough time to me in an emergency appointment. So can you talk us through what you advise in a situation such as this, and how to ultimately manage a situation like this. [Libi]And Firstly, the fact that it was missed, it’s not surprising, because what would have happened is it started interproximately, like we were talking about earlier, we need to be focusing more on interproximal cleaning. And what’s happened is finally the enamels become undermined occlusally, and it’s broken off, and you’ve ended up with this huge hole. So I’ve actually had a few instances, you know, where you get some parents who are quite upset that they’re bringing their child in for regular checkups. But these things are then all of a sudden appearing. And it’s trying to explain to them the reasons why. So that’s one hurdle because you get this parent who’s coming in upset that you know, I’ve been, I’m bringing my child in to see the dentist and why have they missed this to the point where it’s become painful. Now, the first thing to consider is you need to actually ask, you know, do a good pain history. So when you’re saying pain on biting, to me that’s probably because the gingiva is being traumatized. So now it’s exposed that gingiva was being traumatized if that patient didn’t have any pain, due to from hot and cold, or wasn’t keeping them, even if they had it too hot and cold, but it wasn’t keeping them up through the night. I would say that that tooth could probably have a stainless steel crown, okay? So I think this is something which is underutilized by GDPs. As soon as your tooth, the baby tooth has two surfaces involved, or interproximal surface involved, I would go for a stainless steel crown. The main reason being, you cannot put on a rubber dam on a child and get adequate isolation and place a robust composite restoration that you can guarantee you will last five years, which is usually the span that you need, because if they’re coming in at six or seven years old, and they’ve got holes in, a big hole in the tooth, that tooth needs to last until it’s going to expoliate we were looking at five to six years. So ideally stainless steel crown is the option. Now the thing is you said this patient is 10 and a half years old, okay? And they’re already sort of undergoing various treatments for ortho, interceptive orthodontics, let’s say [Jaz]I feel like it might be a bit delayed because there was no mobility of the DFE so maybe we’re looking at really 12- 12 and a half by the time this one goes away. [Libi]Okay. So let’s say we still need to keep that tooth for two years. First thing is, why aren’t GDPs taking x rays? Why are GDPs scared of taking bitewings for children? Do you know that I use taking a bitewing as a measure of cooperation of the child? If you think that that child cannot tolerate bitewings, how are you expecting them to tolerate treatment? Right? [Jaz]Absolutely [Libi]So you need to tell them, you need to say to them, “We need to take a picture, because I forgot my X ray specs today, I can’t see inside your tooth, we need to see how deep this hole is, we need to see how.” So you’re going to see quite a few things from this bitewing but you’re going to say to the child, you know, “It’s so easy. It’s just like taking a selfie, feels a little bit uncomfortable when you bite down on it, but you can probably help me, you’ll be really good at positioning it for me.” And you get them to put it in their mouth with you. Because having the bite wing holder rammed into your mouth is not fun. Especially not for a child but getting them to do it and say “Bite gently. Oh, yeah, you’re doing it perfectly. Thank you so much, you’re helping me so much,” You get the x ray taken quickly. Fantastic. Lots of positive reinforcement, “You are so amazing.” You know, you either say to them, children younger than you manage this, or you say to them, “You’re doing better than children who are older than you.” Just anything you need to say, to get them excited about doing and it’s literally takes seconds on each side. So just getting those x rays is invaluable. You’re going to be able to [Jaz]Can I just ask you now? Because obviously, that’s amazing point. And I think not enough GDPs aren’t taking radiographs for various reasons. But what is the youngest that you start taking bitewings? Because I think that’s the first question everyone’s thinking, okay, what age should I be thinking about it? Is it due to eruption pattern? Or what you might suggest? [Libi]Yeah. So if you, in the SDCEP guidelines, I think it says from four and above. So [Jaz] even if they’re low risk? [Libi] I see, now this is where it is. So if they’re low risk, you have no reason to think that there is caries. But if you had any doubt, if there was any shadowing, if the child had high risk from dietary factors that you identified, they weren’t brushing, well, then your indicate, you can take a bitewing. But if you have a space dentition you can see in between the teeth, obviously, you don’t need to take a bite wing, if the child is you know, has parent reports phenomenal diet and, you know, excellent brushing, you can’t see anything clinically, that would give you any doubt, then no, you’re not going to do it [Jaz]Maybe their siblings who are older, who’ve had no issues and they’re good as well. [Libi]That’s another reason. But if you can see a slight shadow or you know, you just feel like the oral hygiene isn’t there, you know, because usually, when a parent brings a child in for assessment, this is when they brush the best, you know, this is my best brush before I see the dentist, still not on point, then you’re thinking, ah, usually it’s probably worse. So just if you can identify any factor that would make you think, are they higher risk than I think, take a bite wing, it’s very low radiation, it will also help to sort of measure the cooperation of the child going forward, you know if they can tolerate having a bite wing they will be probably cooperative for treatment as well. And like we said, it starts interproximally and you you’ll be surprised, one of my colleagues actually did a research about it, about the difference between the clinical examination and radiographic examination [Jaz]Is this eight times more? Because I remember a study saying that you see eight times more [Libi]Probably, I can’t remember exactly, I have to go back and ask her. But she did that. And it did show that radiographically, we were finding much more cariers than we were clinically. And it changes your treatment plan. And so taking bitewings is really important. So for this child, if this child that you had seen now 10 and a half have had bite wings previously, that would have been spotted earlier before the occlusal surface was undermined. But anyway, we’re always talking about we addressed what situation we have. If we take an x ray to this tooth at this point, what we need to see is how much of the root is resorbing. Because sometimes when you’ve got an infection in a tooth, it can resorb earlier, even if you know and is it worth doing heroics on a tooth which is resorbing? And it’s going to exfoliate earlier than its counterpart on the other side, which is not infected. So that’s one thing to keep in mind. Another thing is to see the depth, so, a hall crown on a non symptomatic tooth. So if you are seeing that the only pain she has is on biting. I would say that that’s probably due to food impaction and not actually [Jaz]Yes. I thought that as well. That was my diagnosis. [Libi]Yeah. So if I don’t have any other symptoms, and that tooth has a band of dentine radiographically visible between the cavity and the pulp, I would put a stainless steel crown on that and monitor it. Because you’ve given it the best chance of a seal. It’s, you know, you’re never gonna get a great seal with a composite or a gic. [Jaz]Can I ask a really clinical question now? [Libi] Yeah [Jaz] In that scenario because we can talk about placing hall crowns and some mistakes I’ve made in the past. But in that situation, when you’re seeking the hall crown, the gingiva, the overgrown gingiva can trap itself between the crown and the cavity. Do you see what I mean? So my way of managing would be I would anesthetize and I would curettage this gingiva away, and then I’ll be able to, then I feel confident I can place restoration or in my hands usually stainless steel crown. Am I being too aggressive? Should I be worrying about this? This is me, it’s my restorative dentistry mind, you know? [Libi]Yeah, so you’re restorative dentist, I’m pediatric dentist, I’m thinking how can I minimize, do the least treatment for this child? So what I would do is if I was really concerned about the gingiva, but it was a little bit of gingiva, I would not be concerned about that when I sit the crown going inside the crown and just dying off and living happily ever after, if I felt like it was really overgrown. Okay, I would put in a gic. Okay, so I would push the gingiva aside, I put some topical anesthetic, I push the gingiva aside with a plastic instrument, I would place some gic and allow the gingiva to grow in a more favorable manner, bring the child back the week after. So I would put in some separators if I needed as well. So besides the gic filling, and what I’ve done is I’ve built up that tooth to push the gingiva away. And then the next time they come in, you just put the hall crowd up. Okay? [Jaz] Okay [Libi] So you’ve sort of pushed the gingiva out of the way you can put a hall crowd on. Because anesthetising a child is not ideal. Even although you know, you’ve had this child has had an extraction, so they might be more cooperative. [Jaz]She’s very good. She’s fantastic. So that’s why I was happy to even consider anesthetising remove that gingiva and place a hall crown. But then again, look, for me, it’s only in this case, it’s only gonna last a year and a half, two years. And I know for a fact that mom’s a bit anxious about having metal, which I know we can easily talk about , parents have objections to hall crowns because of the metal. I know, you’ve told me about a white alternative before and we can you can touch on that. But in this case, what I’m probably gonna do just because the parents are pressured, and the fact that they only has to last a year and a half to two years, I’m probably gonna place the best restoration I can. But if she was around about two years younger than I agree with you, I’d really try and convince the parent about having a stainless steel crown. [Libi]It’s all, you know, there’s so many factors to consider when you’re doing treatment for any patient and pediatric patient is no different. So you have so many factors in play, the parents preference, the child’s preference, you know, I’ve had parents who don’t want the stainless steel crowns And then you tell them Well, you’re saying well, the alternative is that I have to give them an injection and, you know, clean out and put a composite in, and it takes time and they don’t, some of them don’t realize the impact of that until they actually see it happen. And I have had children and parents backtrack and say, actually, you know, once they’ve seen their child be upset by having to have local, be upset by the whole procedure that being longer and you know, having to have your mouth open for so long. They say actually, it’s fine, just put a crown on and I think the stainless steel crowns are just invaluable I think. They do such a good job. I mean, the study in 2018 BaniHani said that it’s the outcome of doing a pulpotomy Okay, on a tooth is the successes 95.3 and the success of the hall crown is like 95.8 [Jaz]Wow. And no anesthetic needed. It’s just a no brainer. [Libi]It’s like why would you put your child, Why would you put a child through having anesthetic having to have a rubber dam on, all those smells of the zinc oxide and the ferric sulfate. It’s like, it’s a no brainer to me, I would rather put a hall crown on and hope for the best, usually it is the best than put a child through all of that and you know what, they come out, they’re so excited. “Look at me with my Iron Man tooth, with my princess crown,” you know, and they show it off to people, they get excited. And again, with the parents, the parents can get upset because they feel like when people look in their child’s mouth that they’re a failure. But look, my child has needed metal in his mouth because his teeth are so bad. Again, it seemed to them, we use these crowns for many reasons, some teeth don’t form properly. And that’s why we have to cover them with these things. Lots of children happen these days for different reasons that isn’t just because of holes in your teeth. And just making them feel a bit reassured that you know that nobody’s judging them for that. [Jaz]I think there’s two, that’s a really good point and in managing the parent and reassuring them. But I think there’s two reasons why there may be more, you might you probably know more than that. But I think there are two reasons as a GDP, why some, a lot of GDPs are not using stainless steel crowns. One is not really their fault, lack of training, it wasn’t taught at the time that they’re at dental school. So lack of training is one and then therefore, they never get the hands on experience. So if you can recommend anything for them to channels for them to learn, and the other one is probably not having the kit, because you know what, the kit is like a 350 pounds, 400 pounds, I think it’s from 3M, I personally think it’s a great investment, because restorations will last longer, less emergencies, less fillings falling out. So I think number two, we can really dismiss and I say you know, speak to your principal, get them to stop being so cheap and buy the bloody, stainless steel crowns. So I think really what we need to tackle is the first point, lack of training. [Libi]So in terms of placement, there’s the hall crown. There’s like a guide that you can you can get off the internet, [Jaz]The University of Dundeen, right? [Libi]Yes. So that’s an, I would say read through that and practice, what I tend to do is put separators, so I use the elastomeric orthodontic separators, the small blue ones. And what I do is at the, so you do an appointment, and then you can have the second appointment a couple of days later or a week later, it’s up to you sort of, I wouldn’t go more than a week because usually they’ll, the space will be created and they’ll fall out and then you start to lose the space. But what that does is it just gives you a tooth that sat on its own spaced, really easy to fit and cement a crown and then the teeth will go back to normal occlusion afterwards. I think it’s about not being scared to do it. So the first appointment putting in the separators is it feels almost the same as having the crown on. So it’s like an introduction to the child. So I put in the separators. And you can use floss or you can use separating pliers. And some children might get scared from seeing separated pliers. But actually how I introduce is I say, “These are my magic fingers because my fingers are too fat to hold this tiny donut” So it’s donut, it’s not seaparator, of course they get you, you get smirk from them when you go, do you want, “I’m gonna put some donuts in your mouth” and they go ‘What is this dentist talking about?” You know, So I’m like “No sugar donuts? Do you really think I’d give you sugar donuts? So yeah, we’re gonna pop in these donuts, they’re so tiny, and can use my magic fingers. And look, the magic fingers can stretch it and squeeze it in between your teeth. And we’re going to wiggle, so I’m going to put it in between your teeth, you have to wiggle as well.” So you get them to wiggle and you’re wiggling. Just to place it in that contact point. Once it sits in you see, it’s gonna feel like you’ve got an a piece of Apple skin or something stuck in between your teeth. If it feels like that it means it’s right. [Jaz] Brilliant. [Libi] So it’s reassuring them that, that sensation is the one that we’re looking for. If you tell them, “You’re not going to feel it, you won’t even notice it’s there.” If you say that, and then they feel it’s there. They feel that you’re lying to them. Whereas if you tell them upfront, “This is what it’s going to feel like it might feel like this, it might feel like that” Some people wouldn’t notice it. So within a few days, you’ll have forgotten about it. They usually forget about it as soon as they walk out the clinic to be honest, but it’s just reassuring them that this is “Oh, it feels like that fabulous. We’ve done the job right? Well don.” You know, just positive, always upbeat. And don’t please [Jaz]Libi that is a routine for you. Because you do this day in day out. Oh my god that Apple skin analogy is I have to just say that Apple skin analogy is amazing. I think [Libi]It’s just all about being truthful with children, children know when you’re lying. So even when you’re giving them local, and you don’t say you’re not gonna feel a thing you say it’s gonna feel like and then you give them something that feels like so I’ll go into that when we talk about local. But going back to the separators I placed the separators because it’s going to help me to size and fit a crown much easier. And it’s going to help the child it’s like in a climatization for them. So you can put fluoride and put in some separators in one appointment. That’s a climatization for them. The next time they come in, you’re gonna say “Oh, have you looked after my doughnuts for me or did you eat them?” Sometimes they’ll have fallen out. Sometimes there’s space created, sometimes there isn’t. If you can get a separator in, you could probably get the crown in, but it’ll need a bit of a push. So if you know if you’ve lost the separator, but you have been able to place the separator there, the space that you need for the crown is less, but it might need a bit of a push, and it’s knowing whether the child would tolerate that or not. If you feel that they’re too anxious, then take place a separator again, bring them back sooner, or place a thicker separator and bring them back sooner, so it doesn’t fall out. And when you fit the crown, it’s about getting a click. So if it clicks on, you say to them, “Oh, it clicked perfect. That’s what we’re looking for.” And also joking around with them. “What size do you think you are? What size tooth are you?” Because you know, we have sizes from two, three to seven. And I’ll say “What size are your feet? Do you think your tooth is as big as your feet? Let’s see, and it’s just like getting a new pair of shoes, we have to try a few sizes to see which one fits.” And they’re gonna say “Does it hurt?” I’ll say “No. Does it hurt when you put a hat on your head?” “Okay, no.” “It just feels like putting a hat on your head.” And I’ll take the crown and maybe put it on their pinky finger. “See, just like putting it like that.” And once I’ve got the right size. Of course, for airway protection, what I do is I cut a piece of half the band, you know, like it’s almost like a plaster strip. And I attach it to the tooth and I say “This is a mermaid tail. So we’re gonna have a tooth with a mermaid tail or a fish tail, or a dinosaur tail” whatever you want to call it. And I say “That so that I don’t drop it. I’m really bad at dropping things.” So you’re just explaining as you’re going and “Let’s try it on. You’ve try it on. It’s the right size. Right? Let’s get the glue. And this is really special loopy glue made by the tooth fairy and Mr. maker.” So Mr. makers, like this popular crafting guy on TV on CD. [Jaz] Okay, I didn’t know that [Libi] And most kids know it, I think, but anyway, so I say the tooth. So I’m chatting away while I’m doing all this. “Yeah, the tooth fairy Mr. maker get together and they make this special glue for us. It doesn’t taste very good. But if you, once I’ve stuck it on, I’ll wipe away the extra bits so you don’t have to taste it.” There’s all about reassuring them that you’re doing the best to make them comfortable. You stick it on, you give them a cotton roll, you ask them to bite down you say “Now I need you to bite as hard as you can like a tiger” You can do a practice of it beforehand, saying “When we’ve got the Iron Man tooth, I’m gonna ask you to bite on this. You’re gonna bite as hard as you can like this or like a tiger, like a lion” you know, just all those analogies and you’re cheering them on when they’re doing it. And then you wipe away the excess I use a wet gauze because I use gic to cement it, which doesn’t taste very nice. Taste some of them are a bit acidic. I’ve actually, I actually taste my cement. You know, somebody told me, one of my supervisors when I was training said, ‘Oh, it tastes like salt vinegar, when you say it tastes like salt vinegar, Chris, I think it says it in the manual actually tastes like tell the child It tastes like this [Jaz] That’s what I say as well [Libi] Great, but have you ever tasted it? [Jaz] No. [Libi] No? So actually, I tasted a few and one of them tastes really lemony. Why didn’t taste like some vinegar crisps? Because it’s just like so that you can when you’re saying something, you know, it’s the truth to taste your cement, see what it tastes like? Like and you can and I say to them, “I know because I’ve tasted it.” Anyway, so we stuck it down, we’ve got them to bite, we’ve washed, we wiped away the access, you can go in with a bit of floss, “Oh here’s our tooth fairy floss, let’s check everything is clean. I want to make sure it’s really shiny for you. Now, do you want that tail, the mermaid tail on? Or do you want me to take it off? Do you want to walk around with the tooth with the tail? That’s what I asked. It’s just all distraction, because now they’ve got this new thing in their mouth. And it feels weird. It’s putting a bit of pressure on their gingiva. If it’s done well. So you’re trying to distract them this whole time from actually linking the feeling to their brain and getting upset. So you’re just constantly talking and saying things to them to distract them. And you’ll say to them, “It’ll feel funny because it’s something new in your mouth.” And I always say to them, especially if they’re a bit older, you know, “Your mouth is so sensitive. Even if you have a grain of sand in it, your teeth can sense that so imagine you’ve got a brand new tooth and you know, it’s amazing and I want you to keep it shine for me.” And at this point, “Fantastic. You’ve done a great job off the chair” Reward. [Jaz]Two things I want to because I assume you’ve moved on to a reward now which is great, but two things I want to ask about the nitty gritty clinical things which I like to do drop. One is when I place a hall crown or sends to crown should I be able to to always be able to floss because it’s so tight sometimes. Is it some scenarios where I won’t be able to floss to help clean the cement? If so, how do you manage that? [Libi]It is possible. And if the child is really upset, I would advise the parent and say there’s still some cement left, which will probably be cleaned away by brushing. But we can check it the next time they come in, because I don’t want to sit there and be so pedantic about a piece of gic stuck in between the teeth, which is going to leech fluoride onto the tooth beside it fantastic. It’s like an added bonus for me. But I’m not gonna sit there and be pedantic about getting rid, to floss, because that will probably upset the child. Yeah, and it’s just giv you more chair time [Jaz] That’s my biggest worry. [Libi] Yeah. So if I would say try with a probe, flick it out. If you can’t, there’s still, so there’s a couple of ways I manage it. The first way is if they tolerate the three in one and suction, I will as soon as I’ve seated it, go at it with the three and one water and air at the same time, blast it through the interproximal and get it you know hoovered up by the dental nurse. And then I will go through it and floss as well, I find this because the gic cement is still viscous, it washes away really quickly. And then you don’t have to do as much cleanup. If they don’t tolerate the 3 in 1, I will use a damp gauze straightaway after, straightaway go through with the damp gauze and get in there with the floss as soon as you can. If you can’t due to cooperation or whatever reason, and it stays there. And it’s interproximal. If you can’t flick it out with the probe, I would just settle for it the way it is and then just see it will brush away gradually. And you know, and try and get in there next time with some flosses, especially if you’re seeing them again. [Jaz]Okay, which cement are you using? [Libi]Previously, I used Fuji 1, which I find is good because it’s quite fluid. And you sometimes you need that bit of extra time with kids as well. Because you know, you might have a bit of a faff around until they let you seated properly. You don’t want something too quick setting [Jaz]Can Dentists use Fuji 2 or Fuji 9? Can they use that? Should they use that? [Libi]And I think it just depends on the work. [Jaz]Because that’s what they have. That’s what they have in their drawers. Right? Like a gic. I’m just thinking for those starting to use this technique should they? Is it just worth two cents? [Libi]I think try it see how this gets it is. I’m not too familiar with the other, I think because I was in pediatric department when we just had that as standard. And now I’m using relyX. But it’s the one that mixes as you squeeze it through the tube, I can double check which one it is exactly. But that one it gives a bit of a longer working time and is viscous. So I think it’s, you just need a bit of a longer working time to make sure that you’ve got that extra leeway to sit because what you don’t want is the child loses cooperation or something or they don’t bite down straightaway. Or you know there’s you’re unable to sit it properly immediately. And you don’t want that gic to set quickly. And then [Jaz]based on how you said there then it makes sense. If it was a situation where you only have Fuji 2 or Fuji 9. Fuji 2 is the RMGIC light cure of a version right? Or it’s a dual cure? So it’s way more runny and without the light it can take a long time to set which might make sense for those who only have the option to use a Fuji 2 rather than the Fuji 9 which should be quicker setting is far more viscous. So I don’t think, the Fuji 2 sounds better. [Libi]Fuji two would be the better option. Yeah, definitely. [Jaz]Brilliant. So we’ve talked about that. And then the other thing I want to say is that when I’ve placed a hall crown, let’s say on the upper left D or E, then to reassure those who may be trying this technique for the first time that actually, when they bite together, it can be alarming as a restorative dentist to see someone and they’ve got a massive like opening and the contralateral side is three or four millimeters opening, but every time they come back [inaudible], the occlusion just magically settles. So just to speak on that. [Libi]Yeah, I think they said it takes around a week for child’s occlusion to settle where you have to bear in mind is they’re not adults, they’re not fully grown, they’re in mixed dentition, they will go through phases where different parts of their occlusion are open, you know, tight contact space, you know, they they’re just going through so many changes that actually it doesn’t make, it doesn’t impact them significantly, and sore tooth would impact them much more significantly in or not being able to eat on that [Jaz]But it’s worth mentioning isn’t it? For those doing it for the first time because it actually can be as a I did the first time I did as a student I was oh my gosh, how is this ever gonna settle and it does. [Libi]If you do feel like it significant open bite, and what you would do is monitor it. So if over the course of, let’s say, a month it didn’t settle or the child was complaining that it was bothering them, then you could take off the crown. So you’d have to cut it off and redo it. So But usually, I haven’t had any cases where that’s been the case. [Jaz]I think it’s a good tip also, and please correct me if I’m wrong, Libi is Never do opposing teeth and never do an upper left E and a lower left E Hall crown the same time because the opening will just be ridiculous, right? Is that still something that you follow? [Libi]The rule? Yeah, so the rule is that you can do two in the same arch on opposite sides. So you can do D and D upper, you can do D and D lower, you can do E and E upper, ED upper at the same time, DE lower at the same time, but you can’t do contralateral. So like you can’t do top and bottom on opposite sides. And you can’t do the same site like upper and lower. Okay? So that’s all in the hall crown manual. So if you have read through that, that’s all. [Jaz]I will stick that on, because I think it’s a really fantastic resource. I know that Dentinal Tubules are setting up a Tubules live for hall crowd. So they’re gonna have study clubs all over the UK, where people will get dentists, will get to place hall crowns on models and stuff. So that there is that coming on, and I’ll share the date with you as well. Because for those GDPs in your network, who because there are some study clubs in Scotland, and maybe you know, if you can go to one of them, be a mentor for these GDPs maybe that might be a good thing. So I’ll be in touch with you about that. So let’s talk about something. We’re gonna have to wrap it up eventually. But let’s talk about a clinical point where local anesthetic in children. I’ve done it both ways. In my earlier years, when I used to work in mixed practice, let’s say and time is of the essence. I’ve done it before that I was okay. It will be okay with that anesthetic and you’re there for the first time pieces doing what you can and then with the slow handpiece roten bur and then just restore to the best of the ability without anesthetic, and I’ve done it also, more routinely now I’m using anesthetic, and what is your take? And what is your advice for GDPs about local anesthetic use when it comes to restorations. Because for Hall crowns where you would advocating not to use LA. But for restoration. Obviously extractions, mostly we’re gonna use LA, but we’re talking about fillings. [Libi]Fillings. So the thing with LA and even with hall crowns, by the way you can use a topical just around the gingiva if the child is is quite uncomfortable if you just paint a bit of chop lines that’s around the gingival margin that can help you with the seating just to make it a bit more comfortable. But topical anesthetic has another use, which is to quantize a child. So most children, what they hate about the local anesthetic is how it feels afterwards. So when they’ve had it, they don’t understand that feeling. So if they’ve never had local before, and you numb them up, and all of a sudden their face feels really weird. And they keep touching it, we keep biting it because they don’t understand or know how to process this, they can actually process pain better than they can process that sensation of being numb. Because it’s something brand new. So sometimes, if you know that next time they’re going to come in, you might use local anesthetic if you give them some topical anesthetic on cotton roll and you ask them to put it on their tongue and say, “Oh, doesn’t your tongue feel funny now? Doesn’t it feel weird? That’s because it’s gone to sleep. And usually when your tongue is asleep, you are asleep. But this time you are awake and your tongue is asleep. That’s why it feels weird.” So that’s wat I say to them, and then it’s about reassuring them that it’s going to go back to normal. So you’re gonna say to them, “I know it feels weird now, but in a few minutes, it’s going to go back to normal. Now, after a few minutes, when it starts to go back to normal, they say “She was telling the truth, it’s going to go back to normal,” They believe you, okay? Even if they go home, and then they realize, “Oh, it’s gone back to normal,” you know, they say it’s reinforcing the message that you’re giving them. Then when you need to give them a local and you tell they have this really strange sensation. You reassured them and say “Do you remember when we did it with the topical aesthetic? How it went back to normal with a magic jelly? It’s going to feel the same again, it’s going to go back to normal. And it’s just because it’s asleep, they’ll wake up later.” So that’s sort of one hurdle with giving them local anethetic. Sometimes in a child who has non painful tooth, so let’s say they have caries in their tooth. It’s not painful to them. Okay? At the moment. They’re not complaining of pain, but you can see the cavity, it needs to be restored. [Jaz]That’s the most of scenario and that’s exactly what I want you to answer for GDPs. [Libi]So I think high speed with water is very difficult to tolerate without LA, because you’ve got the added coldness, which will stimulate the pulp and just the cold water along with the high speed is going to bring about some reaction. So going at first with a slow speed is actually probably more favorable. So if you were going to go without LA, you would, you can say to the child first. So the thing is, if they know what to expect, you’re more likely to get a better outcome. So if you say to them Halfway through once they’ve started to have pain, that actually “I can give you something to make your pain go away”, they’re not going to be cooperative. But if you say to them from the beginning, “I can make your teeth sleepy, which would feel a bit uncomfortable to begin with, but then your tooth would be asleep, and we could clean it really quickly and well.” Or “We could try with the small buzzy toothbrush first. And if it feels uncomfortable, then I can give you the med, the special jelly and medicine to make it sleepy so that you’ll be comfortable.” But it’s, if you say “Some people feel comfortable with the buzzy toothbrush without having the sleeping medicine and others don’t. So do you want to try?” So it’s giving them the options. And then also, you know, they feel a bit in control. And you give them a signal. So you say “If it feels uncomfortable, I want you to put up your left hand” and it’s always the left hand, you say “the left hand so you can hit my nurse, not me.” So I say “You can hit Chloe, but don’t hit me.” And I say “And if you put your hand up, I’m going to make sure it’s safe. And then I’ll stop.” So you don’t say I’m going to stop straightaway. So you don’t give them unrealistic expectations. You make them feel that you care about them. So you saying “I will make sure it’s safe. And I will stop as soon as it’s safe for me to stop once I’ve seen your hand signal, okay?” And you have to follow their hand signal. Even if it gets really annoying, even if they’re doing it every two minutes. If they start to do it too much. And you feel like they’re just doing it for the sake of doing it. Then you go for another tactic, which is to say, “We’ll use the buzzy toothbrush for five seconds. And then we’ll stop.” So we’ll count to five and then we’ll stop and when you’re doing count to five, “Okay, let’s increase it to 10.” Now a child in pain, you’ll realize they’re in pain, you’ll know when it’s just you know, you can tell when somebody is in pain, you’ll see their legs switch, you’ll see their, you know, some kind of reaction body reaction. And if you you can also use the slow speed on their nail, you can draw a [Jaz] Yes, I do that. [Libi] Yeah, so you can use the slow speed on their nail, and just explain to them how it’s going to feel ‘that it’s going to feel bumpy, it’s going to be a bit noisy, it might feel a bit bumpy on your teeth might feel a bit tickly.’ So I think you can do some restorations without local. And the reason being that now we know that if we seal in caries. So if we’re sealing in the caries, we’ve got a good clean margin, that’s actually more important than going deep and taking out every single bit of affected dentine. So if you are taking away the soft dentine and you are leaving affected dentin that isn’t soft, but you have a clean periphery of the cavity, and you can get a good seal on that, then I think that is sufficient to give a good outcome, restoration wise. I don’t think you’re going to get any better by making sure that you’re digging deeper and digging deeper might need local. So it’s kind of balancing up. It’s very different for each child. And some children once they’ve felt it without the local, they will prefer having local. And it’s just gauging that. But like I said just introducing it from the beginning that it’s an option. And I will use it if you want me to, that makes them feel in control when they’re asking for something, then they’re more likely to accept it as well. [Jaz]I really liked that giving them the control and choice and I like your tips about the hand signal. And following that a tactic I use quite a bit is okay, we’ll do 10 second bursts and we’ll see how many bursts we need. So I’ll count down and as you mentioned, that’s a bit quite effective for you as well. So that’s brilliant. In terms of the clinical questions, I want to wrap up in terms of because there’s so much value that we can talk about here. So, two questions I’m gonna wrap up, I’ll ask you in a way and then you can answer them. One will be at what point do you think a child, what is the threshold where you think, Okay, this child really needs to be sent to you. For example, you can contrast that with some children that you see and really you think this could be managed in primary care quite easily. So you can, you know, touch on those both things. So what point Should they be being referred to a pediatric specialist or pediatric dentist? And the other question I want to ask you is, what’s the one tip you can leave everyone with your one main big tip, you can be a repeat tip, what you said in terms of how to be better on Monday morning with children. So those two things, when should we refer essentially? And your overarching Doctor Libi’s Tooth Fairy tip. [Libi]So, in terms of referring, I think, you don’t want to push a child to the point where they’re upset. If you’re getting to the point where you cannot do your treatment, without the child being visibly upset, and the parent agitated, then you need to stop. And there is no shame in stopping and saying, “I think that this child would benefit from having a more specialized approach, and a more time.” And you know, just a different approach. So I think that sometimes dentists will push a child and make them upset, but then they have to realize that afterwards, that child is going to regress and not be able to have dental treatment. So I have some children who is severely anxious, and you look in their mouth, and they’ve got crowns, and they’ve got restorations. And you think, Well, they’ve had all of this done. But they’ve had it done under duress, where they feel like they’re pressured into having it rather than them being cooperative, and being able to have that treatment comfortable. So I think what, I think a few of the signs are, if the child you know, is visibly upset and cries when you’re trying to do anything, doesn’t want to get on the chair, the parent can be, if a parent is dentally anxious, highly likely their child is. So if you know that their parents, the parent doesn’t like going to the dentist, and they’ll come in and say, “I’m really scared to the dentist” That means the child is going to be put off as well, so and children who ask lots of questions, so it’s like a delaying tactic. So you get these like seven, eight year olds, and every time you come near them, “Wait, wait, wait…” and they’ll ask you like 10 questions. “Wait, I’ve got another question. I’ve got another question.” So they’re all tactics for them to delay the treatment, and it’s just a sign that they are anxious. And if you cannot give them the time that they need to get comfortable, and to build that trust, then refer it to somebody who can, because you’re not doing the patient any favors, even if they will need one treatment done. And you know, you can push them and just get it done that day. You’re not doing them any favors in the long term. So I would say, that’s when you should be referring these patients. And another thing is when you see something that needs more inputs, like MIH, so Molar Incisor Hypo-mineralisation, that’s something that needs to be looked at, not with eyes that are looking at those teeth and thinking What can I do for them today, but actually, they need more long term monitoring and treatment. And if it’s outside of your scope, then I would say these refer to a pediatric dentist because there are windows of opportunity for treatment, which will minimize long term needs for that child. And you don’t want to be the cause of them missing out on those opportunities to have a better outcome in the long term. [Jaz]I’m sorry to interrupt you there, I’ve got a really good PDF, I believe from Guys hospital, about it addressed to parents about MIH in your child. So I’m going to include that in the file section as well. I send that to parents and they find it really educational. [Libi]Jaz, that is what I give to parents when I diagnose MIH, and that is the leaflet that I emailed them. I said this is what you need to know, because there’s just a simplified version but what I don’t like seeing, okay, and I don’t think I’ve, we’ve touched on this, but I’ve seen quite a lot of parents who are coming into me who have been to the GDP and have been shamed or guilted about the caries in their child’s sixes when the child has only you know, the tip of just erupted, it’s not caries. It’s carious because of MIH. And we need to recognize that and you know, I put together just a list of the signs that this is MIH and not caries. Okay? So warning signs are if they’ve had hyperplastic teeth, okay, so sometimes we get the either hyper plastic following that we get the MIH or they’ve had no caries in the primary dentition. So you get this child in who’s just got their sixes through, you know, a year ago or six months ago, and they’ve got caries in it. But they’ve never had caries in their primary teeth. That doesn’t make any sense to me. There’s nothing that could have changed significantly diet wise or health wise unless there is a significant event in their life. But there’s nothing to say, you know, if you’ve had no caries and primary dentition, why are you getting caries in your sixes? Okay? So that’s something which I wanted to bring attention to GDPs. And the only thing is when you spot white opacities on the front teeth, on the incisors, you know, that’s also another warning sign for MIH and creamy patches on the molars. So what you want to do at that stage is you do want a specialist input because you don’t want that child to miss out on the opportunity of having the ideal treatment for them to minimize their treatment in the long term. [Jaz] Okay [Libi] and I mean, it’s very preventing that as 40%, some studies are saying it’s 40% prevalence of MIH. So it’s something that we should all be regularly looking out for and checking up on. [Jaz]It’s something that, I don’t want to shame anyone because I feel as though just at the point when I was at dental school, we were getting taught about MIH, but I feel as though three or four years above me, maybe they that was when they weren’t. The pediatric dentists weren’t teaching so much about MIH, when I went on my elective, and I met these Canadian dentist or who I’m still in touch with today, lovely people, great dentist, and they had no idea about and they were 25 years of experience, they had no idea about MIH. And it’s something that a lot of dentists don’t know about. In my own practice where I worked in, when I sent everyone this handout, they were like, no, the hygienist or the dentist had no idea about MIH. So you’re totally right, we should be looking out for the signs. And I’m gonna put some more information for listeners about MIH so that they don’t have that situation, that they’re confusing it for clinical caries, because it just doesn’t match up. [Libi]And the thing is, these, the sixes that we’re talking about that are affected, they are sometimes sensitive. And so what happens is the child actually won’t brush those back teeth, because they’re too sensitive to the cold water. So one of the great tips is to just say to parents to use warm water when you’re brushing, which is just something so simple, but it can be a game changer. And then the second thing is because the enamel, the quality of the enamel isn’t the same, they actually the sealants won’t stick as well to them. So that’s another reason why we’re not able to protect them. And also, if you’re doing a restoration on these sixes, they aren’t numbed up as easily as normal sixes. So you’ve got this sort of this vicious circle that they can’t brush them because they’re sore, but then they’re more poor enamel, they’re getting holes in them. So I think this is the kind of thing that you need to refer to a pediatric dentist because it’s not a straight forward, putting sealants on and put, you know, doing restorations, it’s looking at the long term for that child what is best. So I think I would, I love it when I get referrals for MIH, because I know that I can give them the best chance going possibly, you know, going forward. [Jaz]I mean, the severity of MIH probably has huge bearing on your treatment plan because if it’s mild, and there’s no breakdown and you’ve got a good quality patient with minimal orthodontic needs that would benefit from a six removal. That’s the kind of child is saying, okay, we’ve noticed it, your dentist done a good job to identify it, you’re going to have to be a bit more preventive than the average child let’s say, but thankfully, we don’t need to do it. But on the other end is when there’s severe breakdown, then you have that window to have them removed, that the seven set the place. And that’s where it’s important to get those referrals in at the right time. [Libi]Yeah, and to get an orthodontic opinion at the right time. And you know, it might be a case of needing to temporize these teeth until the right moment to take them out. So this is all things that need to be decided by a pediatric dentist with an orthodontist. So it is outside of the scope of the general dentist. [Jaz]So what age like let’s say they’re six, and they’re coming through and there’s already breakdown, do we need to refer at age six, or wait until age eight, or? [Libi]Any tooth that you see with breakdown, refer. Because what’s gonna happen is the orthodontist is either going to say, you know, if they look like they have a class two tendency, you’re going to say, maybe I want to keep these teeth around until they’re 12. And all of the adult teeth are through and I’m going to use that space for orthodontic treatment, you know, so, it varies from patient to patient, but I would say if it’s mildly affected, and you feel like you can manage it with sealants, and there’s no breakdown, keep that child under your care. If there’s any breakdown at a young age especially you need to refer them in because even the window of opportunity for closing, for extracting and anticipating spontaneous space closure. We’re looking at the window between 9 and 11 depending on how advanced they are. Some children are, you know, their dental age is much higher than their chronological age. And they can you know, that window can be missed, because we’re not referring them early enough. But if they’re coming in at age six or seven, you can take an OPT, and you can see what is developing, do they have any missing teeth? Do they have, you know, this is all things factors that we need to take into consideration and how much will start to break down there is, I would say, Take clinical photos, if you can. And if it is breaking down quite quickly, put a stainless steel crown on it, take a picture of it, put a stainless steel crown, and then you can show that the dentist that you refer on to say, this is what it looks like I was proactive, and I put a stainless steel crown on it, because I didn’t want it to break down further because some of them they get to the point where you can’t even post stainless steel crown on them because they’re so broken down. And the only option you have is to extract tooth, even if it’s not the optimal time. So we don’t want the child to get to that point, basically. We want to be able to pick and choose when and if we’re going to extract. [Jaz]Amazing. Thanks so much Libi. And to wrap up, the final tip that you want to share to GDps? [Libi]Final tip, have fun, actually enjoy your patient. Be excited, you know, go at the weekend and watch a kid’s movie, take your niece, nephew, son, daughter, whoever go with your friend, go watch a kid’s movie so that on Monday morning, when you come in, you can “Say have you seen the latest movie? It’s amazing.” You know, and just have something to talk to them about. And just enjoy it because kids will bounce, you know, they’ll feed off that excitement that you have, and they’ll be excited to see you and that will make you in turn excited to see them. And just enjoy it. Kids are great. Kids are so much fun. And you know, I know they come into you with pain, but the reward that you will have that what you will feel after you’ve treated them and they’re out of that pain and you see how much they trust you and you know, they’re thankful to you and the parents who are grateful or make you feel amazing. [Jaz]Fantistic. I love it when you when you said that I punched the air so I don’t think the video caught that. But that’s it. A lovely ending point to finish on. Libi, how can we follow all the tips that you give? Because you always give them so many tips to GPDs, can you please tell us all your social media channels so we how we can follow your progress and your career and all the lovely things that you’re doing. [Libi]So I’m doing, I have a Instagram page @drlibi. And I have my page on Facebook, which is a bit more active than what I post on both of them. But my videos and things more on I do Facebook live videos and things like that on my Facebook, which is Dr Libi’s Toothfairy Tips. And I’m sure you’ll put a link, Jaz. From those two pages are actually aimed towards parents more than towards dentists. But I’ve found that dentists like to follow it because it gives them, they like to see how I word things to parents, and also just how to bring about the topic. So I’ll post about, you know, what I see in the supermarket that annoys me and all the things that are speaking to parents saying no added sugar, tricking them into thinking they’re doing the best for their child, you know, one of your five the day, but actually it sticks to your teeth and rots them you know, so we get lots of patients who have otherwise healthy diets and they’re having health foods in inverted promise . And but actually, they’re very sugar instinct to the teeth. And what I say about natural sugars to parents and kids is the sugar bugs don’t care where the sugar came from, they will eat it anyway. And poop anyway. So it’s eaten the ship the sugar bugs don’t look at natural sugar and go ‘Oh no Stand back. This is natural. We’re gonna back off.’ They’ll eat it anyway. So just those oral health messages that’s it’ll help you as a dentist to be able to spread them in a more empathetic way. And you know, I post my personal stories, one of the reasons why I have my Facebook pages actually for me to appear human to the children I see. So I say to the parents follow my page, they said I’m not really into Facebook, I see I know. But if I’m not going to see your child for six months, if within those six months, they see a few of my posts and see me going out with my girls and seeing that it makes me more familiar to them. And when they come back in, they know a bit of what I’ve been doing. And they will not feel you know, they won’t have forgotten me and it’ll just make them still be in that comfort zone with me and just keeping up to date and you know, and it helps to motivate them as well with brushing, videos of brushing and things like that as well. And there is a tooth fairy, there is a blog which I have started to follow which is really good on Facebook, which is aimed towards dentists. And I think it’s called Tooth FaiRead. I’ll email, I’ll send you the link for that. [Jaz] Please do that. Because anything that have value, I want to share it [Libi] Yeah. So that’s a new one that started that’s aimed more towards dentists. And they posted an excellent summary of MIH, just last week. And I shared it because I think it was an amazing concise, to the point what we need to be noticing, you know, dentist needs to be noticing. So I’ll give you the link for that. Just, yeah, follow my page. You’ll see that I post mixed things not all dental related sometimes about my life. And yeah, I think people find it interesting. [Jaz]Oh, absolutely. I love your posts. Always. I think my message to you Libi is keep doing your thing. I think you’re helping so many dentists. And you’re showing that you’re having fun. And I think I was saying to my speakers, you know, you are a massive role model to dentist, especially to you know, to audience, but women dentists, you know, we need more women like you in dentistry, sharing, teachings, spreading the word. So on both accounts, thank you so much for coming on the podcast today. I think my listeners over the two episodes have learned so so much. And I’m just in love with all your analogies, and I can’t wait to use them with children. So thanks so much for making me a better pediatric dentist and all the listeners who were listening. And it’s been a pleasure having you on. [Libi]Thank you so much. Thanks for your time. And thanks for your amazing podcast as well. It’s been a privilege. [Jaz]Thank you so much. Jaz’s Outro: Thank you so much for listening all the way to the end. I hope you enjoyed it as much as I did. I really enjoyed speaking to Dr. Libi on both sort of parts of the episode, the first one being prevention. The second one just now as you listen to a bit more clinical. So if you enjoyed it, please follow Dr. Libi and what she’s doing on social media. She’s doing some great things. Got some really cool episodes lined up going ahead. Some great guests coming up. For example, I’m just gonna drop this one there, Chris Orr amongst many others have agreed to come on. I’ve got a great episode about complete dentures coming up as well. But all of that you have to wait for around about once a week I’m averaging at the moment. So again, really appreciate you listening. And if you’d like it, please tell a friend. Tell a dentists. Put a five star review on your platform that you listen to it on, whether it’s Apple or Google or Stitcher or whatever. And give me some feedback. If there’s anything I can improve for you. Let me know. Thank you.

I am joined by Paediatric Dentist Dr Libi Almuzian who is so passionate about Paeds! https://www.youtube.com/watch?v=wPxMqET7Y8s Watch the entire episode on YouTube There were so many knowledge bombs that I made broke this in to a 2 part series. Part 1 (this episode) will focus on Communication and Prevention, and Part 2 will be a bit more clinical with specific scenarios discussed. Need to Read it? Check out the Full Episode Transcript below! If you love seeing Children, you will gain a lot from this episode, but if you currently do NOT like Paediatric Dentistry, Dr Libi shares her top tips to help you! We discuss: How to make a dental visit more playful Techniques in managing children co-operation Importance of creating a no blame culture and gaining and trust of the How you can use an App called Social stories to get maximum engagement with the child patient (this is genius!) We reveal what the MOST IMPORTANT Question to ask your paediatric patient history taking! (this may surprise you!) Lots and lots of techniques shared to improve communication with children and the flow of the appointment during operative procedures Dr Libi reveals The Sugar Bug Story – you will LOVE this. Top tips for prevention! Any downloads promised (SDCEP guidelines, references to apps) are compartmentalised in the Protrusive Dental Community group (closed group), or also viewable below: Here are Dr Libi’s top tips for Dentists: 1. Wear something or have a prop which might be familiar to a child (character sunglasses, a toy, a sticker of a character on your scrubs) This will break the ice and give you something to talk about. 2. Be excited! Your excitement will rub off on them. When you collect them from reception tell them how happy you are to see them and how excited you are about the visit today (So excited to meet your teeth!/ count your teeth!). 3. Teach your nurse to distract the child when you need to talk to the parents, this will make them less worried when you talk to the parents in a more formal manner. 4. Never use an instrument without introducing it, even a sharp probe can be introduced in a way that makes it non-threatening (show them the probe and tell them it helps you to be able to tell if something is hard or soft, then run the side (not the tip!) of it along their nail and fingertip and say “see, now I know your nail is hard and your finger is soft, I’m going to do the same with your tooth to check it” 5. Use child friendly words, even if they make no sense, in fact better if they don’t make sense! This actually makes them laugh and relax. 6. Even if the child is cooperative they will lose patience, so always go for the simplest treatment option with the least steps involved. That way you will retain their cooperation rather than lose it, so go for a Hall crown rather than conventional filling when you can because there is less of a treatment burden involved. 7. If you lose cooperation, try to do something (anything) before they leave, this will build their confidence and stop any avoidance behaviour. For example if you were trying to do a sealant or other treatment and were not able to, reassure them that sometimes it can be hard for some people to do this procedure the first time but they will definitely manage something easier, then apply fluoride (if they are not due a fluoride treatment then even just painting their teeth with water and a micro brush will help build their confidence), just remember to explain to the parents why you are doing this. 8. Motivate the parents to talk positively about the visit when they’re at home, tell them to only refer to the positive aspects and give them a goal to work towards, for example, next time we will polish your teeth with the dentist’s special electric toothbrush and it will tickle, how exciting! 9. Be empathetic with parents, tell them you know it’s difficult it is to brush twice for two minutes, when the day is so busy and the children are so squirmy! Acknowledge the difficulty of controlling sugars and give them one goal like cutting out juice during the weekdays. Small achievable goals are easier to accept and praise them for their efforts in caring to make a change. 10. In your notes write what the child likes so you can talk about it the next time they come in and they will feel special that you “remember”. Also note anything the child really dislikes during examination and treatment, this will save you time the next visit (if they like the chair to be moved before they sit on it and not while they’re sitting, or if they like to move it themselves), if you don’t upset them they will trust you more and they will feel special that you are considerate of their feelings. BONUS TIP: Sing! The singing dentist has the right idea! It doesn’t matter if you’re good or bad at singing, just the fact that you are singing will distract and relax them. My favourite is Disney songs! Also I think it’s important for dentists to realise that if they are unable to treat a child under their time constraints this is not a failure on their part, there is a reason why there are paediatric dentists and why they undergo 3 years of additional training and that is because there are some children who need more than they can provide and that’s ok. A referral can make a big difference to a child who might need extra attention to complete their treatment in a way that will give them confidence in the dental environment and enable future treatment with ease. If you found this useful – Dr Libi shared a very good Paediatric Dentistry Blog aimed at Dentists called Tooth FaiRead Check out Dr Libi’s professional website DrLibi.com Dr Libi runs a very active and informative Facebook page Dr Libi’s Toothfairy Tips Dr Libi’s Instragam page: @drlibi Latest SDCEP guidelines May 2018 Click below for full episode transcript: Opening Snippet: After hearing that story, we've had no resistance to brushing. Because you can't it's like one of those things that you can't unsee I actually have a poop emoji on that I have in the clinic which I put in my big teeth. So I showed them a mouth with teeth with a poop emoji in it. That's it. You can't unsee it... Jaz’s Introduction: Hello everyone and welcome to another episode of Protrusive Dental podcast. I’m your host Jaz Gulati, it’s going to be an epic two part episode with Dr. Libi Almuzian, who is just one of the nicest people in dentistry. She is a fantastic pediatric dentist, and she has some great gems to share with us all. In the first episode, we talk about real world clinical dilemmas for GDPs. Because seeing children is not everyone’s forte, let’s admit it, some of us are better than others at seeing children. So I think what Libi, Dr Libi shares with us will really help everyone not only those who already love seeing children, because she has some great little tips and tricks that she shares, which allows you to build better report with the child and the parents. But also it gives you if you’re not, you know, fond of children or you don’t like seeing children in practice, but you have to see children, how can you make your visit better? How can you make the patient experience for the child in front of you better and for their parent. So we’re going to talk clinical and also very much non clinical, cooperation, communication, we’re going to talk about how to manage the patient, the child patient with multiple caries lesions, and how to actually more importantly, for me, I found it difficult not to manage the actual dentistry. But actually managed the parent, the lot of time you take bitewings the first time, and you may find significant amounts of tooth decay, which the parent had no idea about, and try and break that news to a switched on parent can be quite difficult. And sometimes you’re managing the parents’ emotions, and not just the child. So we’re going to talk about that. Do you have a way in which you communicate caries with your child patient? Do you just say ‘Oh, it’s a whole, it’s a cavity’, ‘You have bugs on your teeth and they ate your enamel away’? I mean, how do you actually communicate caries to a child, right? Well, I think this is the biggest takeaway amongst many takeaways from this two part episode. And this is Dr. Libi’s sugar bug story. So if you struggle, or you want to a better way to communicate caries to a child and a parent in a playful manner. Then I love what Dr. Libi has shared with us about the sugar bug story. So I’m excited for you to hear it. In terms of Protrusive Dental pearl, I have to do a shout out to one of my listeners who messaged me, I believe they live in Edinburgh. I don’t know their name, but they kindly message me and gave me a tip. The Instagram handle is [B gravities]. The tip they have which is relevant to mounting children is that they have a small Lego man, somewhere in the surgery, somewhere where the parents and the child can find it. And you tell the child and the parent that I want you to try and find this Lego man that’s hidden somewhere. And what it allows is for, allows for, in their own worlds, two minutes of peace and quiet while the child and the parents are having this little game around the dental room, around your surgery where they’re looking for this little Lego man. And it actually is, it works really well for them. And I think it’s a great little pearl. So I think you know buy a little toy or a little Lego man, stick it somewhere, slightly hidden but you can still see it from where you want the dental surgery in the dental chair and play a little game so it gives you some peace and quiet and give them something to do so they’re not all going to loud and rowdy in your dental chair. So thank you so much for sharing that little Protrusive Dental pearl with the listeners I really appreciate you reaching out for that. Guys, enjoy the episode in the two part episode myself and Libi. I’ll do another intro for for the second episode. It was you know, just a man of value that Dr. Libi was providing. I had to split it in two episodes. So lots of great content in there. I do realize that by the time you’re listening to this episode, it will probably be the peak of COVID-19 I hope it peaks and the peak finishes ASAP. I just hope wherever you are, wherever you’re listening to this from you are safe, your family is safe and well. And you try and stay positive, stay distracted away from all the terrible things happening in the news and I wish you and your family all the best. Enjoy the episode. I hope you learned something from it. Main Interview: [Jaz] Dr. Libi Almuzian. Thanks so much for coming on the Protrusive Dental podcast. You are a dear friend of mine and my wife. Obviously you and Dr Mo Almuzian who came on you know which episode it was must in episode four or five, the orthodontic one. So you’re going to do very kindly, the peads version, Peads 101, Peads 201. We’re going to really, the aim of this episode, Libi is to help GDPs become better at managing the child patient. I’m going to give you my crappy introduction and then I’m gonna let you do a better one. So to me, you are someone who is a an amazing pediatric dentist. You share so much on your Facebook and Instagram channels, helping GDPs. You’re also helping a lot of orthodontists in terms of managing the ortho pediatric cases. And I feel as though you’re supermom, I know you’re super Mom, I’ve met your three lovely daughters. So that’s my crappy introduction for you. Please, Libi, can you tell the world who’s listening because actually now I can tell my listeners that 94 countries listened to my podcast as it’s done. So can you tell the world, can you tell them a little bit about yourself. [Libi]So it’s a pleasure to be on your podcast. Thank you very much. I’m a pediatric dentist, I recently completed a clinical doctorate in clinical dentistry, in pediatric dentistry. And I’m just really passionate about Pediatric Dentistry and everything about it. And I just want to make everyone better at treating children for the greater good. So I think it’s something that can be done really well. And it just needs you know, a few hints and tricks and tips for dentists to be able to do a great job. So I’m really excited to share what I can today to help everyone really, and that’s the purpose of my pages, really. On Instagram and Facebook are just bring to light all the information that parents are maybe missing and really be misled in the media at the moment. And from, you know, a consumer point of view, lots of the advertising is in towards parents, and it kind of guilts them into buying things that maybe have hidden dangers, to just raising lots of awareness is our role as dentists, really. [Jaz]Brilliant. And as you’re speaking, I’m making notes, because every time you say something like that, and I think of other questions to ask you along the way. So tell us about where you work at the moment. What kind of setting? What are the kind of children that you treat at the moment? [Libi]Yeah, so at the moment, I’m working at the Berkeley clinic in Glasgow, and it’s a private clinic, the kind of children that I see are ones who are anxious, maybe considered too young to be treated. And some of them have some medical complications, some of them have some mental complications. So just people with special needs, and just anybody who maybe hasn’t gotten along with their general dentist, not for reasons, not because the general dentist isn’t good enough. But it’s just that their needs sort of out with that. And that’s why people specialize as pediatric dentist, because they’re, you know, we’ve done three years of training. And in those three years, you learn so much, and you just realize just how much more you can do for children. So that’s my role. I really enjoy using inhalation sedation, which is one of the tools that maybe isn’t available to general dentists. And I found it to be a good sort of stepping stone sort of, between actually just having treatment on the chair, or having to go for a general anesthetic, there’s that little bit in between, where you can use inhalation sedation. And if it works, fantastic, that child doesn’t have to go for general anaesthetic, which is, you know, it’s not that I’m against general anesthetic. It’s just I think that teaching a child who’s really anxious to be able to cope with dental treatment is an investment in their future because nobody can avoid dental treatment their whole lives. So being able to overcome those fears is actually helping them more than putting them to sleep and just dealing with the oral health issues. So it’s a more holistic approach, really. [Jaz]And also, when children are put under, you know, GA, the treatment plan becomes far more aggressive. [Libi]And the reason for that is we don’t want to have children going for a second general anesthetic. And this is, you know, we’re evidence based dentists in the UK. And you know, we, it’s shown that when you’re not drastic in these approaches, you do end up going for a second general anaesthetic and you don’t want to put that child at risk of infection. After you’ve you know, he’s undergone a general anaesthetic and general anaesthetic is not without risk. And it’s also very stressful and traumatic events for the child and for the parents. So you do want to try and avoid it, if you can. [Jaz]Well, there’s two things worth mentioning there, one for perhaps students, because I remember being invited as a student, and one of the questions was, What are the signs with a child that there may be neglect at home going on, or things that you are worried about the child’s sort of general well being and one of them is actually if they’ve been to a second GA you really should be looking at what kind of care they’re getting at home. So I remember that being a viable question. And the other thing is that which I’m sure all dentists in the UK know, but for those in the world listening, unfortunately, we have a situation in the UK where and correct me if I’m wrong and my stats are not up to date, but one in three of GA admissions with children is because of a dental reason. [Libi]Correct. So it is quite a high figure. I mean, considering all the GAs that are happening for kids, yes, most of the, third of them are for dental issues. And while you can’t, you have to take that with a pinch of salt, because some children are going in because they have buried teeth, you know, they’ve got impacted teeth that need to be taken out, they’ve got other issues, like, it is a kinder option when you’ve got a child who’s 9 or 10 years old and needs all four of his adult molars out. Yes, it’s kinder to send them in for GA because that’s quite a lot to cope with at the age of, you know, 9 or 10. So that’s maybe in the case of NIH or something like that. So it’s not to say that these, you know, that it’s unreasonable that we’re sending all these children for GA. Previously, these children may have had everything done on chair and it might have ended up, you know, being more traumatizing to them. But at the same time, when we’re talking about decayed teeth, and very young children, that’s the GAs that we’re trying to avoid? [Jaz]Absolutely. Well, let’s just dive right in because my podcast is very clinically focused, and I want the, you know, the people on the front line, the GDP to really gain value. And that’s what we’re going to talk about. So let’s start with managing a child with multiple caries lesions? How do you manage the child? And how do you manage the patient? manage the parent even? So I know, it’s quite a broad question. And there’s so many factors involved. So for example, I imagine the patient’s age has a significant bearing, what their diets like, what the education levels like, but where, At what point do you think, Okay, this level of caries is should be dealt in primary care, and this is the way it should be dealt? Or what level is that okay, you need to now refer. And just any sort of gems that you can do. I know, it’s too broad of a question, I can narrow it down if you want me to. But just managing the biggest problem that we see is caries in children. And I’m going to come on to later whether when we’re managing caries in general practice, should we use LA? Should we not use LA? that sort of stuff. But if you just start with a general overview of management of caries. [Libi]So overall, when you get a child and if they’re cooperative, and the parent is on board, because you have to remember when you’re dealing with children, it’s not the same as dealing with an adult when they come in to be treated, you have to take into account the dynamic. So there’s a new dynamic that’s between you, the parent and the child. So the parent has to be on board with your plan, and the child has to be working for the plan, and you have to win both of them over. The biggest thing you need to think of is just emphaty. So firstly, when you get a patient in, you need to empathize with the parents, and, you know, make them understand that, you know, everybody can find themselves in this situation where the child has caries in their teeth. And that your job as a dentist is to actually help them identify the reasons why we’ve gotten to where we are, and how to move forward. Okay, so no guilt, and no blame. [Jaz]Can I add something to that, Libi? Because I think that’s a great starting point. So what I say to adult patients, and to the parents of my child patients is I always say, look, in this practice, where we have a policy of no shame, no blame, we just want to help fix this and prevent it. And we said that from the start, and I just find that everyone just breathe a sigh of relief. Yeah. And everyone’s so much more relaxed. Because if you don’t say that one line or put it across in the message that you’ve just said, then all the while. That’s what the parents are thinking that I’m a terrible Mother, I’m a terrible father. And they’re not really absorbing information you’re giving. So such a great starting point, empathize, and then let them off the hook. Because you know what’s happening. If they’ve got the right attitude, it may not happen again. [Libi]Exactly. And it’s just that this, they’re become less defensive and more open to your suggestion. And that’s what you want. That’s for the benefit of the child and parents. And once you get the parent on board, so if your parent is not on board, the parent of the child, you will never succeed in treating that child. Because no matter what the child will feel that that parent doesn’t trust the dentist and they will not trust you. So it’s really important to gain the trust of the family. That’s first thing you need to do so you can motivate them. What I think some GDPs fall into the trap of is treating the tooth which is worst first, which I don’t think is usually the way to go. Because what you’re going to do is you’re, if you’ve got, you know, a pain, a carious tooth, it has the biggest hole it needs, the most amount of treatment that’s going to be quite taxing on the child and you haven’t had a chance to build a relationship with them. And you haven’t had have the chance to actually gain their trust. And it’s a lot about trust, because you’re going into a really personal space of a child, their mouth, not many people are allowed to touch that area of their face. So usually, it’s only their parent or primary carer who will be touching that area. And so for them to allow you to do things that have different smells, different tastes, sounds is really difficult for them. So what you need to do is to build the trust, I would say, when you assess a patient, let them play. So by let them play, I give them the high volume, low volume suction and let them suck out some water from a cup, to show them that they’re allowed to touch these things when I say so you’re still being quite strict with them. So that you’re setting boundaries that you know, and you can say, ‘Right, that’s enough, we’re not going to play any more we’ve finished for today, next time, once we’ve done x, y, z, then we will have another play’, that gives them a bit of a reward system, but also familiarizes them with all the tools that you’re going to use. So if you grab the suction and put it straight in their mouth, and that’s what you would need to do, if you’re doing you know, if you’re using the high speed, you know, you need to get in there with the suction. And so for them to allow you to do that, if you’ve let them already hold the suction and put it in their mouth themselves. That’s like you’ve cut down the time that you have to explain to them and convince them to let you do that. And they won’t jump up and chop. [Jaz]Awesome. I want to highlight that as a tip. So put the suction, let them put the suction in the cup full of water, right? [Libi]Yeah. And you just introduce and say, ‘Oh, he’s so thirsty, likes to drink? Oh let’s give it a drink.’ And then later you say, ‘Oh, look how funny it feels on your hand.’ ‘Oh, let’s Hoover your nose.’ ‘Oh, actually, why don’t you stick out your tongue, I’ll tickle your tongue’ and you get them to put the suction into their mouth. That’s it, you’ve crossed that barrier. They’re not scared of it anymore. [Jaz]That is fantastic. That is really, really good. Because what I do at the moment, and some dentists do this, I give them the mirror, I let them put the mirror in the mouth, I make a little balloon using the glove. But that’s actually one I’ve never come across. And I think that can suction the sound it makes me quite scary. And some of these suctions can be really strong. So I’m definitely implemented that Monday morning. Thank you so much. So we’re gonna have a little play and you’ve set the boundaries. I like how you set boundaries. Okay, playtime is over. Brilliant. [Libi]Yeah. So it’s all about, you know, you have to be kind of strict with them. Otherwise, you know, they tend to oversell it or like push boundaries, that’s what they like to do. So it’s just making sure that you’re, you know, firm that, yes, okay, we’re gonna play now, but we’re only going to do two more times. So if they say, ‘Can we do it again?, we say, ‘Okay, we’re gonna do just one more time.’ But you’ve got to make sure that you follow through. So even if they get a little bit upset, when you say that it, it’s over, you distract them, then with something out there, but you make sure you don’t go back on your work, because that will be key to being able to do some treatment for that child. And so I always start with prevention, I’m going to, when I look at a full mouth of caries, if that child has their sixes through, but their baby molar, you know, deciduous molars are carious, the first thing I’m going to address, I’m going to seal those adult molars. Okay, the reason why is first, they are most important, I need them to stick around for the longest. And second, it’s a good, it’s an easy procedure, easy enough procedure that will help them build trust. And you know, I introduce it as ‘Oh, it’s just like getting your nails painted. Have you seen everybody gets gel nails? and you put the special light on this is exactly the same.’ And you can [Jaz]That’s the Gem. That is so good. That is you’re gonna, I’m sure gonna make a whole list of analogies after this episode. So that’s another one the gel note, I love that. [Libi]It’s actually really funny when I started working in this practice, the nurse had to, my nurse Chloe is fantastic. And that’s another thing having the same nurse. I know that it’s supposed to be rotated and everything. But actually in pediatric dentistry, there’s a huge benefit from having a familiar face that that patient to come in and see the same nurse each time and see the same dentist. There is a big value to that. So if you can do that, that’s ideal. So anyway, my nurse, Chloe had to learn all the language that I use. It’s a different language. So I won’t call things by their names. I wouldn’t say pass me that high speed. I won’t say pass me, you know, long tapered fissured bur.’ I would say, ‘Oh pass me the ice cream cone one,’ just like I didn’t want to [Jaz]Can you give us a favor and like at the end if you got like a maybe a list of 15 things like to translate to help the GDP. So for example, I call the fast handpiece, the buzzy bee, but you might call it something else. I call the suction the Henry Hoover, but I think they could probably do best in that cuz some kids might not know what Henry Hoover is. So if you can give us like 10 to 15 things we’d really love that. [Libi]Oh, that’d be great. I don’t mind doing that. You can all join me in the craziness. So anyway, back to what we would do first. We do the prevention first. And I have actually downloaded an app, which helps and allows you to make a social story. And social stories are used for children with autism. But I found that using them with any child helps so much. So what it is, is I have taken photos of my own daughter coming into the dental clinic, sitting in the reception, lying on a dental chair with the suction in her mouth, sunglasses on, the light on. The next picture is neat, examining her teeth, then cleaning her teeth with a slow speed handpiece and brush, and then the steps for having the fissure sealant. So showing the blue shampoo, which is the etchant, ‘So we’re going to put blue magic, Tooth Fairy blue shampoo on your teeth, and it makes it really nice and clean, but then we have to wash it away, it doesn’t taste nice. So we’re gonna Hoover it away, so you can’t taste it,’ And explaining to them why you need to put cotton wool rolls. ‘So I’ll keep it dry.’ Explain to them why you need to use the Hoover ‘so you can Hoover away and you don’t have to taste it,’ you explain to them, ‘you need to dry it because you can’t paint your nails when they’re wet. It’s the same thing with teeth, we can’t paint your teeth when they’re wet. So we need to dry it with the air.’ And I use the 3 in 1 and I always want to introduce the 3 in 1. I spray their hair first I say ‘Oh, I’m just gonna dry your hair, you come in to get your hair done, that gets the giggles,’ You’re just all the time trying to do playful, or ‘Oh no, I’ll draw your ear so you can hear me’ ‘Wait a second, I’ll just draw your snotty nose.’ That one is just like even if they haven’t laughed at the first two, they’re like, Oh, this is so funny. And then finally you get it into the mouth. So it’s just building up that you know, ‘And I’ll tickle on your neck for that,’ to just gain them to feel like these things are non threatening. And also, when you give a child a reason for you doing something says that ‘I’m just I’m going to dry your tooth. Or I’m going to use the suction.’ If you say ‘I’m using the Hoover so that you don’t have to taste it because it doesn’t taste very nice. So I don’t you know, I want you to be comfortable.’ You’re making them feel as if you care. And that is the bottom line. When they feel that you care about them and you’re doing things to help them, they will trust you and the treatment can go so much smoother. So using the social story is such a game changer for me. So if I have a patient who next time I’m going to do fissure sealants for and I send them this story of what it looks like, what the things look like, and what the steps are. And they go home and read that with their parents once or twice. And they read it the night before and they come in and know what to expect. [Jaz]They read on their parents phone? [Libi]I email it to them, it’s in a PDF format, you can print it out, it’s fantastic. So you can make your own story. And you can actually go back and personalize it. So you can see you know, and you could even do it if you wanted to with the actual child and say, ;Right, let’s take a picture of you on the chair. And we’ll put that in the story.’ Okay. And what it does is, it makes them familiar. So kids are always scared of things that are new, they’re, once something is familiar, it becomes much easier. So just knowing, familiarizing them with the steps that are needed to do something just makes it so much smoother when they come in. And even at the beginning of the appointment, I will summarize I will say ‘Do you remember what we’re going to do? It’s really easy, we’re going to do, we’re going to put in the tooth pillows.’ Not cotton wool rolls. ‘We’re going to put tooth pillows so your tooth can have a rest and keep it dry, we’re going to wash your teeth with the blue shampoo. And then we’re going to wash it and dry it and with the Hoover. And then we’re going to paint it to make it super strong. And we’re going to put the Bluetooth very light on it. And then that will be finished.’ Now some children like a challenge. So what I’ll do is I’ll say ‘Usually it takes me 80 seconds to do each. Do you think we could do it faster? Let’s see how fast we can do it.’ And you get them to count in their head. And when you finished one tooth say ‘How long was that?’ And they’ll say ‘That was 76.’ ‘I think we can do better. Let’s do the next one. Let’s see how long that one.’ So all the time they’re distracted by the counting. They’re excited because they want you to be, to win. And another challenge I say is ‘Oh this is a competition. How many things can I fit into your mouth at once? Let’s count. ‘ And while I’m doing the procedure, I’ll be doing the steps that at the same time going ‘Oh my goodness, I fit the cotton roll in, I fit the tooth pillow in, I’ve got my fingers in, I’ve got the hoover in. How many things is that? Let’s count them.’ So all the time you’re distracting, you’re being playful, you’re being fun with them, and they start to trust you. So building trust is really essential. Now if a child was really really anxious, actually, I wouldn’t even start with fissure sealants. I would just put fluoride on. I would just do an appointment where I put fluoride on and I let them have a play with the chair. And then I say ‘Well done. You were amazing. How cool is it coming here. Come back next time. We’re going to make your teeth super strong.’ [Jaz]At an appointment, you can then I’m assuming your protocol now those nervous patients where you only place fluoride is you start that whole social story as well, you might take a photo of that. I mean, that is amazing. I think anyone who’s serious in the world about using their own practice branding, their own selves, so that child is not nervous. So keep these tell us, I’ll put the link on for this app, or is it on like iPhone or iOS? On Android? [Libi]I know it’s iPhone, it’s on iPhone, to be able to use to be able to make your own social story on it. It’s like 14 pounds 99. It’s a one off payment. I paid a few years ago, and I designed it [Jaz]That’s totally worth it. I mean, that is, I mean, Okay, fair enough. Look, for NHS practice, look, I totally sympathize or empathize my fears, my peers, whereby they might find it difficult to make stories, but the opportunity you get, that’s great. But in private practice, for those seeing children, this is a no brainer, I mean, the amount of, the wow factor in the parents, because they’re going to be at home reinforcing. And then they’re seeing your image and this is magical. [Libi]Helping you and reinforcing the message that you’re working together. And do you know what’s even simpler than all like, the simplest thing, even if you can’t do a social story, even, you know, you have restrictions, whatever. And the first thing I do and your patient assessment is to get the child into the chair, I take a Polaroid picture of them sitting in the chair. So I have a Polaroid camera, I’ll take a picture of them sitting in the chair. Now they think, okay, it’s just fun. Actually, that is them seeing themselves sitting in the chair, smiling, and they’re going to take that picture home, and they’re going to look at that, and they’re going to be proud of it. They’re going to show other people and they’re going to feel like it’s so normal for them to sit in that chair and smile. [Jaz] That is so powerful [Libi] It’s just reinforcing that behavior of it’s ‘you can sit in that dental chair’, and I’ve had many anxious patients who you know, at the beginning, when they first come into the appointment, I don’t force them into the chair straight away. I get stuck in with my first question, which is the most important question ever. What’s your favorite Disney movie? Right. [Jaz]That’s the most important question for sure. I love it. [Libi]Who doesn’t have a favorite Disney movie? [Jaz]What’s your favorite Disney movie? [Libi]At the moment is frozen 2. I’m not gonna lie. Frozen 2. [Jaz]I knew that. I knew that. Toy Story is Disney, right? Toy Story? [Libi]Well, DreamWorks, Pixar, all of these movies that I say to them, ‘What’s your favorite movie?’ And that just breaks the ice. Okay, so I’ll talk about that a bit more in my tips for communication, I think we’ve sort of veered off course of [overlapping conversation] [Jaz]I’m gonna have probably a two part episode. The first bit, let’s make the first bit about managing the child and communication gem. So let’s go with that. And then the second part, I’ll show you my clinical photo, and let’s talk about the nitty gritty about the local anesthetic or not, full crowns, that sort of stuff. So if you tell me, I mean, is this a good point to talk about sugar bugs? Or is that something common to later? Or is that something you wanna talk about? [Libi]Oh, that’s something I do in my assessment appointment. So I’ll talk to them. And I’ll say, ‘Do you brush your teeth? So I really ask, do you brush your teeth?’ ‘Yes, I’ll brush my teeth.’ ‘Okay, how many times?’ ‘Oh, maybe once.’ ‘Yeah, try for two,’ you know, and you ask the parents then, ‘Do you help them with brushing?’ Because, you know, we’re trying to push supervise version. I think parents feel under pressure to give their child independence. So it’s like, yes, they can put their coat on by themselves. Yes, they can dress themselves. Yes, they can feed themselves. Yes, they can brush their teeth by themselves. But actually, they don’t. You have to make the parents understand that it, they’re being misled because their child doesn’t have the manual dexterity to do it. So I say well, ‘Can you tie shoe laces?’ ‘Yeah, I can tie shoelaces okay.’ But even I say to them, ‘I’m a dentist and I brush my own daughter’s teeth. So I can see them really well. And I still misplace it.’ I say to them, ‘And this is my other tip for prevention and motivation, disclosing tablet.’ Oh, my God, I love disclosing tablet. And I think there’s so underutilized, okay? And they’re so cheap. And they’re just so easy to use. And it’s something that you give the parents and you gives the child and it’s so visual, they can see exactly what they need to brush and I say to them, and this is another part of the empathy side of it. I say to them, ‘I’m a parent. I’m a dentist, I’m brushing my daughter’s teeth. I give her disclosing tablet to check that I have brushed your teeth perfect.’ So that’s it, you have to always make sure that you’re not being judgey. Can’t be a judgey dentist, nobody likes a judgey dentist. Children, especially a parent about their child. I mean you’re a parent now, Jaz and I think you can feel, you’ll know that if anybody was to say anything about something you were doing for Ishaan I think you’d be very defensive even if you don’t mean to be you can also [Jaz]Absolutely. Every emotion is intensified a 100 fold [Libi]Exactly that Yeah, and not all of it makes sense. But that’s parethood. [Jaz]So I’d like to share like a little personal thing. I mean, the other day, we were doing cold water babies thing, right? And I’m 30 now, and I’ve achieved some cool things in the past, and I’ve really enjoyed it. But the time that he was dipped underwater, and he swam about one meter, and he came back up, proud stole my mind. Everything else was irrelevant. That was a proudest moment of my life. So definitely parenthood has been amazing, which is why I another reason why, when I’m seeing child patients now, I’m always thinking, Okay, this is someone’s child. And what you said communication is so, so important with his parents, you have to like right at the beginning that you said, they should not feel any shame or blame. And everything you say, has to have the right sort of touch to it. [Libi]Exactly. So when I’m talking to them, I say, ‘okay, when you brush your teeth, you’re brushing twice a day, okay? Do you know why you need to brush?’ and they say, ‘Well clean your teeth.’ And I’m like, ‘Yeah, but why why. And this is, when I introduced my sugar bug story. Well, the sugar bug story. And I said, you know, you’ve got these sugar bugs, they live in your mouth. And you know, if they’re a bit older, I’ll say, bacteria, and chaos in bacteria, you know, sugar bugs, just so that to make it feel a bit less intimidating, but also to acknowledge that if they’re older, you know that, you know it’s bacteria. And I say to them, you know, when you eat your food, so I said, you know, these sugar bugs are living things like you. And when you eat your food, where does it go? And they kind of look at me, and like, tell me, and then where does it come out? And you know, all children love it humor. They like to hear about snacks and foods and all these things. And, you know, I think from a young age, they think it’s hilarious, even through to the teenagers. They’re like [Jaz]It’s like raising the eyebrow and like thinking what, you know, why is my dentist talking about? [Libi]Yeah, do you know, I don’t look at the parents at this point. But by the end I had so much feedback, I’ve had so much feedback from parents saying after hearing that story, we’ve had no resistance to brushing, because you can’t, it’s like one of those things that you can’t unsee I say to them, the sugar bugs, they do lose as well. And it’s all over your teeth. And so every time you eat, they stick to your teeth. The more sugar you eat, the harder they stick, and the bigger they get, the bigger bugs they do. So we need to make sure that we are brushing twice a day to get them off your teeth because those bugs and make holes in your teeth, they make your teeth soft, and they make causing yout teeth, so it’s getting them to understand. And it’s sort of you know, we’re not fobbing them off just saying brush your teeth, you know, you have to give a reason in this day and age, everybody wants to know why they’re doing things. When you give them such a plain explanation. And like I said, they can’t unsee it, I actually have a poop emoji on that I have in the clinic, which I put in my big teeth. So I showed them a mouth with teeth with a poop emoji in it. That’s it, you can’t unsee it. [Jaz]That’s the two reason why that’s so powerful, one is because it’s the visual, you have the poop emoji in the mouth, but you’ve attached is not you said explanation. But it’s an amazing story. When you add a story to something, it becomes memorable. And I think that’s why you probably had so much success with this with children. I think, since you told me about it a few months ago, I’ve used it in a few children now. I’m still refining how I say I don’t think I’ll do it quite as long as you do. But this is what it’s all about. You have to practice. And it’s a good point mentioning, I suppose that I’m fairly good with children. And I get that from parents Oh, you’re really good with children. They always want to come and see me. But I get it where they’ve seen someone else and the child and the parents seen someone else. And it’s usually a man who doesn’t, isn’t able to relate to the child at their level, it’s just not part of their personality. Does that? Talking in a high pitch tone and become a child. And I want to at some point, just give some tips about if people finding difficult to relate to children, but they’re still seeing children. What can they do? I mean, my best advice would be practice in the mirror, practice with the either, if you don’t have children patch it to other children because you need to be able to relate to children in a playful manner like you’ve advocated. [Libi]And the thing is, the more excited you sound, the more excited they get. The more, so if you’re just like, yes, sit in the chair. We’re going to do this and they’re like this boring. They’ll start to look for excuses to get up. They don’t want to do what you’re saying. But if you really like ‘Come on, let’s go. Yeah, this is so fun. You’re amazing. Look at this. Oh my goodness, I love your shoes. How fantastic!’ It’s just picking up little things and the tone of your voice is excited. They get excited. They’re like, Oh my god, I’m so lucky to be here. I’m so you know, I’m so happy to be here. Look how happy she is. I must be happy too. So it’s it. It’s infectious. [Jaz] It’s contagious. [Libi] So Yeah, so that’s what we want. So going back to my sugar bug story, this is when I bring in, this is when I bring in the disclosing tablets, okay, so I’ll say my sugar bug story, I’ll say, you know, this is why we need to brush to get all of your teeth and the sugar bugs which are sticking, they’re really hard. And of course, we don’t want to feed them too much sugar, because they just get bigger and hold on tighter to your teeth, they’re stronger. And I say, and the thing about these sugar bugs and their [inaudible] is that they’re camouflaged. And they are the same color as your teeth, so you can’t see them. And that’s why I give them the disclosing tablets that say, this is really fun, the first time you do it, you’re going to chew it before you’ve brushed, and you’re going to see all the places that you need to brush. And then after that I turned to the parents as they after that, you’re going to do it once or twice a week to check that the brushing has been done thoroughly. And the thing with the disclosing tablets that I use is that there are two tone. So they will show pinkish color for fresh plaque within 12 hours. And then the bits that are being missed, the more frequent, more regularly sort of all the time, they show off in a bluish purple. So I tell the parents that and I say you know, and it’s, again, just making them feel that it’s non threatening thing that I use them, you know, I use them. It’s not something that I’m giving you because you are not a good parent, you are not [overlapping conversation] [Jaz]It’s not a punishment, it’s a routine thing. [Libi]It’s a fun activity. It’s really good for kids, and I say to them, even I say it’s good to motivate your kids to brush because then they can see it visually, why they need to brush they can actually see it when they can’t see it. It doesn’t mean anything to them when they see it in bright pink, they know that that’s what they need to brush away, it just makes it more more rewarding that they brushed it away. And also I find it’s a really good tool for teenagers. Because they kind of think, Oh, you know, my teeth look fine. But then when they can see a bright pink, that’s a different issue. I mean, with my own kids now who brush their own teeth, the older too, I sometimes will say, you know, I’ll hear them going to the bathroom to brush their teeth. And they’ll go in for about 30 seconds you know, when they’re trying to just, you know, say that they brush their teeth, and they’ll come out and I’ll say, I’ll shout, ‘Did you brush your teeth?’ ‘Yeah, I brush my teeth.’ And I’ll say, ‘Okay, then go chew disclosing tablet, I want to see exactly how well you brushed your teeth.’ So I think it’s a very good parenting tool. That’s what I saved. [Jaz]My other thing is using, we give away these little timers that you know the sand ones. and children really respond well to that. What do you think about that? [Libi]They like those, I think everything with children is about, it’s about finding something new to motivate them. So at the moment, so you will, from my own experience, we will have that timer, we’ll use it for a week, we’ll use it for a second week, by the third week, it’s forgotten, by the fourth week, it’s sort of not exciting anymore. You need to always mix things up, which is why I say you know, getting a new toothbrush. So my daughter has an electric toothbrush. But in occasionally if she sees a toothbrush she likes in the supermarket, which is manual. ‘Oh, mommy, let at look at this. It’s frozen. Look at this, it’s minions. Look at this, you know, oh, I’m into dinosaurs at the moment, it’s a dinosaur today toothbrush.’ I’ll buy it her a couple of pounds, but actually motivate her for the next two or three weeks, she’ll be excited to use that toothbrush. At the moment, there’s other tools like so again, the disclosing tablets do act as a motivator. So that’s why you use them sort of every now and then to motivate these things. Like I always recommend brush DJ, which is an app. And it’s free. And you know, it won the best Innovation Award in dentistry, because it’s [Jaz]That’s been around for about eight or nine years. I mean, the guy was on Twitter. I forget the guy who made the app. But I used to speak with him on Twitter about nine years ago. So and that’s been Yeah, used by thousands of the puppy people. [Libi]Yeah, so that just plays music for them while they’re brushing. And it’s free. And it gives tips as well. And also for teenagers. It’s good because it’ll pop up reminders on their phone, saying time to brush your teeth. And then that takes out, you know, the element of the parent having to nag. And we all know and I say to parents, we all know that the kids listen to their phone more than they listen to us. If their phone tells them to brush their teeth. They’re gonna go into it, you know? Yeah, so that’s another motivator. What I’ve just found this week, which I was really excited about. I think you might have seen my posts on this. But there’s a new toothpaste which changes color over the course of two minutes. So you start brushing, it’s clear, it’s got some little specks inside it. And then if you keep brushing over the period of two minutes, it changes to blue. So by the time this bright blue, and it’s genius because you have to keep going and that’s what we want. We want them to be brushing for two minutes, because by two minutes, you know, there’s no, Well, More or less you’ve, you’ve made sure you’ve brushed well within [Jaz]What’s this toothpaste so that dentists can make the [Libi]It’s just the Colgate toothpaste and it’s aimed, I think six to nine years I might actually have a tube just here because I am going to [Jaz]Amazing. That’s really clever. I love that. [Libi]Yeah, here it is. It’s aimed at six to nine years old. It’s called magic toothpaste [Jaz]Magic toothpaste. Fantastic name. [Libi]Fantastic name. It isn’t advertised very well, I didn’t, I think you’d have to really complete the packaging to realize what it does. And I [Jaz]We have Mr. trickier because that is phenomenal is really, really good to get. Well done [Libi]The next thing. So I got really excited when I saw this and I bought a whole box of it. So I just went into the whole box of the shelf. And I’ve been giving it to anyone who will listen, you know, here you go have some magic toothpaste. My kids loved it. I used it. It’s fun, you know and that’s it. So it’s all about changing it up. It’s like okay, for a while me and my daughter were into you know, when frozen first came out, we have a specific song that we brush along to. And it’s just all about constantly keeping them motivated, which is exhausting but that’s what Parenthood is about. I think you’ve realized this. [Jaz]Big time. So just to summarize the last bit you said it start off with a non blaming culture be really playful with all the ways with the suction that you said, social stories just sounds phenomenal. Get the child to count on their head 80 seconds see if they can beat the time, using something like a Polaroid picture. Nowadays, you can get something called like a HP sprocket, which I bought my wife once and it’s like a undergo Bluetooth printer. So that’s something that can be used as long as you can make a photo, print a photo and give it to a child. That’s a genius. Obviously using disclosing tablets, which are massively underutilized. Your Sugar bug story has been phenomenal. And I think it will, you know, relating poop to the teeth is just as a story is just going to stick using the app brush DJ and the magic toothpaste. Is there anything else to wrap up communication? Because I mean, we could go on for days, but just to make it useful. [Libi]We could go on for days, I’ve made a couple of notes for you said for like a dentist who’s not really good at it, you know, relating to kids. So when I first started pediatric dentistry, my kids were quite young. And so I didn’t feel I was able to communicate with me to the teenagers. And what I found is I just needed to find one topic that they liked, and learn a lot about it. So for example, when fortnite became craze, I sat down somebody likes fortnite and said, Tell me about fortnite. And I just learned the key phrases that I would need to say, to look as if I was into fortnite, I would say ‘Do you play fortnite?’ ‘Yeah, I play fortnite.’ ‘I’ve only won one Battle Royale.’ I have no idea what Battle Royale is. But I’ve learned that ‘I have won one Battle Royale. How many of you won? And they’ll say ‘Oh, no, I just, my tactic is when they throw you I just hide where they land me and stay there until it’s over. And that’s how I won that one. But I’m not good at playing it. And I’m still on the first skin just like a purple bear.’ I have no idea. [Jaz]They must be mortified. The parents must be absolutely mortified. [Libi]And but do you know it’s just that icebreaker, it’s that child feeling as if you know something that they know it’s like easily. So even something as simple as putting a sticker on your tunic that day. So on your scrubs, put a superhero sticker on your scrubs. All children know the Avengers, all children know Peppa Pig, even if they don’t like that character, you know, Mickey Mouse, you know, they all know these. It’s something familiar. And once they start to connect you to something familiar, that immediately brings down the anxiety in that child. So just and you should have a favorite movie. So like your homework as a dentist is to have one really , one movie that you know so much about that you could sit there and talk to the child for 10 minutes about you know, ‘Oh, I love this song’ [Jaz]Toy Story. Definitely, Toy Story for me. [Libi]Yeah. So even if they don’t like that movie, it’s just about you having a favorite movie that is something child friendly, that you can talk about and that they can kind of say, ‘Oh, no, I really don’t like the act.’ ‘I know oh, this is my favorite. Don’t you like it when this happens?’ And it’s just about it’s distracting them. It’s making them feel comfortable because you’re, it’s something familiar that they know about. So that’s my tip for dentists. So just try and find something that even if it’s the same thing and your nurse will get sick of you talking about the same thing each time, but it is just about making them feel comfortable and giving if you’re in private practice. And you have the opportunity or the funds to be able to give them something other than a sticker. There’s actually studies that have shown that, you know, cooperation and everything improves, when you give them a small prize, it doesn’t even have to be something amazing. Even like a bottle of bubbles, or like a small bouncy ball, or you know, a pencil, just something that is not a sticker. Because stickers these days, children aren’t too fussed with them. [Jaz] Brilliant. Okay, good to know. [Libi] I mean, I have a sticker, which is personalized, and it says, you know, I’ve been to see Dr. Libi today at the Berkeley clinic. So for me, that’s you know, reinforcing that, you know, that they came to see me and you know, I think it just helps them it’s a bit more personal than just a generic sticker. But at the same time, I give them a price so I have a box, a treasure chest. And what I do is when I’m out if I see something you know, on sale, pencils, whatever. Even those sticker cards which are like a pound a pack, you know football cards and frozen stickers and whatever you can pick up in the supermarket and just having those on hand, it gives them that reward at the end of the appointment and it makes them feel good and it does help them to come back because it’s ‘Oh at the end I get this treasure you know to pick from.’ That’s the last thing that sees [Jaz]I imagine you actually have, I imagined you actually have a like a brown treasure chest do you? [Libi] It is. [Jaz] Yeah, I expected not less from the Libi. That’s how the doctor Libi’s list, ultimate list for prevention. Shoot. [Libi]Okay, so tips for prevention. First thing, fluoride application, always to ask if they’re having fluoride. You know, I think in England, they don’t do it. In Scotland, they do it in schools, but apply fluoride you have nothing to lose if the parent is fine with having the fluoride on their child. Every time you see them every six months, put some fluoride on when you put the fluoride on, make sure that you use a flosser to get it in between the contact. Okay? That’s where does all, Where did all the Lesion start? Interproximally we should be telling parents to floss their children’s teeth. I don’t know why it’s not a normal thing, because that is where all the caries starts. So we need to be telling them to floss. That’s the second promote flossing, especially when you’ve got the six erupted that contacting with the E. That’s really important. Fissure seal. So now the guidelines have changed. You seal every six. It doesn’t matter if the child is high caries risk or low caries risk. You seal those sixes and you check those seals every time they come in to you. Okay? [Jaz]Can I just stop you on that one. So fissure seal on the sixes, Isn’t there some evidence suggests that fluoride varnish is just as efficient or efficacy? Is that the word? Of as doing a fissure sealants. So fluoride varnish, fissure sealants, there’s no difference. Am I right? [Libi]Yeah. But now there’s newer evidence to say that fissure sealant is actually superior. And that’s why the, we have Scottish guidelines. So the SDCEP guidelines. And those guidelines changed in 2018. To reflect that new evidence. And to say that we actually be need, we need to be sealing, we’re going to seal all sixes, and sometimes in a high risk child. So if I have a child who’s had caries, and they have deep on their Ds and Es remaining ones that aren’t carious have sealed those as well. Because what sealing is just so quick and easy. And it just it means that that tip is easier to clean. And it just gives that, gives the child a better chance. Okay, so fissure sealant, and also something really interesting. So when I went into school, and I gave a talk to one of my daughter’s classes, one of the mums sort of sent me a message later on with a picture of her daughter’s tooth, it was a six and it had to pit on the palatal site. And she only discovered that pit because I had given her disclosing tablet. And she had chewed it and the mom was looking at her teeth and said, Why is there a pink dot you know, that side of her tooth, and it was a powerful pit. So we need to be checking these sixes for palatal pit. Because if you seal them, then you’ve saved that tooth from developing caries because even in the best oral hygiene if you’ve got that there’s a high chance that will become caries just because at the backtrack so looking at so it might it ideally if you can disclose the child’s teeth and have a look at them yourself. That’s pretty cool. And it’s quite you can use it as the motivation and you know, teaching experience for the child and parents. And yeah, so I would actually recommend anybody who has any interest in treating children reads the SDCEP guidelines for caries management in children because it gives a very good comprehensive overview of what to do and it really guides you so well and it’s got visual aids you know, pictures and things. It tells you how to speak to parents, how to motivate families. It’s just a really great guide and it’s easy to read. And I mean, I think it’s an invaluable tool. [Libi]Absolutely. And I’m gonna put all these files like the SDCEP and also the social stories app a link to so stories app on my website and also on the Protrusive Dental community Facebook group. So that’s amazing. Do you have any more of those prevention gems? [Libi]I think that’s it really for prevention. [Jaz]So let’s wrap up. That was part one, let’s say that was part one. Because there was so many so much to learn. I’m glad it went that direction with the communication gems, I think that one will gain so much from that. Jaz’s Outro: Thank you so much for listening all the way to the end. That’s all we have time for this episode. The second episode will be out very soon. If you found this useful, or if you know someone who sees children they may not enjoy it so much or there are some aspects, clinical or communication aspects which they struggle with. Please do share this podcast episode with them as well as the next one, and I’ll catch you then stay safe. Stay well.

During this crappy time in our lives (there is never a good time for a Pandemic, right?!) I turn to one of the most positive people I know, Barry Oulton. This 18 minute chat really uplifted me and I think it will help you all. We discuss– Mindset– How to view a problem as an opportunity– The importance of love (verb)– Importance of power posing– Importance of Exercise Need to Read it? Check out the Full Episode Transcript below! https://www.youtube.com/watch?v=xSmEP0H-R_w Link to Amy Cuddy video so we can all ‘do Amy’ haha https://www.youtube.com/watch?v=RWZluriQUzE Instagram – @drbarryoulton FB – The Confident Dentist Twitter – @drbarryoulton www.theconfidentdentist.com www.dentalinjection.com www.oneminutemindset.co.uk Click below for full episode transcript: Jaz's Introduction: It's going to be a quick little birth session to help dentists because the reason I thought of you Barry was when all this kicked off and there was doom and gloom, I'm usually quite a positive person, and I didn't react very well personally in myself, a bit of going through all the stages of denial, stages of grief. [Jaz]I was in denial, then I was getting really depressed and upset about things, and I sort of thought to myself, when was the last time I’d felt this bad and not to take it the wrong way Barry, because I think you know where I’m coming from, but the last time I felt this bad was when I was on your course. [Barry]Well, it’s on me! Yay! [Jaz]Sort of. So just for the benefit of the audience listening and watching right now, what I mean is the reason I felt the last time I felt this bad in life was when I was on Barry’s course is because Barry really brought home and taught me the value of your mindset of the way that you see the world. Cause one of the exercises, one of the first things you do on your course is the way you see the world, so you walk across the corridor, and you see the world, as if it’s a beautiful place. And then you do that walk across the corridor and walk back. And then you see the world as if it’s dangerous. And then you walk across and that same walk, but the world was completely different. And that’s the last time I felt this much doom and gloom in life. So I thought you are the best person to come and just give us a five, ten minute nugget on what can you say? What can you say to everyone? Dentists, nurses, therapists, but what can you say Barry? What’s your message? How can you help us? [Barry]So the first thing to say is, there is a lot of doom and gloom, isn’t there? That if we only focus on the negative stuff, then you’re absolutely right. To talk you through that exercise that we did, we put on some metaphorical glasses, right? The first pair was that the world is a dangerous place. So, I left you on a high, because the first one is, the world is a dangerous place. And through that mindset, through those lenses, what you’re seeing is everything that fits into that mindset. Now a mindset can also be called a belief. So, if I have a belief that all men are bar stewards, then you will only really see men doing things that fit into that framework. You’ll only really meet men that fit into that framework. The world is a dangerous place. You look around the room, you’ll only see tripping hazards, electricity, danger all around you. And so encouraging you to change your mindset is like putting on a fresh pair of glasses. A pair of glasses that is, the world is full of beauty and love. And I look around and I see electricity, connectivity, the ability to see your lovely face and have this conversation. And sunshine being outside, whereas you could see sunshine as being carcinogenic to the skin, or it’s how you process information, and it’s putting on the mindset. Now, it doesn’t take away the fact that SH1T is happening out there. We are in a very uncertain time in our profession. Being that most of us, certainly you and I, are self-employed. Some of us own our own businesses. I own the Confident Dentist Academy. I have staff that I have to pay for. There are some very worrying times. And so what I have done for myself is mentalised my day for the times to think about the tough stuff and then set times of day to have a different mindset and see things in a different light. So do you remember we did problem challenge opportunity? Do you remember that? [Jaz]That was in pairs, wasn’t it? [Barry]No, no. So let me take you through this, right? If you could think right now, in fact, let’s do this, Jaz. [Jaz]Sure. [Barry]Right now, think of a problem in your life. Wife’s temperature could be it, right? [Jaz]It is, yeah. So, as I told you, my wife’s coming down with a little bit of temperature, just over 38, and now we’re like, whoa, is it coronavirus? And all that sort of stuff. [Barry]Okay, so let’s, we can’t change, realistically, there’s certain things that we can’t change, right? We have to let certain things take their course. So let’s think about that as a problem. And what I want you to do is I want you to think in your mind’s eye, who is that a problem for? How is that a problem? What sort of things does that create for you and your son? And all the other things that it involves and impacts on. And I want you to share with me now, Jaz, words that describe what it’s like to have a problem. Give me some words. What’s it like to have a problem? [Jaz]This specific problem that I have. [Barry]Well, you’re not going to share that problem, but that problem, give me some words that describe what it’s like to have a problem, to be stuck. [Jaz]Okay. Sure. Sure. It’s doom and gloom. It’s uncertain. It’s difficult. It’s overall negative. It’s a draining of your energy. It is very much all bad things. [Barry]Yeah, worrying, scary, frustrating, all of those things, right. Okay, so what I want you to do, do you remember, you’re very young, I’m older than you, do you remember what an Etch A Sketch is? [Jaz]Yeah. [Barry]Do you? Okay. For those that are watching that are younger than Jaz, an Etch A Sketch is an iPad with a couple of knobs on, and we would draw with magnetic fibres, wouldn’t we? Do you remember that? How do you clear the screen of an Etch A Sketch? That’s it, you shake it. Right, so what I want you to do, is I want you to clear the screen like this, Jaz. That’s it, good enough. Right, I want you to take the same situation, and I want you to think about that situation again, but I want you to think about the situation as a challenge. So it’s the exact same situation you’ve got and now rather than the way we had it before it’s now a challenge How is it a challenge? What does a challenge bring to you? What kind of things do you use to describe having a challenge? [Jaz]When you’ve got a challenge, I think you’ve got a goal, you bring strategy into it, you bring in mechanisms in terms of how can you actually break down the challenge? How can you make the best out of it? How can you be progressive? So that’s when whenever I want to hit a challenge, I want to just overcome it. So automatically. like a typical bloke, you just want to fix the problem. [Barry]Perfect. So what I’d like you to do instead of fixing a problem is overcome a challenge because the way that you’ve just described the very same situation is completely different when you described it as a problem and now as a challenge. Right? Now clear the screen. Thank you, I need the noises Jaz you have to do that. Love it. Okay, mate same situation only now. I want you to see it as an opportunity. So now sit there and think right this situation that I’ve got, what is it an opportunity for? Who is it an opportunity for? The immediate thing that springs to mind for me is daddy son time, bonding, new skills, all this stuff that you could do with him, but you begin to think about, right, what’s an opportunity for? Because there’s certain aspects of the situation we cannot change. [Jaz]Absolutely. [Barry]And if we focus on the things that we cannot influence and we cannot change, we’re going to end up feeling pretty crappy. If we focus on the things that we can influence and also these new opportunities that are available to us to enhance our lives, somebody else’s life, I’ve just finished, I’ll show you this, I just made paneer for the neighbours, fully only I made two kilos of the stuff so that I can, with my gloves on, I can deliver to local neighbors. One of the best things I think you can do when you’re having a tough time is give to others. If you give to others and you’re thinking about other people who oftentimes are worse off than us, that kind of gives you a perspective that, hey, it could be a lot worse. And it doesn’t change the situation, but it certainly begins to make you feel more resourceful because at the end of the day, when you’re up against adversary, what you need to be is resourceful. And thinking about things as an opportunity creates resource. Who have I got that I can involve in this opportunity? So let me give you an example. I have had everything I’m looking at my year planner, I’ve had everything blown out of my diary for six months. There is no income. And that is for the confident dentist or my lecturing, trips to Paris, Glasgow, Ireland, all sorts of places. No income. And I’ve still got staff to pay for. I’m in my dental practice, no income. And so, if I focused on that side of it, now I have to address that. Let’s not get me wrong. I have to address that. But if I just purely focused on that, I’d end up being really down and depressed. It’s important that I give some time and energy to that and then I’ve sat going right what is this an opportunity for I’ve got a lot more time to create content to write courses to go out into the community to volunteer for the NHS to be careful I’ve just taken down gloves and viral wipes and some paneer down to the local shop, because the guy there is serving the community and I just went down and said you got no gloves, you got no masks, here’s some gloves, here’s some masks, here’s some lunch. And just pulling together as a community. So that’s the first thing I would say is, begin to look at the language in your own head that you’re using to describe the situation that you find yourself in. It’s a large step to go from problem to opportunity. So if you break it in the middle and you go problem, challenge, opportunity, you find that you can actually start to come up with a completely different feeling towards the situation that you’re in. [Jaz]A hundred percent agree, Barry. And this is something I’ve already said on the podcast already is that now, and in the messages that I’ve sent out is that a hundred percent agree. This is a crap situation, but it’s an opportunity, an opportunity for you to do anything that you want to do. Now you are doing absolutely wonderful, godly things. The fact that you can make paneer is just, but then to distribute it to people who can benefit from that paneer and also all the content creation that you can be doing. And I think based on the problem that I have in my life right this very second, right now with my wife. Just having a little bit of a temperature now, and we’re just openly discussing that, and I’m cool with that. And it’s an opportunity for me to care, because my wife’s such a great carer. It’s time for me to give back to her. I want to be able to care for her. I want to be able to- So tonight, me and my son sleeping alone. Usually it’s the three of us, and I’m so excited to be able to look after my son the whole night’s night and also be able to look after my wife and those out there. And I’ve already said this is, use this as an opportunity to love and love is not, and your parents, your family, your friends, anyone, and love is not a emotion. Love is a verb. So that’s my main message really for you. It’s a, a great message. See, go from problem, challenge, opportunity, and I just want to add onto that. Find love in your life wherever you can and just pursue that. [Barry]Yeah, I totally agree, mate. And I think the more that we do for others, the more that we benefit ourselves. Another thing, can I, have you got time for this? [Jaz]We have. [Barry]So, many years ago when I did Tony Robbins, this course, one of the things that I learned very quickly was that when I was feeling really crap, I might not be able to influence the external factors, but the ability that I had to ask myself some really good quality questions. Oftentimes when we’re in the crap, we say things like, why me? What am I going to do? Why has this happened to me? I’ve got all of this stuff going on. I’ve got this, I’ve got that. And we ask ourselves questions that can only realistically come up with crappy answers. And a good exercise to practice and get into a routine of doing is asking yourself really good questions because the subconscious mind if it’s asked a question it has to search for an answer. So if I said to you why is it? That this has happened to you, you have to search for an answer of well It could have been this or it could have been that and you start thinking all of the BS Reasons why this might happen. If I ask myself, right, what can I be grateful for right now? Life is tough There’s a lot going on. I need to sit for two minutes and just list what can I be grateful for. The thing about gratitude and anxiety or stress or worry is they can’t live in the same body You cannot genuinely be grateful, have gratitude, and feel grateful, and feel stressed, and angry, and worried. So by asking yourself a really great question of what can I be grateful for, you have to search for the answers. Well, I’m grateful for health, I’m grateful for my wife and my kids, I’m grateful for this, I’m grateful for friends. And you start to, and then start to really think about those. The way that we think about those in our internal representation is to put yourself into that position. Think of the things that you would see, hear, feel, connect with when you are in that situation of gratitude. And that removes the negativity, that removes this anxiety and worry. Now it doesn’t change the external factors. And yet, when we feel more centred, more at peace, we are better to handle those difficult, stressful situations. So if you’re ever feeling stressed, just sit for a minute, peacefully, and go, right, what am I grateful for? What have I got? What can I give thanks for? [Jaz]This is what we need now more than ever. To summarise this short little, thank you Barry for your time, to summarise this short little burst of an injection of positivity. We’re going to focus everyone. We’re going to focus on our mindset, which spectacles we wear. We’re going to turn our problem into a challenge, into an opportunity. We’re going to find and share love. And most of all, we’re going to be grateful. We’re going to find what are we grateful for so that because we cannot be in a grateful state and in a stressed, worrying state at the same time, and it’s a great thing you put there. Barry, I wish you and your family all the best. Yes, please, please, please. [Barry]One more thing, right? I’m doing a lot of mental health at the moment, and part of, one large part of my lectures. is talking about the, you’ll remember the model of communication in NLP, where we’re bombarded by information, we delete, distort, and generalize, it goes through our own unique internal filters, creating our internal representation. That is a picture, a sound, a movie, some self-talk, and some feelings, right? They dictate our emotional states. And that also impacts our physiology. You don’t see anybody depressed and anxious walking around like this, arms in the air, chin up, chest out, shoulders back. You’ve heard the phrase, come on, shoulders back, chin up. What I want people to do is I want to encourage them to go and watch a video online. by a lady called Amy Cuddy. Power pose! Yes, my man. Amy Cuddy. She’s a psychologist from Harvard University. And this is the scientific research that backs up the reason why we need to stand tall, heads up, because this decreases our cortisol and increases our endorphins. And so in the moment that you’re also giving gratitude, what am I grateful for? Do yourself a favor, stand up and look up at the sky and put your arms in the air. Do it privately. So people don’t go, what the heck are they doing? And exercise, okay? I know that Boris has said get out once a day, but get out in the garden, do Joe Wicks at nine o’clock in the morning, get your bodies moving because motion creates emotion and if you’re moving it only increases the quality of the positive emotions within you. So if you’re feeling a bit crap get up and jump up and down, stretch, watch Amy Cuddy, it’s from Edinburgh, TED Talk. [Jaz]I’ll put a link up when I post this up, which will be in a couple of hours basically. I’ll put the link up, Amy Cuddy, fantastic video. And yeah, stop slouching everyone. I know we’re not in a great place at the moment, but we can only influence the situation in our own world by adopting a power pose and doing a bit of exercise. [Barry]Absolutely. So everybody get doing Amy. You know what I mean? Hashtag awkward. [Jaz]Barry, thank you so much, as always. [Barry]It’s lovely to see you again, mate. You take care, look after the family, and I hope your wife’s okay. [Jaz]Thank you so much.

I recorded this a few weeks ago and recently finished editing it (always enjoy chatting with Barry G) – I was pretty much ‘shy’ and dare I say ’embarassed’ to post this/make it public because in the grand scheme of things, our world is being rocked by Covid-19 at the moment and we have so much to worry about… But then two people independently sent me a photo on Instagram of them at home watching my YouTube/IGTV interviews I posted recently telling me they are learning so much from the guests on Protrusive. If this video or any of my content can get you to chill on your sofa and learn while you #stayathome – then that would be awesome. Need to Read it? Check out the Full Episode Transcript below! Sending my best wishes to all – stay home as much as reasonably possible 🙏🏼I hope all this will reunite our profession. https://www.youtube.com/watch?v=n1Bla9N9PS8 In this episode: – Jaz shares a Parable of the 12 Blind Men relevant to TMD and makes a mess of it!– We discuss if the role of teeth/occlusion/malocclusion/Restorative really has a role to play in TMD/pain?– What is macro trauma and micro trauma, and how is it relevant to TMJ pathology?– What is Barry’s message? What does he mean by ‘Occlusion does not matter unless you’re occluding?’– Why MIP is pathalogical– We discuss Confirmation bias in Dentistry– Can we reliably stop parafunction?– What adjunctive support therapies are prescribed for complex oro-facial pain patients?– Can you use an AMPSA with a patient with Degenerative Joint Disease?– The first 20mm of opening is pure condylar RO- NOT! It’s not pure rotation!– What is an Enthesis and why is that relevant?– Can you give an anterior only appliance to someone with clicking?– Why might a patient say their click has now stopped? YouTube Link: www.jaz.dental/YouTube Click below for full episode transcript: Opening Snippet: Welcome 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’s Introduction: Hello, everyone. Welcome to Episode 22 with Dr. Barry Glassman. He likes me to call him Barry, as you’ll see. So this is a my first ever full intro and outro video podcast. And I’m glad to see Barry, he also featured in episode eight, which if you haven’t listened to it, it’s a great episode, I urge you to check it out. Episode eight was all about anterior midpoint stop appliances, and do they cause a OBS. So if you haven’t heard that already, it’s really great. You can hear Barry’s passion in that in what he believes. And I guess I want to give you some context, in terms of what you’re about to watch or listen to if you listen on the podcast between the conversation between myself and Barry. Basically, what Barry teaches and what he’s all about, and I heavily recommend going on one of his courses because it’s a different way to see occlusion and basically the crux of it is, is that it’s not the occlusion, or the malocclusion that causes a lot of problems. Let’s call this let you know whether it’s chipping or things breaking TMD, which is a very loose term. It’s not because of the occlusion per se, it’s because of occluding. And what Barry always says on his courses, nouns don’t hurt people, verbs do. So the occlusion is not as important as the occluding. So if you’ve got someone who’s like a 17 and a half minute a day chewer, then they’re not likely to cause that much problems when in terms of destroying their teeth, or TMD. Because essentially, what we’re talking about is the relationship between parafunction and causing repetitive micro trauma in the temporomandibular joint is quite, we will discuss a fair bit of anatomy at the end. So it’s actually a good revision for that. And I’d actually encourage people to if you’re listening on the audio podcast version, to actually go to the video version, which some of you are watching right now, because Barry actually shows the temporomandibular joint and the disc, and he describes about the lateral pole and the media pole, which is something that’s not very well understood. It took me years to get the hang of that myself. So people might say that ‘Jaz, you know, you’ve just said and you agree with Barry that occlusion doesn’t matter. So why do you, Jaz go on so many different occlusion courses?’ And as you know, I’m a bit of a junkie for learning about occlusion. And I guess the answer I have and I sort of touched on it a little bit on the episode is this, is that yes, occluding is the problem. And the occlusion per se is not as important. But remember that not all of your patients are going to wear appliances, and not all of your patients will adapt to one. And when you have an opportunity to rehabilitate someone, or reorganize their occlusion for whatever reason, then you obviously want to set out for a minimal stress occlusion, which is something I learned from Ian Buckle at the Dawson Academy. So if you’re going to go through the effort of really doing placing lots of restorations, you’d be foolish not to design it for so that when they do parafunction, they parafunction in a more dentally beautiful way as someone recently put it on a Facebook group I saw. So that’s why I continue to learn about occlusion. And it’s good to have that hat on. But also, it’s really good to have Barry’s hat on about and actually occlusion doesn’t matter. It’s the occluding. So I like to marry them both together. I started off the discussion with Barry by introducing a parable that I read about it involves 12 blind men and an elephant and this parable is quite a famous parable in religion obviously, but there is one version of it I read that is very relevant to TMD and if anyone has read this Parable you will know exactly what I’m talking about. If you have read it, can you please send it to me? There’s like a PDF version? And I’ve always remembered it I’ve never been able to find it again online so if you know what I’m talking about, can you please send me that parable? So listen to, I make a bit of a pamphlet but you can listen to it anyway as I share it with Barry. So Barry is an oral facial pain specialist. So I speak to him about how to manage these complex patients, what therapy is he does adjunctively to let’s say an anterior midpoint stop appliance were indicated. Also towards the end of the episode we discuss about anatomy and clicking joints and whether an anterior midpoint stop appliance as some people may argue is contraindicated for someone with clicking joints so you can hear about his view and the anatomy and how it relates to it. So the Protrusive Dental Pearl I want to share with you before we jump straight to the episode with myself and Barry is I’ve had a lot of people ask me because they saw that when the smilefast course and they asked me about the smilefast course. So firstly want to say I have no financial interest with smilefast. I just went on the course. And I have the utmost respect for Thomas Sealey and Mide who were the founders of smilefast, clinical founders. And I have to, you know, give it to them. They’ve set up a fantastic system. So if you’re someone who’s doing or planning composite veneers or rehabs I think it’s a great ROI. Because I think I’m already at the moment spending time and money on digital wax ups, the stents that I usually make myself, and I think the whole package they’ve created is really slick. So I quite like to smilefast. Unfortunately, we’re in the midst of the Coronavirus crisis at the moment. So there’s not going to be much dentistry happening in the next couple of months. But I like to think that I’ll be using it more and more in my daily practice. So the pearl is, if you’re sitting on the fence about smilefast to do it, it’s actually, I actually really enjoyed the course and I think it’s gonna be very clinically applicable, it’s going to save me time and money. So that’s my pearl shared with you. So let’s jump to the episode with Barry and I and I’ll catch you in the outro. Main Interview: [Jaz] Barry, listen, I think we [Barry]You are having trouble with your mustache you keep playing with it. [Jaz]Everyone says that. One of my guests they say that so I stopped playing with it. It’s so I don’t know. It’s just a natural thing for me to do you know. Every time I’ve been to a long course the instructor at the end says you know what, there’s a sign like when you’re thinking, when you’re in deep thought or when you’re interacting. Occasionally, you do this [Barry]then you’re, then I’m in trouble because you’re thinking all the time now. [Jaz]I generally am, my other trademark is really stroking my beard as well. So this is not one of my professors told me about and they identified that and so it’s definitely a trait of mine. So get used to either or video get used to it. Everyone welcome back to another episode with Dr. Barry Glassman, who’s in sunny Florida right now. And we’ve evolved since episode eight, where we talked about AOBs evolved into video. Neither myself or Dr. Glassman has have had plastic surgery which both our wives recommended. But yet we’re still on video. [Barry] You can call me Barry. [Jaz] Okay, yeah, thank you. Barry, thanks for coming on, again, that episode about AMPAs or anterior midpoint stop appliance and AOBs was very well received. It’s had over 3000 listens, you know, counting on Facebook and on through my podcast platform and stuff. So the message is getting out there. Now if you’re listening to this, and you haven’t heard episode eight of the Protrusive Dental podcast, please listen to it because I see it all the time still on social media, bashing these appliances, anterior only appliances because people still think that the posterior teeth will overerupt. We’re not talking about that today, because we’ve covered that extensively and to a good standard, I’d say Barry on episode eight. So I think we’re way past that. But I want to bring you back to do some more mythbusting with occlusion. [Barry] I’m here. Let’s bust it. [Jaz] So let’s, I wanna, Let’s bust it. Absolutely. So the first thing I’m gonna ask you is, Have you ever heard of a parable with the 12 blind men? Does that ring a bell to 12 blind men? [Barry]My wife also tell did you here a parable of 12 blind men? 12 blind men? No. [Jaz]Okay, I’m surprised. I’m surprised. But okay. Let me tell you this and the guests a parable. And then from that parable, I think will lead to our first question I’m doing I’m making a fun thing. Okay. So the parable is, this is set, the parable is set in India, and this is 12 blind men walking through the jungle, I don’t know how like, enter through some guide or something. But anyway, they’re 12 blind men, and they come across an elephant. Now, none of them, none of these guys can see the elephant. So each blind person grabs on to a part of the elephant. So we’re talking about occlusion and TMD. But they’re essentially attacking this elephant. Why in the sense that one person is holding the elephant’s leg and says the elephant is about yay big. And I can feel some hard nails and the elephant is almost like circular in sort of cross reference in cross section. And then the other person’s like, No, I mean, the elephant is really hard. It’s really tough. It’s obviously holding on to the tusk of the elephant. And on the other person’s like, No, no, I mean, elephants got like a long dangly bit and a hairy sort of a tail type thing. And no one can agree what this elephant is, right? And of course, that the elephant is being perceived by each blind person based on the part of the elephant they’re touching, and how can we relate that to TMD and occlusion? Well, if you go to a particular dentist, that dentist might say that TMD and occlusion can be treated by finding an interference, deleting that interference and doing lots of funny things to the teeth to realign their jaws. And suddenly all the problems will go away, right? Another dentist might hold on to a different part of the elephant in this TMD and occlusion type elephant, and might say that actually appliance A or appliance B will sort everything out. Another elephant entirely might say, actually, in other dentists, he might actually say, actually, it’s the combination of the chiropractor and physiotherapy and having Botox in the Masseters is what’s the right thing to do. And the fourth one will do a TMJ surgery. So this is the situation I think, and I think that parable represents the current situation. Well, that actually, depending on which speciality or which dentist or which clinician you go to, you will get completely different opinions and none more so than in the whole topic of TMD and occlusion. So what do you think of that parable in relation to TMD? And occlusion? [Barry]I think we should keep it in India. No, no I show my wife is saying to me, boy, that’s really good. They look at one part. And where’s the, where they, Think about this. What, where is the problem? The problem with the parable, is that we have an actual physical thing at the end. That’s true. It is an elephant. [Jaz]Yes. And what the elephant represents is what parafunction? [Barry]Ah, no, I think the elephant represents, unfortunately, TMD the results of knowledge what we’re trying to find. It’s not the cause. I know we can get the blindness here is the puzzle that the cause, but it’s not the cause that they’re coming up with. It’s the end result. It’s that final thing. What is, they’re trying to identify what this is? And the answer is, it’s not just what you feel in the leg. It’s not just what you feel on the tusk. It’s not what you just feel in the ear. It’s the whole thing. The whole thing represents, therefore, the what we’re trying to identify, which is, “TMD” And the problem is, there is no such thing. So while the para, I get it, because were the parable was really good. Were it’s really good, is that what it’s suggesting is that there are contributing factors, that we can do different things and wind up with a positive result. And then what happens is we assume a mechanism, we assume the mechanism based upon what we did, and then assume that that’s the mechanism that was at play, that caused the result. And assume, therefore, that the next person who shows up, the next elephant that shows up that TMD thing, that I can do the same thing I did. Because it worked before, and that’s going to be there for work again. And if I don’t do it, the way I was taught, and it doesn’t succeed, one of two things happen. Either this person’s psychologically involved, and they can’t get better. Because after all, I did it as well as I could have possibly done it. And I know how good I am. Or I’m insecure. And I think to myself, boy, if only I could have equilibrate, as well as the person who taught me If only I could put it in appliances, as well as Barry does, wouldn’t that be great? And the answer is you probably can. But in this particular complicated case, with its own unique factors, the mechanisms the contributing factors may be different, even though we identified it as an elephant. [Jaz]Absolutely. I think I told my story a little bit wrong. I think that in the story, the way I read it, I’ve been trying to find this website where I read this parable initially, and it was on like this TMD type website, but I like the story better in the way I read it because actually, the elephant represented para function. And everyone’s trying to treat a different thing. But it was the story that the author was trying to make the connection was that actually we need, the parafunction and the trauma that results in the anatomy from that be it the muscles that take a hit, the teeth, or the joint is the parafunctions, the main thing that we need to help. So that was that and to what degree do you think is everything is responsible and all the problems that we face is from parafunction and you know, in the dental TMD, occlusion type things that we’re going to be talking about parafunction has a huge role to play [Barry]In my way of thinking there are those Jaz that don’t agree with us. There’s a big movement in Italy, led by a dear friend of mine, Daniel Manfredini. And they’re spending a lot of time accepting the fact that parafunction may play a role, but don’t really think that appliance therapy has much of a role. And they’re looking more at access tooth, they’re looking more at psychological component, and which blows my mind, because when, you know, most of the damage that the general dentist is looking at isn’t significant pain, it isn’t significant headaches. They’re not the secondary care patients that I saw on a regular basis, the general dentist sees the wear patterns that you see, the general dentists sees the initial joint dysfunction, maybe some limited joint pain, but more clicking or low grade discomfort? This is what the general dentist is seeing. And don’t you know, I’m having a little trouble dealing with someone telling me that this is, these are access to patients. These are psychologically and this is a physically damaged joint. You can identify. And and we can do. And how did it get that way? And what we know is that it got that way always as a result of some sort of trauma and the absolute absence of trauma, these joints, these ligaments, the tendons, joints, that they don’t get damaged. And so they get damaged, not from the forces of function, but the forces of trauma. And that trauma can be micro trauma, which is the parafunction that you’re referring to, or macro trauma, you know, your wife punching you in the mouth on a regular basis that says that awful, [Jaz]or road traffic accident or [Barry]A football injury, for goodness sakes, you know, so super, you’re supposed to be impressive. I came up with football rather than soccer. So yeah, I think from a general dental standpoint, parafunctions are incredibly important and so easy, as we’ve learned to control and but that’s what the that’s a greatest frustration. I think, at one point in my life, Jaz, I really thought that I was going to be able to, I noticed outs, I thought I’d be able to help my profession more than I have. And I, in some ways really looked at my career of a somewhat of better, only because I thought I could make the restorative gurus understand that what they were teaching was extremely important. What if we would just add this simple parafunctional control concept? That is, you know, the we have study after study that shows with decreased forces with anterior midpoints, up from Hitori up to the Becker, I mean, it just, it’s over. It’s overwhelming the predominance of the evidence. And why not apply that to protect our patients and the dentistry we do for them. It makes no sense to me, and I thought it was so simple. But it flew in the face of them trying to make this restorative pain dysfunction connection. And they wanted to teach the player a greater role as though the craniomandibular system is dominated by teeth, it’s dominated by teeth, because that’s what we see. That’s what, you know, the chiropractors thinks it’s dominated by your cervical spine. You know, the neural [Jaz]and the physiotherapist will think something different and these are the people who are, these blind, we are all the blind, you know, men in the parable. [Barry]In fact that the neurologist thinks it’s all you know, it’s neuromuscular, it’s controlled by the brainstem. And, you know, we, in dentistry, tried to create these mechanisms that we talked about. Neurology doesn’t do that, ask an neurologists the cause of a common headache, and what will they tell you? [Jaz]I hope they’ll say dehydration. [Barry]No. Well, the reality is we don’t know you know, it’s dehydration as you’re drinking and I’m drinking coffee at causing increased dehydration but the reality is, is that there are many contributing factors. We’re still battling over what a migraine, the physiology of the actual migraine, it just changed three years ago, we no longer consider it a vascular headache. It’s fascinating, right? So that we all know a lot about science that we don’t know. But there’s very little about dentistry, we don’t know. And so dentistry needs to find answers and it creates the very mechanisms we just explained, because they want to feel good about what they want it, they want to be able to look at a patient says, You have TMD. This is what I do for you, I put Botox, I’s adjust your bite, I’d use flat plane appliances, I’d use a Tanner, I should know because I’m well trained by Dawson. And and I see an increased influence of, of the restorative gurus By the way, in England, which is fascinating to me. And there is a certain I don’t mean to be offensive, but there is a certain arrogance to knowing all the answers, and the day and looks at the rest of us dentistry. Like we’re the stupid ones, we don’t understand what interferences do what and how important your position is and we don’t understand fencing and some really absurd when we look at the science myths. And that’s what we, my goal in my teachings is to truly simplify this for the general but it’s not that complicated. Truly simplify this for the general dentists not so that you treat migraines not so that you wind up treating, you know, advanced headache, any referral patterns in oral facial pain, but that you can look at the you’re at that patient who is starting down that road and you can make a recommendation, it’s so simple. And really help them, really help them and then get to use your brain in a positive way. And but you have to unlearn these things that are being brought across the sea. And the old [Jaz]Any example to make it tangible to listeners about the most common things, misconceptions that people initially when they come on your course that they have. So what are these common myths? Because there’s a common question I want to ask you about parafunction control. But before we get to that, hat is the most common myth that you’d like to bust? What’s the main message that you want Dentists to get from this episode? [Barry] What do you think it is? [Jaz] I think having been on your course which was a great for changing my mindset is that occlusion doesn’t matter. [Barry]Watch your occluding [Jaz]Unless you’re occluding so basically those who have been on Barry’s course I strongly suggest going up. That’s not to say that in this my opinion, Barry okay. That’s not to say you shouldn’t learn how to do a full mouth rehabilitation it for those who want to do itin the gold standard way. Because when you’re reconstructing the dentition, you want to set it up so that you have a mechanical advantage within your dentistry in case the patient, all my patient at the end of her reconstruction again, a night guard, wheter an NTI, SCi, FOS whatever, you know all the appliances I use. So they would get an appliance because I know that their parafunction will most likely still continue because we know that putting their jaw into centric relation will not stop there bruxism. Doing fiddling around with all interferences will not stop them from still parafunctioning. So if their parafunction before on their natural dentition, and they destroy the natural dentition. And then when you give them a full mouth rehabilitation, it’s going to continue, right? But the whole reason we learn to do it in that way is that in case they forget to wear the appliance, but things are in a mechanical in aadvantage for you the forces are low. So that’s what you know that’s an important part of it as well, I think for those who are giving the people the dentistry they want. [Barry]So therefore, the message that you just expounded upon better than I can was that we build occlusions for function as opposed for parafunction so that the [Jaz]Other way around, right? Other way around, we build the occlusion for parafunction. [Barry]For parafunction. Not function. I’m sorry. Right. So thank you. So that this concept that I want even context all around to distribute the forces is nonsense. [Jaz] Yep, absolutely. [Barry] That’s the myth. I don’t want forces to exist in the first place. So the first myth is that or an understanding the first big piece that’s really hard to accept is that maximum intercuspation is pathological. Yep, We test tap tap tap, shouldn’t happen. May does a study that shows that there are some form of dental contact in a 24 hour period in a normal patient who may parafunction. 20 minutes out of the 24 hours. Now that dental contact is not MIP, that’s incline to incline that’s the devil touching when you when you do it in some way that you could never ever predict, you know what you check when you check occlusion, You’re not checking in any way shape or form how somebody chews. It’s impossible. [Jaz]Absolutely. So you know, I learned that on your, Sorry [Barry]That’s the first myth. [Jaz]Teeth shouldn’t be touching in the first place. [Barry] That’s not why I want it. [Jaz] Absolutely. In this studies go back to the 1960s, I believe is a Graf, G-R-A-F, that showed that in the classical study that in the way that they found that was like 17 minutes and a half minutes in a day that teeth should be touching and and some studies expand on that, that in your sleep, it should be eight minutes. But Barry, the reality is that I think I see wear patterns in about 90% of the patients. I do I see all the time. And it’s because I’m looking for it. There I see it. So I think for whatever reason we have, you know, the populations that we see our parafunctioning a lot. The issue is that people are keeping the teeth together for longer than the average 17 and a half minutes, that’s the problem. [Barry]And the reality is that all of the people who claim they were stopped, let’s just say you’ve got a patient who’s got facial pain is and joint clicking, and you do an equilibration. And in three months, they no longer are facial pain or joint clicking. The assumption is therefore what? My patients stop grinding and clenching, because they’re better. And the reality is that when ever that was studied with EMGs, there was no change in the initiation of muscular activity that brought the teeth together, while they should be totally separated at night, as the muscles become more and more relaxed as we go deeper to sleep. So what is it that happened? You change the force vectors, when they in fact did parafunction that got them within their adaptive capacity? [Jaz]Yeah, absolutely. [Barry]So and we can create ideal force vectors with anterior midpoint stop. And that’s the end of you know, it’s [Jaz]You’re right, so you know, the anterior midpoint stop appliance can create the ideal force vector. But the word you use and the or, you know, it’s good that you say is that it’s parafunctional control, right? But I don’t want people to misinterpret that you’re not controlling the parafunction, ie, you’re not stopping the parafunction in most people. Right? You’re controlling the parafunction, you’re managing the parafunction, you’re localizing the parafunction, if anything, and then you’re improving or decreasing the force levels being produced by the muscles switching off, but the parafunction largely still continues. Right? [Barry]So that’s like, 100%. Right. And I think that points out to me, that I disagree with you. My term of parafunctional control isn’t good. It is problematic, because I never thought about that. I never thought that it would make someone think that I was suggesting we could stop parafunction. Parafunctional control plane, [inaudible] [Jaz]When I first came across it. It was a Pav teaching. S4S in the UK at the time. And when I came to his lecture that I must have been a student at this time, right? And I literally thought saw the lecture title. And I thought, okay, we’re controlling it, you know, this, there’s going to be finished in a way. So how can we stop the para function? So yeah, but then I learned that, you know, we’re controlling it, we’re managing. [Barry]We’re controlling the forces as the result from. So I need to rethink that. And when Matt listens to this, I want to change the name of the course. And I’m teaching this weekend I leave tomorrow. For for St. Pete. I’m teaching a two day course with Jim Boyd, who is the creator, the inventor of the NTI. And he came to me said, Well, what do you want to call the course and I said occlusion and parafunctional control for the general dentists. They said, Oh, that’s great. And I gotta be honest with you. There are I have many weaknesses. Some of them I don’t want to discuss right here. But unfortunately, my wife’s not in the room because she will quickly discuss them. So I have I have many weaknesses. No one has no weaknesses greater than my inability to properly entitle a course. I just suck at that I just I could never come up with good titles. And the one I thought I had, thank you very much because they pointed out to me that it’s not so good. [Jaz]That was not my intention. That was not my intention that was just in case any young dentist out there thinking, Okay, this appliance is going to stop someone’s para function. No, it’s not we’re just in your way controlling it, we’re reducing the forces, we’re changing the force vectors, were then creating an environment whereby the patient can start feeling better if they are symptomatic. Or if they’re not symptomatic, then they can be protecting, depending on the reason that you’re using the appliance. [Barry]We reduce, we often many. And this also upsets a lot of people because I don’t think is, you know, keep in mind my practice, Jaz, my practice was truly secondary care, severe pain patterns, oral facial pain, migraine patients that were reconstituted to a board of and preventive therapy. Very, very complex, complicated patients. And a great number of them got significantly better. We are there. Not all of them and not. [Jaz]And by your therapy, you mean usually like an appliance, right? Like, [Barry]Almost. That’s absolutely fascinating. So when you look at a history of mine, like someone like me, that was that’s an old codger and started doing, started looking into paint therapy for dentists as the dentist in the late 70s. So in the late 70s, we really didn’t know much and we were taking every job. We were shoving them back guys with Niles cache, and we were taking the jaw and deprogramming it and then shoving it back to we heard a clunk, putting the condyle in the external auditory meatus and then and adjusting the bites. And some of our patients got better. When I met Harold Gelb, Harold Gelb said to me, no, no, you know, you can’t, you’re putting the condyles in the wrong place. And he made mincemeat of me at a lecture at Temple University in Philadelphia. And they met me afterwards, they took me to dinner, and he said, Barry, you’ve got potential. And I worked with him for seven years in his office. And then when I realized that what he was doing wasn’t quite as successful as he claimed, he was [Jaz]Because the Gelb appliance is literally the opposite appliance of [Barry]So yeah, and then I started studying with neuro muscular people, I was tensing people and making them you know, AM, but when I was with the people, when I was with the, and then with everybody else I was using, at that point, we were learning, teaching deprogrammer 6 to 11, which is opera three, opera three to three. And we’ll put those appliances in and then then it came back and said, Oh, we got to take these appliance out, they’re going to cause trouble. And I said, Okay, and I took the appliances out. And in my private practice, what I found was all my patients started that pain again. So without telling them I start putting appliance back in this is about when I meet Jim Boyd, and Jim Boyd’s going, Oh, my God, this, this, this, and then you have to do this, you have to do this. And I met afterwards, after his lecture. I said, Oh, my God, it’s amazing. He said, Well, did you find that you have to, for example, you can’t let the canines touch. I never thought about that. But I lied. And I said, Oh, yeah, you can’t let the canine flex and then I went home back to my practices. No canine contact. And lo and behold, what I then all of a sudden, I make this realization as we’ve learned all this stuff. I mean, I’ve learned how to diagnose, I do blood studies, we do all the things you’re supposed to do. We know when you’re supposed to do imaging, we don’t because these are advanced patients. But when the simple ones that the beginning it gets so many simple cases was the click, was with a degenerative joint disease, there was some oral facial pain, some style of mandibular insertion, gnosis, some referred pain patterns from sprained ligaments, these were easy to fix. I would give these long treatment plans, and it started with an appliance and then come back three weeks later and said, Okay, now we’re going to start the supportive therapy and the patient would say why? As we want to make it sound better. [Jaz]So it’s what in the US a lot of dentist called phase two, right? So Phase One is the appliance, and phase two would be a six figure. [Barry]This is still phase one. And so this was supportive therapy. I never ever did phase two where I told people you got to you’re now in a new job position. That’s then neuromuscular concepts and I knew all while I never ever recommend that. So having said that, but but even in phase one was more complicated. And then I was it suddenly struck me it. These patients didn’t need me. They didn’t need the background I had. They need the training, I had in sleep and pain. They didn’t need that. They needed a dentist who understood parafunctional control. And if a general dentist could do that, then they could send it to me for the supportive therapy that they wouldn’t need, but they would already have been started with the appliance therapy that for the most part, got them all better. [Jaz]So for the most patients, for the simple patients, they would get better with the appliance with their dentist. And what I want to know now is what kind of support therapy adjunctively do you think well? [Barry]Okay, so [Jaz]I mean, that might be a complicated question, because it really depends on the exact diagnosis. [Barry]So I’m not going to go into our patients with Ms or MSIS patients or patients with more complicated altered autonomic system responses, I’m not going to go into that, I’m just going to talk about that patient with a degenerative joint disease. So the patient with degenerative joint disease, there’s no better way to treat them, interestingly enough, than with an anterior midpoint stop appliance even though one of the big messes we have to fight is that you can never use an anterior midpoint stop applaiance in a patient with a joint problem, because you’ll compress the joints. Well, the study after study we showed us in the course shows that that’s not the case, that we don’t compress this concept of taking the condyle with no posterior support. And that, and therefore, allowing the condyles to move up and back into the retro discal tissue doesn’t happen. And we have tomographic proof of that. [Jaz]And because I’m a real geek, I respect and I agree with that. But the I like to find out why and the you know, the nitty gritty of each bit. And the way I rationalize that was the function of the anterior temporalis a vector that does actually doesn’t allow it to go all the way back. [Barry]So the anterior temporalis is a little more vertical. But the masseter temporalis is extremely anterior. Remember, the origins is the inferior [Jaz] Yup, the zygomatic [Barry] the zygoma and it’s hatching. So the attachment is really, so so when you combine, you add the force vectors, your physics, finally physics, [Jaz]All the physics A-level everything. [Barry]So but when you combine the force vectors, it’s Furthermore, remember what we were taught another myth is the first 20 millimeters of opening as pure? [Jaz]Rotation? It’s not. It’s translation. And, you know, I think MRI has shown that right? [Barry]Translates immediately. Yeah. And it makes sense, because the lateral pterygoid is in contracts at the same time that the other. And so if when it contracts, the only thing the condyle can do is move forward. Well, as it’s moving forward, how in the world is it going up and back? Because it’s move forward, because there’s something between the teeth, you’re not allowed into full closure. [Jaz]I didn’t think about that. So that really scratches that itch your head in a really good way. So that’s brilliant. So not only is the vectors of the muscle, which I already sort of had in my head, it’s also the fact that actually the lateral pterygoid is already activated, because you’re slightly open. So it’s actually giving that sort of anterior position of the condyle. [Barry]Right. I’m not sure the turbos activate it, but it’s not allowed. [Jaz]It doesn’t allow it to go all the way back. Yeah. [Barry]It can’t go back. And we see that we, when we take someone with a just as a deprogrammer, just I’ve just an NTI or SCI, we put it we take a picture of it, the condyle’s down and forward. We didn’t bring them forward. No. So the answer is that of that. So with the general cases, we now what else do we want to do? Well do we want to go on, if it’s severe pain with a general case, we want to put them on steroids for a short period of time, we want to put them on AdSense for a short period of time, do we actually want to we use a process called iontophoresis that uses electrical current and the process that is the concept that likes repel, so it goes two phases, the positive and the negative phase and the positive phase forces the lidocaine, which is a positive charge, local anesthetic through the tissue into that and then negative forces, negatively charged which would be the steroids and so we can get steriod into the joint without an injection. So we can treat them with six sessions of iontophoresis. Put them on. Again, the splint therapy which everyone will think oh my god, you’re crushing the joint and degenerative disease gets now under control. And with less pain and less dysfunction. [Jaz]Now what about the role of massage and physio? [Barry]Okay, so it’s interesting. Don’t get me wrong physio can be very, very helpful in some cases, I personally have found and teach that muscles are overrated, ligament insertions are underrated. So, muscles tend to be the ones that are doing the pushing. They don’t tend to get hurt. We don’t even understand muscle pain very well, we know that there’s an increase in glutamate, for example, in patients with muscle pain, but we don’t really understand much about how muscles and why muscles hurt. And to be honest with you, there aren’t many people when I palpate, the masseter, despite pain, reported pain words that are hurt here. When I palpate the masseter and what do they say? ‘A can feel little bit more that what my grandmother does. They love that.’ [Jaz]Temporalis, oh, that was really good. What’s your hourly rate? they say. [Barry]That’s exactly it. You know, I don’t worry if you find a source like that’s why they’re getting into your temporalis. No, anterior temporal headaches are not sore anterior temporal muscles. And so I think muscles are overrated. And muscles are the ones that you know, if you’re standing at the edge of the cliff, and someone pushes you, the object now wouldn’t be to fix the pusher. It’s the treat the damage that’s done as a result of the pushing. We tend to look at the pusher. I don’t think the pushers are the issues. [Jaz] Interesting [Barry] though, is the and again, so physiotherapy can really be helpful in patients where we’ve reached our limit, then we want to increase the range of motion. Physical therapy can be really helpful because some dentists don’t want to do the iontophoresis, do the ligament insertion injuries where we do a lot of injection therapy on those patients. And we really, you know, I used to show those extra those clips of me doing these [inaudible] or ligament insertions and masseter insertion, insertion injections, but I don’t show them anymore because I, the legal world’s gotten kind of interesting. And he I don’t want anybody getting in trouble because of what I taught them. And the use of extra oral injections in some in the states and some, I just tried to defend some really good practitioners in Sydney, Australia, because they were doing trigger point injections. Now, I’m not even talking about trigger point injections. I think they are really overrated. And I may think that because I may not be as good at them, as some other people, I just wasn’t. Personally I couldn’t find the trigger points as readily as some people claim they could. [Jaz] Interesting. [Barry] Let’s say they didn’t, I’m saying, I’m not talking about them, I’m talking about me. And I didn’t get as positive response from doing trigger, as I did from ligament insertion injections. So we look at [inaudible] mandibular, the masseter insertion. And the major insertions in the posterior cervical. A lot of our patients that wake up in the morning and they say, did you wake up with a headache, is it? Oh, yeah. Where is it? At that point right here, their point right to the attachment to the end of the line. And it’s fascinating because when Lavigne’s group, Kato did a study what they showed was right before, these muscles contract, the temporalis master contract, right before that happens, the depressors contract almost as in an attempt, careful, I don’t try to predict why God or Darwin’s doing what they’re doing. But almost as though to protect the structure so that you don’t slam. It raises the mandible for the masseters and temporalis when they suddenly contract at the same time. Thus, posterior cervical muscles contract. And they stay contracted in what we call isometric co contractions during the clenching activity. Well, when you’re pulling like that constant contraction, where’s the injury likely to take place in the muscle itself? no. We’re the at the enthesis, where the muscle attaches to the end for nickel wine, [Jaz]and I believe whenever I’m doing a muscle examination, you know, I’m not expecting to find a positive result when I’m actually massaging the meat of the muscle is always at the origin and the insertion where you know, you’d get a positive if there is a true positive response, right? [Barry]Exactly. So we palpate the origin of that the deep cervical capitus. Here we showed people how to do that, and that injury is the most common one to improve with parafunctional control. [Jaz]I’m actually learning a lot even though I already thought you know what I’m getting the hang of it, then you throw new things out there. So yeah, muscles are important. But ligaments may be even more as what you showed showed that and ligaments and PCs. And so that’s very interesting. [Barry]I think of all the things we talked about today, I think the thing that I would like, if someone said to me what was a message that you are hoping that someone watching this is getting? And what that message is, is that we as dentists shouldn’t be afraid of unlearning, and learning about occlusion, that it’s not as complicated. It’s not as complicated. The answer is, we don’t want people occluding, and we’ll show you how to protect people from doing that. And sometimes a flat plane appliance is the right appliance. Sometimes a Tanner appliance might be the right appliance, more often than not, anterior midpoint stop is appropriate. And we show you why and how, and to understand that this is not for the pain specialist. This is not for the guy that wants to treat migraines, though, would be awfully nice if some of your patients migraines, decrease in intensity and frequency as a result of your therapy. But I would never make that promise or may never make that diagnosis as a dentist. Those bruxism, nocturnal parafunction. [Jaz]I think it’s important to communicate in the correct way as dentists to our patients because we’re not here legally, we should we can’t be treating these these migraines, so we should be very much say Look. It’s interesting, that get these migraines, I wanted to help treat your reduce your forces, because I don’t want you to hurt your teeth and hurt your jaw anymore. Let’s see how that goes. Some patients help some patient doesn’t. But I’m not treating you specifically for that I’m treating other things.’ [Barry]The good news is that while we protect your teeth and your jaws and your joint, a lot of our patients with migraines tell us they significantly decreased in intensity and frequency. Let’s keep our fingers crossed. Wouldn’t that be great? Hello? [Jaz]That’s a good way to put it. There’s actually so many questions, but I have to cut it short because we’re already coming up to the almost 50-minute mark. It’s very easy chatting to you, Barry. So I’m going okay, so you touched on the occlusion course stuff. So I’m hoping to come see you in Glasgow in June for the part two because I’ve done your part one, but I’m gonna do the part two as well in June. I think you’re in Glasgow and in London? [Barry]Yes. So we’re in Glasgow, I don’t have the dates right in front of me. You could have them. But the day [Jaz] I’ll put them on. [Barry] That’s great. And the dates are. So there’s a two day in Glasgow, where it’s a one day the lecture and then the second day is the hands on. And then we move the follow, that’s a Friday and a Saturday. And then we move to London the very next week and we’re in London doing the exact same thing Thursday and Friday at the BDA [Jaz]Brilliant, so then I’ll make sure the details are there. So one more question. I thought of it that some people say that you shouldn’t prescribe an anterior midpoint stop appliance for someone who’s got clicking. So anatomically, I can see where they’re coming from, because that is disc displacement. So the disc is now a usually a bit more anterior. Not always because it’s a bit more complicated than that, because it could be lateral pole and the medial pole could be fine, then Henceforth, an anterior midpoint stop appliance should not be contraindicated. I know over a video even podcast episode. For those who are new to this and learning about this and anatomy. They’re like, what the hell am I saying, and I’ve been there, but I think want to learn more about this. The Anatomy, I think once you learn the TMJ anatomy, you can really visualize it better, but in that same scenario where you have anterior disc displacement, and you do get some degree of seating just from the lateral pterygoid relaxing, right? With the anterior midpoint midpoint stop appliance, there is a potential that it could be impinging on retro discal tissue. My thinking and please correct me if I’m wrong, Barry, my thinking is that a lot of times because the muscles themselves are reducing in force, that doesn’t seem to be a significant issue. [Barry]I don’t even know where to start. I have to unpack that. Okay, so let’s go back. This disc is fibrocartilage. Very bony like, and it’s attached. If I can show you it’s attached. This is my condyle. It’s attached on the media pole and a lateral pole. It’s attached anteriorly by the superior head of the lateral pterygoid, right? And posteriorly what’s called a retro discal lamina, we used to call it a posterior ligament but that’s not really ligament and is irrelevant right now. And then when I this thing is well tethered. Wherever it goes, there’s a if your compartment, the superior compartment and it stays well tethered, and it stays interposed between the condyle and the glenoid fossa. And it’s smooth and as the temporomandibular joint ligament around it, [Jaz]And the lateral collateral ligament. [Barry]And this is similar other synovial fluid. There’s a lot there’s a temporal mandibular joint ligament around the whole thing. This is a lateral collateral ligament, this the medial collateral ligament, okay, so that attaches it at the lateral pole, and the medial pole. Okay, lateral pole and the medial. Lateral pole. Medial pole. Now, the superior head of the lateral pterygoid runs medially, because it attaches that the lateral pterygoid [inaudible] sphenoid bone, which is closer to the midline. So when it contracts, it tends to do damage to more often a lateral pole. And when it does damage to the lateral pole, the tethering is now altered, it’s weakened. And here’s the thing about ligament damage, it tends to be permanent. It doesn’t heal. So now [Jaz]It doesn’t heal, and also the only way south I mean, it can only really throughout someone’s lifespan over the next decades, decades, decades, the eventual and I’ve heard some people say this eventual pathophysiology is that eventually, if the forces aren’t controlled, and the micro trauma continues, then it can only get worse and worse and worse [Barry]And just keep in mind that a third of our patients who are adults without symptoms, have internal injuries that are significant. So I don’t want to overstate the need to stop this from happening. And there’s, we go through, in the course we go through how to make a decision whether or not someone needs to be treated. And it’s simply because they’re clicking. It’s just not that simple. So now this disc tends to be anterior and medial just tends to be that way, because the lateral pole is been compromised. And if it gets that way enough, there’s a big thick poster rim. And then when you open, the click is the reduction, the rim coming back over the condyle. That’s what makes that click. Now, how did it get that way? Well, it got that way through some sort of trauma to this lateral pole. You’re right. If we don’t stop that trauma. Will this get worse? And the answer is? I don’t know. [Jaz]Back to episode eight. Well, you know, I don’t know. Yeah, that was a revelation. Absolutely. It’s not. [Barry]I don’t know, I can’t say. Is the patient still grinding? Clenching? I don’t know. Because they’ve got wear patterns on their teeth, does that mean they’re grinding and clenching? No, that means they grind it and clenched it, but it’s not time stamped? I don’t know. So now the patient’s reported, you know, lately, the click is getting worse. All right. Now, I don’t care where this disc is, what’s causing the click? Forces. What do I think? I think they’re grinding and clenching. Where are the forces greater? More disruptive. During eating or drink dysfunction, during parafunction, so if I can control the parafunctional forces, that patient may be able, it’s fascinating, maybe they believe I very rarely need to tell a TMD patient with joint pain, you need to eat soft foods. It’s very rare. Because most of the time, those aren’t the forces that hurt them. Now, if they’re damaged enough, until they get better. Sometimes that’s necessary. It’s often usually not. That if I can, so wherever that I don’t care what condyle, it could be medial, it could be, If I can decrease the forces, I go into anterior midpoint stop. [Jaz]Yep. So yeah, that’s sort of what I thought but you explained it so much better. So it’s basically we’re decreasing the forces. And that in itself, will mean that the sort of what’s happening in the anatomy, which is, you know, we know, like we said, right, the beginning of this episode, that actually, there’s only a defined position, the condyle can go, it won’t go all the way back. [Barry]And this is interesting. Jaz, what happens now in two months, when the patient says, Dr. Barry, I don’t have pain, and I stopped clicking. Okay, what happened? [Jaz]So one of two things could have happened. One of a lot more than two things. Okay. So disc could have come back unlikely, I think because like you said, [Barry] Let’s throw that out. Okay? Go. [Jaz] Okay. So yeah. The disc won’t come back. The other thing is that the posterior band has thinned a bit. So maybe it’s changed morphology so that the click is much more subtle. So it’s not audible to the patient as much. [Barry]That is really good. So the number of people that would have come up with that I have to tell you is real. So for those that are listening, what Jaz need said the posterior band, what he’s referring to, is the posterior rim of the disc, The posterior rim of the disc, which was responsible for that clicking because it was so thick. That is if you decrease the forces, and now they’re no longer destructive, but they’re within the patient’s ability to adapt. Part of that adaptation becomes remodeling of the posterior rim from the pressure, instead of doing damage to the ligament, it now is altering that disc that change the direction forces, and now that this is recovering, but with less veracity, and now no noise, really good, really good. Some people would say all now it’s disc displacement without reduction. And you’d say No, because there’s been no change in range [Jaz] opening. Exactly. [Barry] There wouldn’t be a change in range of motion, suddenly, as a young professional and a younger person. [Jaz]You know, as much as I don’t want to be known as a TMD guy, but the more I spend time with you, it’s like my inner geek coming out. But it is one of those really interesting joints. It’s one of most fascinating joints, the body and I can’t stop learning about it. So it’s great, and to help our patients with parafunctional control, which I believe is the biggest source of consistent trauma to the joint, is a great thing to be part of. [Barry]Yep. Very good. All good. Always is. [Jaz]Barry, thanks so much for coming on this, on my show again. I’m have to bring you back again, because the next time because I had some questions about sleep and airway, and I had so much with time is of the essence, my friend, [Barry]Can I tell you that we really should do that, because there’s an awful lot of myths out there. And people making a big deal about something that can be very, very important. But like everything else, there’s that knee jerk reaction to make it more important and more difficult or complicated than it really is. [Jaz]Well, let’s make that happen. And I’m just going to leave a three words, that’s going to make you probably feel sick inside, I imagine, okay. And it’s an airway, websites, orthodontic practice marketing themselves as providing airway friendly orthodontics. [Barry]It’s sad, it’s really, really sad and please don’t underestimate the incredible value of understanding the role of functional therapy in our younger patients, and the potential that it has. So I don’t mean to underestimate that in any way, shape, or form. But it’s our professionals habit, to take some good information and put it, take it out of perspective and make it a bigger deal because you can sell a course with it or you can or you believe in it. People often ask me, do I What do I believe in? And what’s my response to that? You know that, What do you care? I’m the, Who am I? You know what do I mean, but it’s not a matter of what I believe. You know, I went through all that when I went through camp after camp after camp and what and suddenly I realized that belief means religion and religion is cultish. And it has nothing to do with the science. What, if you asked me what the predominance of the evidence is? I’m very happy to tell you. If he asked me what I believe, what do you care? And unfortunately, they walk into these things. They want to know what is the belief and the people creating their own belief systems and the role models and their own techniques and their own you know, it’s very disturbing. [Jaz]Well, we have to come back to cover this sort of topic one day. It could be very very good to do so. Enjoy Florida, and I think I’ve done quite well. I don’t think I touched my moustache. [Barry] Is that why you are [inaudible] [Jaz] I don’t know what that mean. I don’t know. I don’t know what that means. [Barry]It’s good. Oh please I hope to see, if anybody’s actually listening to this. [Jaz]You made it this far through our TMJ mumbo jumbo then well done firstly. [Barry]We were very excited about this London trip has been just exciting to me. I really enjoyed initially when I first came to London, Jasneet, I will tell you that I think my style was at that point was 10 years ago was kind of difficult. They weren’t used to my presentation style, which was you know. And either Londoners have changed, the UK, The world has changed or you’ve been watching the parliament too much and I seem calm. I don’t know. But it’s, I so enjoy coming when people are so eager to learn and I am so appreciative of the difficult world in which you exist. I know the preference of the National Health System, I appreciate that. And my goal is to make your lives better, safely. [Jaz]I hope to see you in June, myself and I can’t do the London date, but I probably can do the Glasgow one. So I’m gonna take a flight to Glasgow, to you. So I’ll see you then. Barry, it’s nice catch up over a drink. And again, I’m going to bring you back. [Barry] I would love that [Jaz] Brilliant, but we’ll have to bring you back for an airway episode. [Barry]Sounds good. Jaz’s Outro: Thank you so much for watching or listening all the way to the end. I really appreciate it. Please share it far and wide to your dental colleagues if you enjoyed it, and I’ll catch you in the next episode. Like I said before, I’ve got so many recordings lined up that I’m really excited to get them out. Some really great pediatric stuff, a really revolutionary episode about how to look after your back as a dental professional, which is going to shock you I kid you not. So I look forward to getting all that out there. And thanks so much for supporting my podcast by listening to it and I’ll catch you in the next one.

Last week it was International Women’s Day, which makes me especially proud to share this absolute clinical blockbuster with one of the most inspirational Women in Dentistry – Dr Manrina Rhode. In this very clinical episode of PDP, she teaches us about Veneers – she has been placing them for several years and has developed awesome systems in her practice for this. Full Video version on YouTube or IGTV @jazzygulati https://www.youtube.com/watch?v=1_AZh3spMUU The Protrusive Dental Pearl in this Episode is a Communication one! Let me know what you think. Need to Read it? Check out the Full Episode Transcript below! We discuss: Manrina’s journey with cosmetic Dentistry and veneers – how did she get the exposure early on in her career? Ceramic vs composite veneers – composite has lifted off last few years, what has been your experience? What percentage of her patients have pre-restorative orthodontics? Which burs does she use for her preps? (Bur codes listed on Protrusive Dental Community: www.facebook.com/groups/protrusive/ ) What prep protocols does she use? What kind of stents? How do you communicate shade with lab and the patient? Does Manrina follow an ‘Occlusal Philosophy’ to ensure (para)functional longevity of her veneers? How do you manage patients with ultra-high expectations? How she uses Photoshop to show patient possibilities with their own smile Why awesome temporary/provisional veneers are so important How does she fabricate good looking, long lasting provisional veneers? What is her bonding protocol? How does she reduce mistakes during a stressful bonding appointment? Hint: teamwork! She gives a very good veneer bonding hack towards the end! Instagram @DrManrinaRhodeAsk Dr Manrina every tuesday on @DrManrinaRhode in storiesAsk her your dental questions! Her Veneer course (next cohort in June 2020) : https://designingsmiles.co.uk/ Bur codes listed on Protrusive Dental Community: www.facebook.com/groups/protrusive/Or pasted here: Bur Kit Dental Directory Mandril KTM010Mandril K5F009 582 (red mosquito) BD582F Komet 6844.314.014 (red/green prep bur)6844.314.016 379EF.314.023 (rugby ball shaped yellow bur) 856EF.314.012 (yellow polishing) 834.314.021 (depth cutters)834.314.016 (Thank you for selflessly sharing these, Manrina!) Click below for full episode transcript: Opening Snippet: Welcome to the Protrusive Dental podcast, the forward thinking podcast for dental professionals. Join us as we discuss hot topics in dentistry, clinical tips, continuing education and adding value to your life and career with your host, Jaz Gulati... Main Interview: [Jaz] Marina, thank you so much for coming on the Protrusive Dental Podcast. It’s great to have you on. How are you? [Manrina]Yeah, really good. Thanks, Jaz. [Jaz]You’re always smiling. You’re always always always smiling and you got your most beautiful whitest teeth ever. [Manrina]I’m like promoting my own work. [Jaz]You have to, right? Because that’s exactly what you’re doing. You’re doing veneers. You’re doing cosmetic dentistry, and you know, you talk the talk, you walk the walk, right? [Manrina]Right. That’s exactly. It makes my job easy. Cuz my patients will come in and they’ll be like, Can you give me a smile like yours? I’m like, you know what I can. And that’s half the job done. [Jaz]Perfect. So tell to my listeners a little bit about yourself, about your journey and how you got into cosmetic dentistry and veneers in particular. [Manrina]So I have a really interesting career pathway. A really unusual one, I think. When I graduated from university, and at the time, it was VT. So I graduated in 2002. From Guys hospital, which is now Kings. And there was a job opening that came up for Harvey Nichols, first dentist. And they were asking, yeah, so they were asking for someone that was two years graduated, and someone that was five years graduated, like as a minimum requirement. And obviously, I just graduated, so I didn’t fulfill either of those. But in my VT group, everyone was like, Manrina, you have to apply for this like you are JHarvey Nichols’ dentist. It sounds like, Right, I’m gonna do it. [Jaz]So what made your group like affiliate you with that? I mean, it’s really flattering that everyone said that you’re the girl for this job. So that what is it about? Was it the sort of stuff that you were already interested in? [Manrina]So I think I’m quite fashion-y, like, I quite like my clothes and my fashion and, you know, interested in the way things look. And so that’s what people have always known me for at university, and then I guess, by the VT group as well. People always assume I’m wearing designer stuff, which I’m not necessarily but you know, I like to put things together in a certain way. And think about what I’m wearing, and maybe not repeat outfits too much. And certainly more so when I was younger, and maybe I’ve relaxed a little bit about it now. But I’m the same still now. Now when I go out, like I really enjoy dressing up and putting things together. And that comes from my mother. My mother’s exactly the same at her age. You know, she made sure that we were always coordinated, that you know, to like, you know, when we have had these long plaid, and our hair bands at the bottom bar plot would match our top boy shoes. So that’s just the way we were brought out. [Jaz]You know, Manrina, there is this certain questions. You never ask women, but I don’t think this is. I think I can ask you this, but please tell me if I’m wrong. How many? [Manrina]How many shoes? [Jaz]How many pairs of shoes do you own? [Manrina]Oh, yeah, I do. I couldn’t even count. I have shoe cupboards and shoe cupboards and shoe cupboards in my house. So yeah, there’s a lot of shoes, a lot of boots, and a lot of sandals. And yeah, a lot of heels every type in every color, and every brand. [Jaz]I messaged you a few weeks ago, and I said, Look, when I told my wife, she’s also a dentist. When I told my wife Manrina’s agreed to come on the podcast. She was like, “Oh, I might start listening to the podcast now.” [Manrina] Oh I loved it! Women power! [Jaz] So I’m gonna have to cut that bit out by the shoes, though. So cuz I don’t want her to get an ideas. So I’m so sorry. You were telling about your story about Harvey Nicks. So how did you get the job? [Manrina]Yeah, so that was Yeah. So just to go back. I also really love the way the amount of support I’ve got from women l through this journey. So that’s a classic example that was so beautiful of your wife to say that. And there’s been, I’ve been inundated with messages from women on social media since I released my course saying that, “Oh, great. So great to see a female educator.” And I think that’s really lovely as well. But anyway, so yeah, well, I’m sure we’ll come back to that. Let’s go back to my career pathway. So yeah, I fight this job that I was very unqualified, well, I had a dental degree, but that’s about it. And it was a bit of a process. So it was weird that I learned Ostler, which some of you may know or may not know, but it was really the first practice of its kind back in the day, the first Dental Spa in the UK. And the interview process, so I was shortlisted for this interview, and the interview process was an interview with the owner and the manager and written exam and we were given a recommended reading list of like five to seven cosmetic textbooks and then patient exam as well and they would then mark us on how the patient felt about being examined by us. [Jaz]That is like a high level interview. I mean, I haven’t you heard of an interview process quite like that? It’s pretty cool. [Manrina]But, you know, it was an opportunity of a lifetime like, you know, getting that job completely changed my life. I you know, it’s been such an amazing journey from there on in and I’m so grateful to Surinder for giving me the opportunity back then. So yeah, I think rightly so. That it was such a process because they were looking for the right person for it. And so, yeah, we did, I did the interview and Surinder and Surinder had known the manager at the time, like my personality, so they were like, Okay, so what one thing was to get shortlisted, and you know, and then do that interview. And then there was the written exam. And because I just come out of university, I was really used to reading textbooks and absorbing knowledge. So I went, you know, read all those textbooks, took it all in, took the exam and did really well in that. And then, with a new patient exam, you know, again, which I just come out of university. So we’ve been taught the gold standard way to do an exam and everything needed to be checked. So that’s the way that I did my exams. I hadn’t been sort of ruined by [Jaz]I haven’t like started taking shortcuts just yet. You haven’t cut corners. You’re doing things by the book. [Manrina]Yeah, exactly. So we did all that. And anyway, so yeah. And it was amazing. When I walked in all the shortlist of dentists, it was this beautiful clinic with this waiting room with all these beautiful dentists. I think, you know, you chosen a bunch of good looking people who had a dental degree, and then he chose from them to take the job according to those three stages that we went through. So it was really fortunate to get that job. And at the time, I told him, I was like, you know, I don’t have the qualifications, the experience that you asked for. And he was like, Well, you know, you’ve got the right load and the right personality. And as long as you’re keen to learn, I’ll teach you, I’ll teach you the dentistry. And that was it. [Jaz]It’s like a mentor to you. [Manrina]Such a mentor. And I think I really like the way that he was, I think it’s correct. I think, you know, if I ever open my own clinic, I’ll do the same thing. I’ll take on dentist, you have the right attitude, they don’t necessarily need to have all the skills yet. They just need to be willing to learn, you know, without ego, and I put the hard work in and I was fully there. I was like, yeah, I’ll work any hours. I’ll do anything. You know, you tell me to do work wise, I just want to learn. And it was never about money. It was always about just getting the experience and absorbing the knowledge. Cuz I wanted this so bad and I wanted to make him proud. And feel like he made the right decision. [Jaz]Perfect. And then from there, your cosmetic dentistry experience and your exposure through the mentorship grew and grew, I imagine. [Manrina]So that was 18 years ago. Yeah, that he took me on and then from there, obviously, you know, yeah, we were the first sort of Dental Spa in the country. And then we’re going to clinic in Harrods as well. So then he moved me from Harvey Nichols to Harrods, and then I was their first dentist. And then we got the TV show, 10 years younger. So at the time, there was no sky TV. And that used to air on channel four, eight o’clock every Thursday night. And it was only me and Surinder doing smile makeovers in the clinic. So it would be 200 new patients that would contact us every Friday morning, trying to book in to win those slot. And then between the two of us, we had to do all these smile makeovers. So I spent my 20s doing veneers, prepping veneers like, every day, and I would work till midnight, I would work weekends, you know, we had to get them in and I didn’t mind doing it. This was my protein it was where I was happy. And actually the way that clinic was, we were like family. So I felt like I was with family. We were all working together anyway, we had this aim to be the best and [Jaz]I totally get that vibe, Manrina, I get that vibe from your Instagram stories and the way you manage your patients and the way that you get you know, friendly in the right in a professional way. But you really, I can tell that you go the extra effort to make them feel comfortable. Definitely get that vibe. And the cases, the volume of cases you produce. Excellent veneer cases. The reason that when I thought okay, my listeners asked for a podcast episode about veneers I thought of you straight away. And of course you’re telling me your story about how many veneers you got to place so early on. And just reminds me of the 10,000 hour rule. You know, Malcolm Gladwell made it famous and you had such a lot of exposure to veneers. So that’s why I’m excited to the next half an hour or so to download as much knowledge as possible, that’s reasonable within half an hour through this podcast [Manrina] Lets’ do it! [Jaz] about veneers. So I obviously got a few, list a few questions for you. So let me start with question number one, which is probably the most common question I’ve come across with my fellow listeners is ceramic versus composite. We’ve seen composite veneers boom in the last maybe three years. I don’t know what it is. But suddenly everyone’s doing composite veneers now. You tend to from what I’ve seen on Instagram, you tend to place more porcelain veneers. What’s the conversation that you have with your patients? What’s your experience with ceramic versus composite veneers? And what would you advise? [Manrina]Yeah, so without a doubt, there’s been a massive boom. And there’s been a really big boom, actually, in younger patients, I feel like the older patients are still coming in and asking and happy to have porcelain. But the younger patients, there’s been a lot of scare tactics around porcelain. And people are really worried about their teeth being cut. And so they’re like, Can we do composite? Does that mean you don’t have to cut my teeth? And I think it’s a matter of a conversation, I think some people are suitable for composite bonding. And that’s fine. And I will do that in those cases. But if it’s a case that needs full labial coverage, then I would prefer to place porcelain, I think where there isn’t advantage to composite is a lot of people aren’t very confident with porcelain veneers. And so perhaps they’re over prepping them, or they’re worried that their porcelain veneers will fall off. And so they’re prepping tooth for crowns, as opposed to veneers. And so there’s some quite heavy preps going on with them. And so I understand, you know, what, why patients would want it and the risks associated with that. However, if a small modification is done correctly, and you know, the lab I’ve been working with them for 18 years, they now make me these beautiful Emaxs, I use Emaxs veneers. And they can be 0.3 of a millimeter thick. So they’re very, very thin, and they’re very strong and very beautiful. So where you’re broadening the smile quite often on the on the premolars, on the side of the smile, there’s, no prep, I just prep a margin and stick these veneers on. So there’s no risk associated with that, or very low risk associated with that. And in areas that I maybe do need to prep, then I’ll encourage my patients to have pre alignment first. So I’ll align the teeth accordingly. So again, there’s very little prep needed. And because ortho has also evolved massively, it’s very quick and easy now to move to it’s not like the old age, you know, asking patients to wear brackets. And so there’s a really big take up with that. I don’t mind doing [Jaz]What percentage of your patients, would you say, have both an ortho-restorative treatment from you rather than purely restorative driven? [Manrina]Yeah, so percentage wise, most, I would say more than not, will have some sort of ortho first, even if it’s just a few clear aligners. So maybe I’d say 60-40 some patients come to me with already straight teeth, they’ve had ortho as a child, they may even still have retainers on. And then that they’re having that they you know, they’ve worn, they take teeth away because of grinding heavy. I mean, that’s a massive issue everywhere, but certainly in London. And so then the teeth are already straight. And then it’s not, really an issue [Jaz]I completely agree with. And that’s why I went on to study an ortho diploma because I figured out in while I like doing is tooth wear cases and big cases. And what I see is that I think yes, 60-70% of patients who need a rehabilitation would benefit from orthodontics, because it means you can do a more minimally invasive job. So you mentioned, obviously that, you know, if you’re only doing zero, in some cases doing 0.3 millimeters, and that’s going to be quite invasive, but what technique would you use? Because some you know, I’m assuming use the Gürel technique or whatever other, what techniques can you do to teach my listeners about how to be more minimal, because what you don’t want to do, as some Dentists have done and I know this is that they look they open up [schellenberg], and they see that Oh, and then you see prep 0.8 millimeters. And no matter what the position of teeth is, you’ll just prep 0.8 millimeters everywhere, which we know is not the right way to do but for those who are less experienced of veneers. Can you please explain your protocol? [Manrina]Yeah. [Jaz] that makes sense. [Manrina] So that’s Yeah, so I think it’s really important before you try and do something like this for your patient, it’s a cosmetic treatment that they don’t necessarily need to have, but they want to have, and it’s not something that you’re taught how to do at university. So it’s very important to go on some sort, of course, and learn how to do this properly, learn about wax ups, and how to set up a case and make sure that your work is going to last. And I know Michael’s again, the way that I taught it was that we do a wax up, stick impressions of the smile, design the new smile, get a wax up made of that, and then get a putty index made of wax up that can be placed in the mouth, over the teeth. So if the putty index just on the incisal edges of the teeth, and you place that in the mouth, and then from there, you can see which bits need to be removed, so that the veneer won’t, won’t stick out. And so that’s what we do with the delegates as you say and you look at it, and then you mark those areas. So you’re gonna something? [Jaz]No, no, no. So as you were saying that, I mean, I do that a lot, by the way. So hope doesn’t put you off. But so you’ve got the putty and I want to make it very tangible. So lots of learning points, lots of learning points in there. So you’ve got the putty index on, what is the typical labial reduction, which are the 0.3 millimeter cases and which are the 0.7 millimeter cases, how would you differentiate? [Manrina]You look at your putty index, and then you have a look at how much space you have labially and then you see if you have that sort of point. In a standard case, you have 0.3 millimeters and any way you don’t, or you would just remove the extra bit of soft tissues. So I mark it, and then you can remove it. And then you put the index in again, so that you can see that. So you can see you’ve taken off the excess. Now, also, there’s the bur. And actually, I’ve even got the number of the burs, so we’re just making a list, [Jaz]That’d be great. I mean, if you can read it out, and then I always put it in the blog post as well. That’d be great. My listeners love burcodes. [Manrina]I need to take you for walk though. So I would thake you for walk. [Jaz]Let’s go. Let’s go for a tour. Share Road. [Manrina] Yeah, there you go. Exactly. [Jaz] So obviously the bur aid you to prep the correct amount. So it’s like a guide, right? [Manrina]Yes, exactly. So we’ve got the 0.3 reduction. So the bur that I use, to prep with, so to actually prep my margins, I use the 6. So this is from, Komet. So the 6844.314.014 and also the .016 you’ll have to write that down. Because that’s [Jaz]So what I’ll do is at the exact moment that I play this bit, and people are watching this, magically, in my hand, the bur will appear over here. So but I’ll put that on. So when people need to contact Komet to buy it. So obviously, you know, I was explaining to my listeners, in my last episode, actually, or two episodes ago about how to interpret burcode. So the last four digits would mean how thick it is at the tip. So what you’re suggesting there is the 1.4 and the 1.6. But only part of that is the is it is yeah, is the diamond that’s cutting and then while using that bur, is it the one that’s like the Christmas tree shaped like it’s got little bits on, right? Like, it’s got a gap? [Manrina]Oh, yeah. So this is a prepper. So this is for doing the actual margins. So it’s just a straight bur. It’s just a straight bur. Right? Cool with a red o rgreen margin. But yeah, I was just looking at the list. And then it looks like, you know what I haven’t got. Haven’t got it written next to it. But I can [Jaz]Just send it to me. And I’ll put it on. So Manrina’s burs that she recommends. We’ll put that on post. [Manrina]Yeah, I know, I’m going to contact them and get this made as a bur kit. The problem is, it’s from dental directory and Komet from two different places. So I don’t know, I don’t know who’s going to make this bur kit for me. [Jaz]They’ll be fighting, they’ll be fighting to make a bur kit, Manrina. [Manrina]Fighting. Yeah, there you go. And so yeah, one of these two will be the depth reduction bur. But yeah, I’ll double check which one is and make sure I’m giving you the right number. [Jaz]Technique where once you’ve sort of made a temporary or once you’ve done a trial smile, then you prep and then you color it in, I see that being as a technique like you coloring with a pencil where it hasn’t been reduced enough. Is that something that you use? [Manrina]Yeah, so we use a pencil a lot. So first of all, when you put the putty index on, use a pencil to remove the bits that are jutting out, that stopped the index from sitting comfortably. And then you go ahead with this depth reduction bur and over, you know, on the areas. So on the premolars is where you can see there’s all, say that you’re broadening and you can see there’s already enough space, don’t even bother doing this before the cheat where you can see that you’re just at the margin at the putty margin. This is quite difficult to explain. Without having a visual [Jaz]Audio only have Yeah, I know. I mean, but try it. Try your best. [Manrina]Yeah. If it doesn’t make much sense, then yeah, I don’t know. Yeah. [Jaz]We’ll do some videos. [Manrina]Oh, yeah, we have to do a video. So, then you use the depth reduction bur you put it parallel to the tooth, you go across the labial surface. And then you take a pencil, and you mark the depth. And then you can make sure you prep until you remove the pencil and then you know, you’ve removed enough. But actually, again, on my course we do this two ways. So first of all, I showed them the Galip Gürel technique. So we’ll go through that as well. Should go through that now? [Jaz]What is Galip Gürel technique? And then what is the Manrina technique? [Manrina]Yeah, exactly. So in the Manrina technique is the one that I just told you. That’s how typically, I will do it, I will use the putty index. So I will take my putty index, I’ll cut it to the incisal I place it over the teeth, I’ll mark where I need to reduce. And then I’ll just go through eyeballing and reducing where I need to. But Originally, I used to do it Galip’s way. The reason why I stopped doing that is because I think it’s really good aid initially, but sometimes it can mean that when you put the actual temporaries on they’re not as smooth as they are when you’re using the stent for the first time. Because I think you need a bit of resin stays on this stent And so yeah, just for the sake of that but but as a learning aid. It’s really good, really good technique. So the way that works is when you do your setup, so you have your wax up done, you design your wax up, you have it created, you have this incisal index made, and you also get a temporary stent made so that you can place your temporaries. So at the beginning of the appointment, actually, I think there might still be some benefit here to putting the incisal index on and still removing the extra bits that you can see, obviously jot out, if there are those bits, hopefully you’ve done your pre alignment and there aren’t issues, then you fill the stent with temporary materials. So that would be ProTemp or Luxatemp, or whatever brand you decide to use. And then you pop that in the mouth, and those stents can be in any color. And then you take this depth reduction bur, you hold it flat against the tooth, and you put your your depth marks through the temporary, then you take your pencil, you mark the depth marks, just as we talked about doing this now on the tooth, and then you peel off the temporary. And you see whether any of those pencil marks actually mark your teeth. And actually, I think when we did that just when I did it just now on my course for the patient we were doing there, I’ve made, we may have got one little pencil mark, like most of the teeth that need any prep, which is really interesting, because then suddenly, you’re like, Oh, I would have gone ahead with the depth bur and cut all of these away. And actually there was no need to get to the final result that we’re wanting. [Jaz]So a lot of these areas are going to be additive and through the wax up. And a lot of these are therefore very minimal. So that’s the way to do it. Rather than just going around prepping an arbitrary number. You got to begin with the end in mind, like you said, with the wax up control process, the only question that comes to my mind is, how do you factor in a tooth that might be slightly more discolored? So let’s say a darker central incisor or let’s say the scenario where they’re all dark teeth, or the other scenario, which is very annoying is when actually one tooth is darker. Can you talk, tell us about how you would treat a veneer case any differently in your hands? [Manrina]Yeah. Oh, no, of course. Yeah. So you’d have to prep, you’d have to prep much deeper. And actually, within the depth reduction burs, we have a 0.3 millimeter and a 0.5 millimeter depth reduction bur, so that we can prep a little bit further. And you may even want to prep a little further than that, to be honest. And it depends how you decide you want to tackle the case, you may decide that if it’s a full tetracycline case, for example, it’s all quite dark, your prep is all a little bit heavier. So you’re looking at least 0.5 millimeter reduction, maybe even a little bit more than that, to be honest. Looking at I mean, I can’t give you an exact amount, but I would you put 0.5 and let go a little bit further with it. So that the lab have got space to place the layers to mask out the depth of color. But if it’s a single tooth, or if it’s just isolated areas that are quite dark for some reason, then I’ll prep just that area deeper. And I’ll mask the darkness with a composite so with a quite a opaque. [Jaz]Okay, like something like the pink opaque, like that sort of stuff? Or like resin? [Manrina]Yeah, it’s just an opaque composite. So within my set of my Venus Pearl composites, which is what I’m using at the moment. Yeah, there’s some a opaque, pacifiers or opaquers? So I take quite an opaque shade, and just stick that on. So that I’ve done the job for the lab, and then they’re not masking any [Jaz]But more importantly, what the lab get is a cast. Right? So tell us about your documentation, which then aids the color and which percentage of patients are you actually sending to the lab to actually get some, you know, custom shade match? Or is it all mostly through photography and your relationship with your laboratories? [Manrina]Yeah, so for a smile makeover, so anything actually usually even just for four units, or, and more than that, so 4, 6, 8, 10 whatever, 20, 24 whatever, it will be through my own. I’ll take the records myself, and I’ll let the lab know what it is that I want. But for majority, if not all, 99% of single centrals I’ll send them to the lab. [Jaz]Okay, perfect. But then the photos you’re sending tells the laboratory the starting shade, or the dye shade, as you wanna call it stumps, shades used to be called so that the lab know exactly what color they started with. Right? [Manrina] So they have all the information. [Jaz] What’s the most popular shade that patients and yourself in the patient select in your clinic? [Manrina] BL3 three [Jaz] Is that the whitest or BL4 or what? [Manrina]BL1 is the whitest. So I always tell my, you know, my patients quite often will come in and then I’ll be like, we’re gonna do these in BL3 because BL3 is my favorite. And they’ll be like, okay, let’s have a look. And then you know, they’ll always pick up BL1 and be like, ‘Can we do this color?’ And I always tell them the story that you know, I done over 10,000 ceramics in my, 10,000 veneer in my career, and within that I’ve already done two cases in BL1. And one of them, she came, had the teeth done pay be 15 grand, insisted on having the done on BL1. I was like, ‘Don’t do it. Don’t do it don’t do it.’ And she was like, ‘No, no, no, this is what I want to do.’ So at the end fine, we did them the BL1. And she came back the following year, as say ‘You were right, they’re too light’ Had been redone in A2. And that’s been another 15 grand to do it [Jaz]It’s like to go from BL1 to A2 is a significant jump [Manrina]Yeah, like she knew that they were too white. She hated them so much that she was like, just give me, then there was another argument, right? Because I’m like, at least let’s do B1. An A2 and I showed pictures of that case, again on my course because it’s just an intersting one. [Jaz]Awesome. That is a great learning point, you know, about communication. Really good. [Manrina]Most of them do. To be honest. Most of they start saying they’ll be on BL1. And by the end of the conversation, they’re like, okay, I’ll trust you on this. Let’s do BL3. And BL3 is a great color. [Jaz]Before but some levels they’ll say what shade Are you but then I was also gonna ask you what shader Simon Cowell? [Manira] Yeah, probably a BL1. [Jaz] Okay, did you use that example? No one wants to have teeth like Simon Cowell. [Manrina]Some do. Yeah, they’ll say, Oh, don’t make me look like Simon Cowell. And then they’ll like pick up a piece of paper and be like, Oh, can we do in this color? I want to look like him. Also has to do with the anatomy. And so you could get away with like a much whiter color. If you put the correct anatomy in. And that’s something really important to understand with the patient. You know, some people will say, don’t ask your patients Oh, it’s so annoying when patients, send in pictures of celebrities. Because how are you going to make them look like a celebrity. Whereas I always ask my patients to do that. I send you pictures of smiles that you like, because it gives me an idea about their vibe, whether sometimes what they say and what they actually want doesn’t correlate. So once they send pictures. I’m like, okay, that’s a good one [Jaz]Interesting. Okay, I see what you mean there. Very good. The next thing I want to ask then is, do you follow an occlusion camp like some people are like following like Pankey or Dawson? People know what I think and whatnot. But what Well, how do you manage the cases where you have got tooth wear people are parafunctioning or bruxing, so you need to be a little bit smarter about the way you design the occlusion. Particularly if you’re placing lower veneers, because that’s taken the sort of including, you know, the whole guidance involved in the fact that the sort of the forces going on a lower veneer is quite different to what goes on upper veneer. So how do you manage just a few points about occlusion management with your veneer cases? [Manrina]Yeah, so I’m really big on occlusion. I teach occlusion to the DFTs every year in the VT scheme. And that’s always scary, scary how little they know. But yeah, I did the Dawson courses over three years in Florida, back in the day, like 2004 to 2007. And [Jaz]That’s so much more glamorous, you went to Florida and I have to go to the Wirral [Manrina]I love that though, Ian Buckle. So I studied aesthetic advantage with Larry Rosen style. And, you know, Ian was studying at the same time as me, so I got to know him back then in 2004. And then, you know, at the time, we were both learning all these things, and yeah, he was learning it at Dawson and I was learning about Dawson and then obviously, he went on to teach it. And I always recommend people who ask me about please go to the Wirral and learn with him because I think that’s a really good course. [Jaz]A great story. I never knew that you and Ian sort of went to the same place to learn. That is so cool. Honestly. You need to send Ian some of the cream that you use though. You need to send Ian some of the moisturizers. Sorry, Ian, I love you really, mate I’m gonna see you in March. I’m seeing you like I’m doing the Dawson Academy at the moment the Wirral at the moment. So I’m seeing Ian in March and he’s probably gonna kick my ass for if he listen to this, so hopefully he won’t. But anyway, so you did the Dawson in Florida. Is that with Pete Dawson himself? [Manrina]Yeah, exactly. So Karina was teaching us and Pete Dawson was around by 10 he gave me He gave me odd lecture. And actually, oh my God, I’ve got this book. Like, right here. As I was referring to it, yeah, for some slides that I was waiting for my course. So yeah, so that’s my thought. That’s where my learning is from. And occlusions must be important because I can’t have my my veneers fail. And so I’m not worried about my veneers debonding, they’re not going to debond and the technique that I use, they show recent studies have shown that you can hang a man off the veneer and it won’t debond. So that’s not my concern. My concern is patience breaking their veneers and anything that can break. Exactly. Anything that will break a tooth will break your veneers. That’s what I tell them. So I’m like You know, you’re grinding habit, the reason your teeth already worn is because of this habit that we need to control. And we need to reset your bite as it should be. And also obviously biting fingernails and eating peanuts, opening packets with teeth, opening bottles with teeth, and all these other things, that’s a conversation that we always have. But my patients always restored in canine guidance. And we look so we check that it’s the canines that are taking the load on their lateral excursions, and we have a look at protrusive and we check that the bite is set up correctly, but also, if they’re grinding on their back, so Okay, 85% of my patients grind their teeth. And that’s because people in London grind their teeth like [Jaz] 100% agreed [Manrina] stressful, right? Crossing the road is stressful, getting on the tube is stressful. These people, everyone’s stressed, I grind my teeth. You know what I’m working, I love my job but when I prep [Jaz] I do big time. [Manrina] Yeah, I clench release, so my nurse will see me doing it. And actually, I Botox my masseters because I had this really quite square face from my grinding habit. And so yeah, I stopped some Botox in there [Jaz]So tell me, just on that point, do you feel like a reduction in your bite force? [Manrina]Yeah, of course, it’s massive, massively reduced. So I can eat and drink as normal. But I used to eat packs of nuts. Like I would just empty out a whole pack of nut which was too many nuts, right? So it wasn’t, this is what I tell my patients and that you can’t eat a pack of nuts, after I Botox your masseters. But you can eat a few nuts, which is all you should be eating anyway. So now when I tried to do that, my masseter gets tired. And I stopped, I have a few and I stopped [Jaz]Interested, so the feeling is that after a few nuts, you get tired. [Manrina]Yeah. And that’s why I’m not grinding as well. So I go to grind, and then I’m tired, and then I stop. So I feel like I’m going off course. So good to go. Yeah, so the reason, we look at patients, and they either grind on their back teeth, or they grind on their front teeth, you know, they have all of these strange habits, some just grind of one side. And you want to have a look at what that habit is and look at the wear pattern and try and work out what it is that they’re doing. And then you want to try and manage that habit for them. So if they are not just clenching really nicely, and it’s not really nice, it’s really bad on their molars and cracking all of them, then it will be because there’s a prematurity back there. So there’s something that’s uncomfortable for them to bite on at the back. And so in that case, I know that I want to equilibrate them, so that if they are going to continue with this grinding habit, and they’re not going to follow protocol and wear their night guard or put Botox, their masseters or the other things that we’ll discuss, then at least they’re grinding on their back teeth. So there’s bigger teeth to take the force, rather than them trying to break the porcelain work that I put in their mouth. So yeah, a lot of my patients get equilibrated [Jaz]So you’re taking the loads in your case, you’re taking the loads away from the anteriors from for your veneers. But then all of your veneer patients are given a splint or a retainer or you know, or not really or it depends [Manrina]Yes, so the majority, the vast majority of them all, and some of them will refuse it because they say I’m not going to use it. And in those cases, I’ll usually give them one anyway. And then I might just give it free of charge and just say, at least I felt like I’ve given it to you, but then I’m aware that they’re not going to use it. And then we have a further conversation about what we’re going to do about that. So yeah, potentially, it’s very toxic the masseters, which is really appealing to women, and so a lot of them, you know, will do that as part of their treatment plan. But for some of the men, because it’s slimming for your face, you know, they want their big jaw. And so they you know, they didn’t want to do that. And so then add to check where those loads are going. And what I also want to do for a lot of them, is show the pictures of really horrible wear cases and tell them, you know, this is the sort of thing that I see every day. That’s why I’m paranoid about eating my enamel. It never grows back. And so I wear my night guard every night doesn’t matter what time I go to bed, or you know what I’ve been doing, I will go and I’ll put that in, because I’m paranoid about it. So I would like you to be paranoid about it, too. And show them why. And equally for this ironic work is that you’ve got this beautiful smile now. You haven’t loved your smile, you haven’t looked off it brilliantly. But now you love it. And it’s very expensive. So if you love it, look after it. And you’re gonna have to wear this to sleep. And to be fair, the majority of the will give in, ‘Okay, Manrina’ Yeah! [Jaz]That was amazing. That whole minute, that’s gonna be my opening snippet of the podcast. I really like that. I’m gonna, like memorize exactly word for word and say to my patients, just like that. That was that. I really like that. Thank you for sharing that. [Manrina]I feel like I should like record and press play because I have so many like me record, [Jaz]You know, it’s patient communication. That’s the crux of it. So you know, you said to the patient that you know, I want you to be paranoid like I am. I really like that. So tell me about let’s talk about some Patient Management. Moving away from the tooth slightly might come back to it but patients who come and ask for veneers, okay, they can be character sometimes. Let’s call it, right? Some of them may even have body dysmorphia, which is a real problem nowadays. Do you ever encounter difficult characters? The kind that, you know, the expectations are so high that it’s not even real, like no matter what job you do, what they’re after is is just never gonna happen. And it’s difficult to make it tangible, because every case is different. But do you see what I mean? I mean, some people call them crazies, or whatever. But there is a group of people that, you know, I would get nervous to treat. So do you get patients like that? Not because you don’t feel that you have the right skills because obviously, you place so many units, but it’s just that their expectations are just something else. [Manrina]Yeah, so you know, again, I talk about this on my course, I don’t have that issue very often. And I think it’s because I’ve been in high end, cosmetic dental treatments, my whole career. You know, that’s all I’ve known since I graduated. So at [London] where started, it was known for being the most expensive clinic in the country. And the reason that people came to us were because we were the most expensive, and they showed off about it over dinner. And so that in itself attracts a certain type of patient that’s looking for the most expensive clinic. And so I started off with that type of patient, right? the really demanding patients us really, really need everything to be perfect. And so there’s a lot of things that I put in place throughout the smile makeover process, to make sure that I don’t end up with an unhappy patient. The first thing is that at the initial consultation, we use Photoshop, and I’ll put the patient’s face up and on Photoshop, I’ll start showing them what the smile that we’re designing will look like, if they’ve got, say, a mid line . And I’ll show you some examples of closing doen the diastema, leaving the diastema. But because we’re using Photoshop, and not just using a perfect smile stuck on to the patient’s face, it’s showing them what actually realistically achievable for them. I do a lot of gum surgery [Jaz]Do to teach that on your course? To how to manipulate images on Photoshop? [Manrina]Yeah, so there’s a really small part of the introduction to it. But actually, [Tim Locksmith] who owns the clinic, where I work now is planning on doing a full course about that. So he’s just in the process of setting that up. So it’s like an introduction [Jaz]You do this, Manrina? You do this yourself, like on Photoshop, you’re doing the Photoshop. [Manrina]For my patients, and it takes a while to learn it, which is why I can’t teach the full, basic version of it on my course. But then say go on a four day course if you want to learn about it properly. And do the same thing with photography, I show a really basic version, but do recommend that you go into a four day course to learn about [Jaz]I like the idea of manipulating the patient’s own teeth, rather than putting on the teeth. So what you said there I really like, okay, so you’re manipulating on Photoshop. So that’s one part of communication, what else would you do? [Manrina]But also within that, quite often, I would say, more than half at least half of my patients, I moved their gums as well. So I do my own gum surgery. And so the photoshops really useful for that, because they’ll be like, Oh, no, my gums are fine. But then once you start moving things, they can see that for symmetry, they’re not fine. And then even though that seems like an added expense, and a procedure, they don’t necessarily want they see that, that visual benefit of it. And so that’s why they’re often they’ll go for the gum surgery, and they’ll see how short their teeth are compared to the length they should be. So they also become aware of how much damage they’ve done. And then they’re more likely to take their grinding habit more seriously. Because usually at that stage, they’re not even aware of their grinding habit. So the first stage is convincing them that they’ve even got it. So yeah, first things like Photoshop, and then we do the wax up. And then obviously, I showed them the wax up, and they put it in their mouth. And then after the prep appointment, they’ve got their temporaries on, and then I do a review appointment two days later. And so at that stage, we look at the temporaries. And we talk about the color and we talk about shape. And if they don’t walk in that room and say to me, “Oh, Manrina I love them,” Then we’re not leaving that appointment, or we’re not leaving that stage. Until that’s their reaction to their temporaries. So, I mean, most of the time we achieve that in that one appointment. But if we don’t, I’m happy to leave them in temporaries for a month, and just keep seeing them every few days, until we have something that they’re like, ‘Oh, these were amazing. And this is exactly what I want.’ So I think that [Jaz]So what kind would you have to do in typical case to get them happy? Would you have to completely put a new set of the temporaries that are different shape usually or color or what? [Manrina]Yeah, so no, we never, I can’t remember the last time I changed the temporaries completely, but you change them yourself. So I take flowable composite, and I can make them shorter. Or I’ll take a soft flex desk and I’ll make them so some like even shorter, flowable composite make them longer. If they feel they feel too wide, I’ll change the line angles. Sometimes myself, I want to change the, you know, we have this whole conversation about midlines the human eye will see the midline can be up to four millimeters to either side and the human eye won’t see it. So you know at that initial consultation, we go through mid lines and I’ll say to them, you know your midline is not quite in the middle. But if I want to move it for you, I will have to prep the teeth more. So it’s less than four millimeters. Should we accept it where it is. And you know there’ll be like “Yeah, that’s fine.” But then once everything else is perfect, maybe it’s not fine. And so that gives them an opportunity as well at that stage to look at that. The other thing I do is I make and you may have seen this video on my Instagram recently, when I when I was showing showing you a patient I did this with the lab will make both the laterals asymmetrical. So something that I’ll often do in my smile makeover visits, you know, the centrals need to be very symmetrical, I want everything to be very symmetrical. But if you wanted to add some asymmetry, so that it wasn’t too perfect to smile, then I would add it within the lateral. So anyway, in the wax up, we make the lateral tooth different shapes. And then at this conversation, we say, “Okay, Which one do you like better?” And sometimes they’ll say, “Oh, I really like that they different, or they’ll say, Oh, I like the round one. I like the square one.” Sometimes it can feel too square and then we’ll open up embrasures and they can feel too wide, and then we’ll change line angles to make them look more narrow, you know, they can feel too long, they can feel too short. They can feel too white. And then I’ll put a glaze on to darken them. [Jaz]There’s so much you could do using their own temporaries. [Manrina]Oh, yeah. And I don’t have them saying they want them whiter, because I always put them on the same or whiter than I think they would want. So if anything, they’ll go darker. So I don’t have that problem. Because that’s how it [Jaz]What’s your record for the longest time you’ve kept something temporary is because there’s so many modifications. [Manrina]It wasn’t modifications, but one guy just disappeared for six months. He loved this temp so much. And we kept calling him saying come into your finals, come in for your finals. He was like, No, I’m fine. I’m good. If you don’t understand. My face is not there. And so they don’t typically want to come. [Jaz]So this guy’s temporary survived the whole six months? [Manrina]Yeah. And they can, you know [Jaz]Well done. So. today, I put my Instagram story today, right? I asked everyone. Have you got any questions for Manrina? So one of the questions I got was tell us about multi unit veneer temporarisation. So can you tell us about how you make temporaries? [Manrina]Yeah, of course, yeah. So we use that stent that we talked about earlier. So the lab, it’s a lab made, copy of the wax up. And so when you’re ready for your temps, I spot etch the teeth that you want to temporized, so just a little drop of etch, and then a little drop of bond and cure that and then you take the stent, and you fill that up as a single unit with the Protemp, Luxatemp whichever one you’ve decided to use. And then you pop that in the mouth. And you also squeeze a little bit on your gloves, and you can check when it’s set. And then my stent is typically two layers, so like almost like a special tray with a stent inside. So then I’ll take off the special tray and have a look how it’s looking. And then peel off the stent for the temporaries are left in the mouth. And then remove all the access and cleanup. And then I use a mosquito Bur, which I have a number for that hair as well. 582 mosquitoes in Dental Directory or Komet, maybe? I have to give you a list of these. And as I go through and clean up interproximally. So even though they’re all stuck together, they look like separate units. [Jaz]Brilliant. So they’re linked together and you’re using the shrink fit then right there. You’re not using any, they shrink fit. Cool. And it’s been [Manrina]I spot etch-bond on every tooth. [Jaz]Yep. And then the bis-acryl just wrapped over. [Manrina]Yeah, you don’t want, you want them to be stuck to every tooth. So even if something was to break, they would still stay on the individual teeth. But you don’t want them to be so well stuck. You can’t flick them off when it comes to removing them. And because the temporary material so sort of stiff. It doesn’t, It’s all sort of stuck together and stay solid in there anyway. So it’s not easy to take off anyway, when it comes to taking off. [Jaz]Perfect. That’s answered your question, Jamie. I think you asked that today. So thanks so much for answering that. So I want to now ask you about your bonding protocol. So now your veneers are there, the patient’s approved the temporaries, tell us about your bonding protocol. Rubber dam? No rubber dam? Which cement? Are using heated composite? Are you using Panavia? I mean, there’s so many ways to do it. What is your usual protocol? [Manrina]Okay, so I used to use rubber dam and I use to used to split down. But I like to see the whole face when I’m bonding to see what’s going on and see how these teeth look because I always tell my patients that 9 out of 10 times I will fit this case at fit appointment, but 1 out of 10 times I won’t and if I go to fit and something doesn’t look perfect to me, I’m not going to fit it. So I’ll just put their temporaries back on and I’ll send them back in and get them changed so I kind of need to see the face, the position of the nose and the eyes and everything else what I’m bonding. So I moved from rubber dam to using an OptraGate. So I use an OptraGate just to keep the lips out of the way. I had like really nice suction for my nurse, keep things dry or I put some gauze on the tongue just in case I dropped any veneers so it doesn’t go down the throat. And then so first of all, we removed the temps and then I take my veneers, they’ve already on the model so they’re already set up, I know which tooth is going to go where in the mouth. And my nurse does the same thing on her side, she draws a chart so she can put the relevant veneer on the relevant tooth. Because I’ve had problems in the past where the nurse gives you or you know, you asked for the wrong veneer, you asked for the upper left tooth, you meant for the upper right tooth or the nurse gives you the wrong veneer and then you go to stick it out, it’s a mess. And you really because you’re sticking 10 veneers on at the same time, you really need the process to be smooth and easy. So I take the OptraGate, gauze, take the tooth off model, dip it in water, so the water gives me, gives it a little bit of sort of sticking power to the tooth. [Jaz] I was gonna ask you that how you do that. So yeah, you do it with water. Cool. [Manrina] with water, yeah, and try in paste if need be. But first of all do with water and see. And then and then I placed the mold in the mouth and check that I look at everything in check if I’m happy with it. If I’m not, if I feel like ‘Oh, they look a bit wide or a bit dark or something compared to the lowers’ So you’re not renewing all the teeth, or say you’re just doing for and you want to match it to the other teeth. And then I use a try in paste. So it’s from from Ivoclar. And it’s called Variolink, the kit that I use. And so they have all these try ins, they have white and opaque, I normally go for translucent. Because most of you don’t have to make a change. But sometimes you’ll use bleach, I think, and then you also have yellow and you have brown. So there’s lots of different shades that you can use. And I’ll pop the trials in. And usually at that stage, I’ll show the patient as well. And be like, “Okay, this is what I decided, this is what they look like.” And they’ll be like, “Oh my god, amazing. Like, yeah, let’s do this great.” Then I take off each veneer one at a time, as I take them off, I wash off, Iwash them. So wash and dry with my three in one, the nurse holds a plastic cup for me to wash and dry them with. And then she goes and puts them on their relevant chart. So as I give them to her, I say upper left one. And then whatever I say she has to repeat. And that’s always awkward for new nurses that come to work with me because they said, you know, it feels so extra. But it’s [Jaz]Like it’s a system, it’s a system. [Manrina]Yeah I got all these little systems in place, just because of as a problem has occurred in my career over the years, I put a system in place to make sure that never happens again. So there’s lots of them. But that’s and that’s one of them, that we always do. So I say and then she repeats and same thing when she passes to me. She has them all. And then on her end, she etches them. And then she places monobond, which is the silane. And then she and then I use an OptiBond™ FL as my bonding. And so she places OptiBond™ FL bonds like the OptiBond™ FL 2 on the veneers, on the fit surface. And then she covers them over so that that doesn’t set. And in the meantime in the mouth, I etc all the dentine and enamel, I just do it as one big block. And then I go through and then I wash all my etch off. And then I have a little dappen dish full of primer, and they still OptiBond™ FL number one, and then I soak each tooth in primer, I just keep soaking it and watching the tooth absorb all the liquid. And then just keep going. And then once I’ve done all that, then sometimes I’ll take if, I feel like there’s still excess around like it’s soak and I put some more on. And now it’s not soaking it up anymore. Then I’ll take the large suction and just suction around the any excess. And then I do the same thing with one. So I have a dappen dish then I go and I soak it, which is the bond, and then I’ll take the suction, just make sure it’s a nice thin layer. And then whichever order I tried the veneer on in, I cement in that same order. So again, that’s another little veneer hack that you can get caught out. If you don’t do it in the same order, then that may be the only order they fit. So if you change your order, they may or may not sit next to each other as nicely or be really difficult. And you don’t want that stress when you’re about to cement. So in that same order upper right one, typically it’s upper right one, upper left one, upper right two, upper left two, and so on and so forth. I take the veneer, I could take my Variolink, and normally it’s trans. For just a veneer. I’ll use a trans just base and for something bigger, an inlay, onlay, a veneer onlay, I’ll use base plus catalyst. So it’s got a drill formula the Variolink, squeeze that onto the fit surface and then put it on the tooth. And as I placed it on the tooth, I want to see cement squeezed out. And again, the amount of cement you put is really important, because you want to put enough that you see it squeeze out. You don’t want to put so much that it’s fixed squeeze on because these veneers are very thin, and you don’t want to risk breaking them. You don’t want to put, you don’t want to use force when you’re placing them [Jaz]Has that ever happened to you as you’re placing it and it’s like, broken [Manrina]Oh yeah, of course that’s [Jaz]Exactly. And hence why the systems and hence why we [Manrina]Of course it’d be ridiculous to think that everything is in place because of things that have gone wrong over the years initially. And that’s what I think young dentist or dentist starting out need to know that Yeah, it’s scary. And definitely don’t do this sort of treatment without having some sort of education behind it, even when you do. I mean, I was really fortunate when I was learning because I was taught, it was like university, I would prep my case and then Surinder would check it before we take the impression then I would take the impression and then Surinder would check it before I could send to do the temp, you know, so every stage was checked. And that’s what how until I was good enough, didn’t need to check anymore. And so I understand that not everyone has that, a little things will go wrong along the way, or the impression won’t be good enough. So you know, nowadays, I’ll take one impression before I always took two. So there was something a margin or something there that lab can’t see. And it’s so many units, at least they’ve got two impressions to that they can look up. Anyway, back to cementing. And then you place all the veneers on, make sure that they’re all nicely seated, and then I clean up. So I take a brush and I clean up all the excess. And then I want to floss. And sometimes what mostly I’ll feel nervous about flossing without some sort of cure. So this is a dangerous part. And your nurse needs to be very good. And so again, I’m very strict with this, that I hold, I thought on one side, I hold the veneer in place. I hold it in place with maybe like a scalar or I use something to hold it. And then I’ll use my finger to cover the tooth next door. And then I’ll tell them to spot cure, so if you have a spot cure light that’s fine. Anyway, regardless, whatever light cure you’re using, she goes on to the gingival margin. And she goes one two, and moves away. And that’s how she has to do it. She moves in and she says out loud, one, two, and then she physically moves away so that I can see what’s going on. And I do the same thing, place the next one, make sure it’s perfect. And then she and then so then they’re cured. But they’re only cured for like a second or so. And so and then I can floss. So then I go through and I floss them all [Jaz]So only once you tack cure them all then you start flossing? And are you still quite gentle as you’re flossing. [Manrina]Vvery gentle because it’s still soft. There’s cement you needed to be stopping you need to be gentle. Now you also need perfect oral hygiene because you cannot cement a blood and again, I’ve done this in the past, even if they look good, but there’s a little bit of blood, blood’s going on to the veneer and then they’ve got a black veneer because that blood stays there and it stains. So now my patients I will not touch them until their oral hygiene is perfect. And they know that, they have to keep seeing the hygienist. They have to change the way they clean at home. They have to be flossing. They have to be brushing twice a day with electric toothbrush. And then yeah, [Jaz]That’s so foundational but I’m so glad you said it because you know you have such a beautiful Instagram profile you have so many great cases but we don’t appreciate that what you’re doing, you’ve got the foundation set first from good mentorship. [Manrina] Everything’s set. [Jaz] The really good gingival health which is so imperative to bonding veneers I’m so glad you mentioned that it’s all about the glitz and glam at the end. It’s about having proper dentistry with good respecting the biology. And so I’m really pleased you mentioned that. [Manrina]Well there’s this other Instagram veneers guy that’s got like, I don’t know, 250,000 followers, and one of his patients came to see me and she was like, Oh, you know, he’s flying into London, and he worked between LA and London. And I’m having my veneers done with him tomorrow. And he’s charging me like 50 grand and I suddenly panicked and someone told me that I should be seeing you and say Can you have a look at my teeth? And I hadn’t looked at she had raging gingivitis. And because he hadn’t done a consultation at all, she just messaged saying she wanted to have veneers, he said he’s flying in on this day, I’ll do them for you. I don’t know how he was planning on doing them with her bleeding gums, but [Jaz]I’m glad you’re advocating the correct way. So you’re now flossed [Manrina]For me, it makes my life easy, the less I prep, the less sensitivity they’re gonna have, the less likely they’re going to need a root canal. The less problems I have. My biggest practice builder is referrals, right? Every patient that comes to me, I want them to replace themselves with another patient. And the only way I’m going to do that is if they love my work, they enjoy coming to see me and they don’t have any problems. So that’s the way my practice has had to evolve to beat you. I’ve been doing this for so many years, and my patients be coming back to me 10 years later when it was time 15 years later to replace their veneers and coming finding me to do it. It’s because you know you have you practice like that. [Jaz]So just to finish off the bonding protocol, you’re now gently floss, you now pick up your light cure to [Manrina]Clean up. My nurses light curing so at least 40 seconds on each tooth individually. But then the other probably end up getting 60 I know some dentists doing it at the margins too. I don’t. I did learn with Pascal Magne and probably did it for a while and then stopped. And so I don’t put Listerine but they do get a really good cure. And then once they’ve all been cured, I take a polishing bur and that is 856EF.314.012 and I remove all the excess composite at the margin that’s really really important to do that while they’re numb because you don’t want any cement there because that will cause gingival inflammation. If you get recession and that’s a disaster. And then I take it, I’ll floss. And if there is a little bit of cement stuck there, then I’ll take a serrated strip, clean in between the teeth, then I’ll take a yellow metal strip and still clean in between the teeth. And so I need, and then I take a yellow rugby ball, and I clean the back the margin between the porcelain and the tooth, removing cement beds. So [Jaz]How many hours would have typical fit of, let’s say, eight units, for example, take you? [Manrina]So I will book two hours, but it will take an hour. And the reason I always work longer is because I want my patients to feel like they have a lot of time. Like if they want to stop and they want to talk and or they want to, you know, wherever they want to do will do. And I don’t want them to ever feel like I’m rushing to see another patient. So yeah. [Jaz]Brilliant. So now you’ve [Manrina] Then we’ve take the occlusion? [Jaz] Yes. Perfect. [Manrina]Yeah, check occlusion, check everything looks good. I warn them before they come that their lips going to be swollen, so they won’t be able to tell what they look like. And I say don’t even worry about it. Go ahead and go home, go relax, book a review appointment which always booked two days later. And they come in. And that’s when we look at them. And then if we want to, we can make some small changes with shape if I want to make them look more round or more square. But to be fair, 95% of the time, there’s no change, because we’ve already done all that in the temporaries. So if there are they’re minor changes, and we make them [Jaz]Has it ever happened to you? Because that is something that I speak to dentists and a lot of dentist are going to describe this scenario is, you do some veneers I mean, I think it probably doesn’t happen to you because your temporarization process sounds really good. But they do some venners, and then they go back to their partner or husband or family. And then someone makes a comment. And they come back and they’re upset that oh, this person didn’t like them or someone said this and then they’re suddenly debating Have I made the wrong decision? Is that, have you encountered that scenario? Did they come for you for advice like that? Has that happen to you? [Manrina]Yeah. So some of my patients, I would say all my patients say, I wish I’d done this sooner. So they all love it in the end. But definitely, they can come back at the temporary stage and have opinions and I asked them to ask for opinions. I was like, you’ve got two days between your prep appointment and your annual review appointment. So go and ask opinions, make sure you show your husband or wife, show your friends and come back to me. And then whatever comments they come back with, we manage them. So it’s all managed at the temporary stage. So by the time you get to fit they love them. And even at the temporary stage, we don’t leave that until they love them. I know you said before, how long have I gone through the temporary stage, which is modifications, I think I told you about the six months ago and that wasn’t one of the modifications he just didn’t want to come back. I wouldn’t leave them in temps intentionally for longer than a month. And actually 95% the time, it the modifications are made and they’re happy within that review appointment. And it’s rare that I need to get them back. But there certainly has been cases where I got them back. But I wouldn’t leave them for longer than a month. But within a month we have to get there. [Jaz]Other temporaries like a tepe-able, Is that what you advocate them to like religiously tepe them? [Manrina]Yes, they have to clean it and then gingival health has to be optimal for the fit appointment. Because I can’t have any bleeding. So I give them tepes, pink tepes and Corsodyl gel. And so they they need to brush twice a day with their electric toothbrush, then they rinse with peroxyl. I get them to rinse peroxyl and then I get them to dip their tepe brushes in Corsodyl gel. And then I use my little mosquito bur. I think I gave you the code for earlier, 582 and you go and make sure there’s these, Oh I got these codes, I love that. I’ve just got these handy. [Jaz] Cheat Sheet. [Manrina] And then yeah, open up and make sure that it’s not a visible hole. But to make sure they can get in there. Put the gel in and leave it there. So they don’t rinse it off. And they do that twice a day. So yeah, the gums are beautiful when they come in for fit in [Jaz]Beautiful. So now I’ve got my final three questions, because we’ll have to wrap up, we could speak forever about this. So these final three questions. So they are and I’ll list them together and you can answer them. One is when does a veneer become a crown for you? So when do you think actually now I’m not gonna veneer this I’m gonna go for traditional retention resistance form. So when does the veneer become a crown? The next question I will ask you then after that will be just your final tips for success to young dentists. And the last one, you know, please tell us about you know, I think you’re obviously doing some veneer courses. Tell us about what that involves and what dates because I think this episode will probably be coming out in late Feb. I think so tell us about what dates are available. So those three questions when is a veneer a crown, tips for young dentists and tell us about your course. Sounds like [Manrina]So, first of all, I don’t crown very often at all. And also I don’t differentiate between veneers, three quarter veneers and crowns, price wise, I tell my patients that I’m going to prep however I need to prep whatever I need to remove to get the best result for you. The only thing reasons I would crown is maybe I’ve got a patient recently that came into over two actually last week that had really a lot of labial wear from Bolivia. Besides, I mean, think they were both bilinear as a child as children. And even for those cases, I would rather put composite veneers on the palatal. And then porcelain veneers on the labial. Just with the, you know, there’s a quite normally, there’s a grinding habit there as well. I don’t want them grinding on porcelain. And so it’s still nice to do two veneers. But yeah, you could do sometimes you need to do a three quarter, or you may just do a full coverage. And then it’s a crown. So yeah, veneer crown. No, I don’t like to differentiate, it’s just wherever it is the minimum amount of tooth tissue that needs to be removed, to get the result of [Jaz] to get the job done. [Manrina] Get the job done. And then for dentist wanting it. My advice to young dentists is learning. And I think I talk about this a lot on my Instagram page. I spent a lot of money on my education, all through my career even now even you know in 2019. And people always like question the amount that I spent saying, wow, you spend so much on your education, I was flying around the world and getting my education and you don’t need to do that anymore, but you did back then. Because there’s really good UK courses now. And don’t be scared of that. Like if you want, if you’re interested in something and you want to learn about it, then learn about it properly, go on a course and learn about it. And don’t be scared about the expense of it. Because you will only earn more from what you’ve learned. [Jaz] 100% [Manrina] And so yeah, I always say to dentists, so they don’t get bored and so they’re building off what they could do, you know, keep going on a simple ortho course then about that, put that into practice, you know, go on and whitening course learn about that. Definitely go on an occlusion course. If you’re interested in smile design, they come on a smile design course. And that leads on to question number three. Well, there are smile design courses in the UK. And they maybe there wasn’t one that everyone was knew about. Oh, there wasn’t I don’t know, maybe there wasn’t the best one. I think, yeah, probably all good ones. I did my studies in America, I did the aesthetic advantage in New York over three years with Larry Rosenthal and APA. And you know, I had to fly to New York, and it cost me 7000 pounds to do each level. It’s $7,000. And I did it. I get to fly my patient out there. And it was amazing. And that was great. But [Jaz]Cool. So you flew your patient, your patient flew with a sat next to you on the airplane? [Manrina]No. I think Yeah, yeah. Because we go for lectures as well. And then they can’t we do the preps, they fly back. And it was the same thing. Two weeks later, they come and they fly again. So I’m very much. I’m not emulating that for what my course what I’m doing here. But I’m offering a similar service here because it really wasn’t something like that. And that education is what I needed. And that’s what kick started my career for me. And I’m offering that same thing. There were far too many dentists that are trying to do these cases and don’t know how to do them. So they were failing. And then their patients are coming to see me and I’m having to redo it. And there are too many dentists prepping crowns rather than veneers, you know, my friends are doing it when I talk to them, because they’re scared that veneers will fall off. So I don’t want people to do that anymore. So I’m offering a course that gives you a really nice outline. And the people on my course this time, you have had a range of skills, and someone who’s only been graduated two years. Certainly when I went into the course it started the course in New York, I’d only been graduated two years to another guy who’s been graduated 20 years and done a restorative MSC, but really not done any smile makeovers. So it’s one thing to do an MSc and another thing to actually learn about how it works in practice with something that I’ve been doing every day for the last 18 years because you know even now, I work in a cosmetic practice all we do is cosmetic work. We don’t do general dentistry. So this is my everyday job. And there’s a lot of lot of tips and tricks that I can give you about how to make this predictable make it minimally invasive make it you don’t have any problems and go through the things that weren’t wrong me and make sure they don’t go wrong for you and also support you then moving forward because I had a lot of support and you need that. So at least a major support network they’re moving forward. So we have the course states that are running now but the next ones are in June [Jaz]I’ll just put the dates and the link on the blog post [Manrina]Yeah. Come down. [Jaz]You owe me some website, you owe me some dates. Yeah, and you owe me some bur codes. [Manrina]Yes. I will send them all. [Jaz]Where is it? It’s a central London [Manrina]Yes it’s being held at the clinic by work the London smile clinic, it’s Rovio. So really easy to get to. I can give you hotel details for people who are flying in, this time we had someone flying from Sweden, someone flying from Dubai and then obviously the number from the UK Yeah, and [Jaz]Flying the flag for UK dentist and flying the flag for women dentist. So that’s just really good. And that’s it like you said the beginning right. And my wife was happy that I’m bringing a very successful and very good woman dentist. So you know, I echo all the people’s thoughts and views that have been reaching out to you with positivity and I think that’s exactly with you know, on behalf of me and my listeners. I wish you all the best within, I wish all the women in dentistry the best but I’m just so pleased that I had you on as a role model for the women in dentistry. And the three really nice stories I got from this episode from you as your the role of mentorship that was, yeah, your career and I was always banging on about. I’m always banging on about that mentorship, how you’ve invested so much time and money to spend time in the dirt. What I mean by that is you actually work your socks off courses. [Manrina]Yeah. There’s no space for ego. You can’t. Yeah, [Jaz]Absolutely. And then just now your attitude to give back through all the posts that you put on Instagram and also now the course is running. So you’ve been a brilliant guest to interview, Manrina. Thank you so much for coming on the show. [Manrina]Thank you for inviting me.

In this episode I am joined by Restorative Specialist, Dr Kushal Gadhia who is one of the educators for ACE Courses. He is one of the most passionate people about Occlusion I have met, so it was great to geek out with him. Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Have you located your local physiotherapist who has an interest in treating Temporomandibular Disorders? You can find them on the following website: ACPTMD You can download the latest Glossary of Prosthodontic Terms from Protrusive Dental Community Facebook group alongside hundreds of other papers and downloadable resources. What we discuss in this episode: We discuss our reason and love for continual study in the field of occlusion Definition of Centric Relation (CR) (applicable one!) and why we have to rely on teeth as references Why is the ‘reproducibility’ of CR useful? When should you NOT use CR as the position to rehabilitate? 2 Good examples given (a 3rd one I suggest at the end) In those situations you use an arbritary treatment position, how can you ensure success? We briefly discuss about Orthdodontics and the controversy of whether Orthodontists should be planning from CR What happens to patients rehabilitated in CR position over time If you restore someone in CR – can you stop their Bruxism? There may also be an anatomical reason not to use CR which we discuss at the end Remember – most of our Dentistry is Conformative and in ICP/MIP – Become a GOOD conformer first! Handouts:Glossary of Prosthodontic Terms 9th Edition Loads more episodes to come out this month to make up for February – we had the first successful ‘THE Dental Splint Course’ hosted at Precision Dental Studio in Reading. View this post on Instagram If You’re Not in Centric Relation, You will Die! 😉 Protrusive Dental Pearl – how to find your local ‘TMD’ Specialist Physiotherapist: http://www.acptmd.co.uk/find-your-nearest-tmd-specialist/ What we discuss in this episode: – We discuss our reason and love for continual study in the field of Occlusion – Definition of Centric Relation (CR) (applicable one!) and why we have to rely on teeth as references – Why is the ‘reproducibility’ of CR useful? – When should you NOT use CR as the position to rehabilitate? 2 Good examples given (a 3rd one I suggest at the end) – In those situations you use an arbritary treatment position, how can you ensure success? – We briefly discuss about Orthdodontics and the controversy of whether Orthodontists should be planning from CR – What happens to patients rehabilitated in CR position over time – If you restore someone in CR – can you stop their Bruxism? – There may also be an anatomical reason not to use CR which we discuss at the end – Remember – most of our Dentistry is Conformative and in ICP/MIP – Become a GOOD conformer first! Listen on your favourite Podcast Player. Direct Download MP3 file on the blog: https://jaz.dental/centricrelation Handouts: Glossary of Prosthodontic Terms 9th Edition Link to group: https://www.facebook.com/groups/protrusive Subscribe on Apple: http://jaz.dental/apple Subscribe on Spotify: http://jaz.dental/spotify Thanks again to Dr Kushal Gadhia for sharing his knowledge with us all. A post shared by Jaz Gulati 🦷Dentist 🎤Podcaster (@jazzygulati) on Mar 10, 2020 at 10:46am PDT Click below for full episode transcript:  Opening Snippet: Evidence tells us that centric relation is a dynamic position. We are not buildings which will then remain in those fixed positions... Jaz’s Introduction: Hello everyone, it’s Jaz Gulati again, welcome to Episode 20 got a really fun episode with Kushal Gadhia. Guys, It’s been a long time coming from this episode, but I do apologize. February was super busy. I was basically so busy setting up and finalizing my splintcourse that we delivered precision in studio in February. And thankfully it went really well. So that’s like a big, big sort of thing of my list I had to do and it was great fun doing it and I’m so happy and how it went. But now I can get back to focusing on some podcasting. I actually got so many episodes recorded with great guests, including today, Kushal Gadhia. I hope you like the title, bit tongue in cheek obviously. We’ve got so many more guests. In fact, I’m actually in a hotel. I’m in a Premier Inn right now in Cheshire and part of the Dawson Academy. And today I’ll be interviewing Dr. Hameet Grewal on rubberdam. So probably in about five or six episodes time it will be Harmeet, that’s why I’m recording from at the moment. So for those of you that Remember, this is gonna be the first episode that’s going to be offering enhanced CPD. So now you can actually get CPD for listening to Protrusive Dental podcasts. So the way you do it is I’ll post up a link in the next week or so and you can then visit Dentinal Tubules. So you have to be Dentinal Tubules member to get the enhanced CPD, answer few questions echnology aims and objectives and you will get your enhanced CPD now and from this episode onwards, we’ll try and do that for every episode so you can now get enhanced CPD. Protrusive Dental Pearl I have for you today is basically to find your nearest TMD based physiotherapist. The way you do that is I’m going to go to a website and I’m obviously put this in the show notes and actually on that note, the Facebook group, the Protrusive Dental community Facebook group has really taken off. I’ve got people like Richard McIndoe and Zak Kara on there who are making amazing so we custom screens on there that are really helpful. I’ve got other people sharing papers to someone asked question there will sort of help each other out. It’s basically not a replacement for you know, your usual big Facebook groups, but it’s a way for me to connect to my listeners and share my files and stuff as I promise you so this website I’m about to recommend, I’m going to be sharing on the group also on the website, jaz.dental, and basically it is the Association of Chartered Physiotherapists in Temporomandibular Disorder. So it’s basically ACP TMD. And the website is acptmd.co.uk, you go on there and you sort of look you’ll find your local chartered physiotherapist in TMD. And this is amazing guys is so important to have that sort of referral pathway. Physio is really underutilized from dentists as referrals. It’s incredibly helpful with people suffering from anything within the realm of TMD. And anyone who you know has an in depth discussion, we know how much I don’t actually like that term TMD. It’s a very broad term, but hey, let’s go with it. So my advice is find your local TMD physiotherapists do what I did and buy them out for coffee, have lunch with them and just learn about the type of treatments they offer. And so many my patients have had benefit from meeting the local physiotherapist I refer to now and it’s great for your learning and your patients ultimately, really benefit so that’s my Protrusive Dental pearl. We’re gonna just cuz I’m gonna get stuck in with the episode. So got Kushal Gadhia now. I hope you like it, and I’ll see the outro. Enjoy. Main Interview: [Jaz]Kushal, we’re gonna dry dive right in and welcome to the Protrusive Dental podcast, Kush. Thank you so much for coming on. [Kushal]My pleasure, Jaz. Thanks for inviting me. [Jaz]And we’re going to talk about something really cool. But before we come on to that, and I do a crappy introduction of you, as I do for my guests nowadays, so Kush for to me, You are such a giving dentist, you’re obviously a restorative specialist, I believe in the specialist register for all the specialties, correct me if I’m wrong? [Kushal]For perio, endo, prostho and restorative? Yes. [Jaz]Yep. And what you know, I learned about you through Tubules you know, your two fellow tubulite as well, you probably run one of the most successful dentinal tubule study clubs in the world, let’s say, because I believe you’re one in, is it North London, or? [Kushal]That’s right Northland and Stanmore. [Jaz]You guys have like, you know, waiting lists here to turn people away every time. So I mean, that just speaks volumes about you and the environment that you’ve created your practice. And obviously, with the ACE courses, which I’ve been I’m part of the alumni what you guys have set up there is just phenomenal. So you are someone who is a massive inspiration to me and all dentists. So what would you like to add to that description? Please tell everyone where you work. [Kushal]I’m just a dentist. I have a passion for dentistry. I’ve had this since I was an undergraduate. So I’m nothing exceptional, but constantly striving to do the best I can. I work part time in hospital and part time in practice, referral practices. So that’s how I split my week and a couple of days teaching every month. So that’s me in a nutshell. [Jaz]Awesome. And are you allowed to say in public whether you prefer practice more or hospital more? [Kushal]I prefer both of them. Because one keeps me real, which is the practice setting, you know, time is money. And practice allows you to make sure your treatment plans are not lengthy as sometimes they can be in hospital. But on the flip side, the satisfaction of working in a hospital setting, treating some very complex cases, not as much oncology I do now, but from cleft cases, to trauma to hypodontia, to [ ? ], any congenital deformities, and to see these patients from a very young age, sometimes going all the way into adulthood and appreciating not just dental outcomes, but life in general, that keeps me real in that sense. So for me, having trained in an NHS background, giving back to the NHS, seeing those patients, treating those complex cases, and feeling that love from that is, you know, you won’t compromise any day for any value of money. [Jaz]That’s amazing. That’s really good. No, no, it’s great that you have your sort of foot in each, you know, practice and hospital. And I think it makes you a great clinician you are and that you know, you have so much to offer. So one of the favorite things that we mean, you love discussing about I learned about how passionate you are about occlusion when I came on the three day ACE courses, which was phenomenal, by the way, if anyone’s thinking of doing it, and I want to speak to you on the podcast about the very funny title that we came up with was, which is if you’re not in centric relation, you will die. [Kushal]Yeah, I remember you sending me that. And I love the [inaudible] one on that. So I think these [Jaz]and it’s 100% true, right? It’s 100% true. If you’re not in CR, you will die. [Kushal]Yeah, well, it depends on the scenario. But not every case needs to be in centric. I think there’s this myth that every case has to be in centric. If you don’t, then everything you do will fail. There are cases when we don’t treat in centric, but I am sure we’ll discuss and elaborate of this. [Jaz]That’s exactly I want to touch on these points. So the mean, the first thing I want to say to you know, for the benefit of my listeners is as a young dentist, which obviously I’m still young, I suppose is when I qualify, newly qualified or when I was a student, I found getting my head around centric relation, very tricky. I really struggled with it. And now that I feel I know it to let you know to where I am my career now compared to where I was five years ago, let’s say. Now that I am much more confident with these definitions and the clinical application of it, I can now look back and think you know, I was really over complicating it. And I think that’s what everyone does. And I think part of the reason why everyone over complicates occlusion and definitions and centric relation is because the bloody definitions keep changing, and the terminologies keep changing. [Kushal]Definitions keep changing. We don’t get taught occlusion in the depth we should be taught as undergraduates. And sometimes it’s taught not in the easiest ways to understand and then we sort of carry that weight with us when we become dentists, and then come across people who may have different opinions of occlusion. And it’s such a interesting topic. But it has been not that well taught that it doesn’t become of that much significance. Yet, from a clinical point, it is the most important factor for me when I assess a treatment plan my patients, and I think it’s just keep it simple, keep it real, make it applicable, you know, we can go and talk about the science and the evolution of the whole concept of occlusion. But is that necessary? What matters to us is what matters to our patients. And if we assess them well, and we execute the plans well, what I call using the logical approach, then we will be able to provide very predictable dentistry. [Jaz]And the reason I mean you summarize it well, but the reason why I love occlusion so much, and I love studying it and I love applying it is because for me occlusion not only brings you predictability in what you’re doing, but it also makes dentistry so much more fun. You know, there’s nothing worse than single tooth dentistry, in my opinion. [Kushal]Yep. And then from single tooth to multiple teeth, the concepts of occlusion, the more you study, the more you will start seeing. You’ve been through the course and I keep sort of saying this, that to me, when I started developing passion for occlusion, the more I kept an eye for it, the more I’ve learned about occlusion, the more I’ve then gone and read about it, the more it sort of consolidated in my mind, and it is making it applicable, which is very, very important. There’s no point one person reading the theory and then knowing the whole book about it when they can’t translate that theory into clinical world. [Jaz]Which is exactly why not, you know, another reason why you know, as a newly qualified dentist, I struggle with it a lot, because it’s difficult at that stage to start learning so much and applying it and of course, going back to what I said earlier about the whole definitions, if you actually look at the glossary of prosthodontic terms, their previous editions and the newer editions and by the way, for listening to this, I’m gonna stick the latest link to the glossary of the Prosthodontic terms on this sort of blog page for this episode, so everyone can download it. But yeah, it’s funny the definitions of CR keep changing. And the other definitions for example, centric occlusion has also changed definitions over the last two, three sort of editions. But if we just started about with the following, which is what is the definition of centric relation that you teach, Kusahl? And you know, why do you like this definition? Isn’t it just because it’s the latest one the glossary? Or is this the one that you find is most applicable? [Kushal]I find this definition that I use most applicable. Before I tell you the definition of what I use. I want everyone who’s listening to this to understand that centric relation, by all the definitions, we have non looks at the position of the condyle within the glenoid fossa, yet clinically, we can’t visually see that position. So we use teeth as references, because that’s what we’re trying to see and trying to look at. So for me the definition that I’ve read and seen in Mike Weiss’ textbook, and the definition being it’s the relationship of the mandible to the maxilla, when our condyles are in its most superior position within the glenoid fossa, and when their anterior surfaces are against the posterior surfaces of the eminence. Now, I know there is variations to this, I’m fully aware of it. [Jaz]Yeah, I like what you just said there about, you know, it’s difficult to clinically verify. And that’s why I use teeth as references. I mean, one of my mentors, Michael Melkers, obviously, coming in May, and you’re you guys, ACE crews are also coming along to us, I’m really looking forward to being a massive sort of geeky convention of occlusion if you like, but one of the things that he told me was unless you get a scalpel and actually peel back the sort of and actually visually look at the condyle in the glenoid fossa, there’s no way of actually 100% knowing for sure, and the hence why the you know, the references of the teeth coming in comes into play. [Kushal]Absolutely. We as dentists use teeth as references, and therefore when we talk about and I’m jumping a little bit, but I’ll put this in context in that when we tell people every case needs to be restored in car or car is the most reproducible position we need to restore patients tooth. We are using teeth as references, we are not like Michael Melkers said and like I said earlier on, we don’t visually go and inspect the condyle by dissecting somebody’s mandible. And this then boils down to if you do choose to restore somebody to CR. You want those candles to be in a position that are reproducible, that are comfortable for the patient. And when you start doing the restorative work, you have to test and verify either initially using your splint therapies, your temporaries your wax up, your mock ups, whatever stages you take, but at the end of the day, we use teeth as references to ensure those condyles are in the position they should be. [Jaz]Absolutely. So first off, first thing someone would wonder is okay, so why do we need to use CR and then the whole thing about being reproducible I think every single person listening and every single person who’s you know, final year student at dental school can you know, if an exam paper comes up, why use centric relation? Everyone always write, it’s reproducible. It was never actually made tangible to me because the way I think about it is my own bite at the moment, my MIP, my maximum intercuspation is reproducible for me because I can reproduce it right? Because my muscles have memory. So to me, I was I never really got that. And what actually made me learn the definition and learn appreciate it better was actually when you appreciate what happens when you don’t use CR in a rehab. And that gives the scope for posterior interferences, ie if you’re an MRP, and you can slide back a few millimeters to you know, where your condyle in central relation, then you can be in for example, in bruxism, you could be doing a lot of damage on that sort of back movement, if you like. And to me that made it right, Oh, now I get it in the sense that if you have a reproducible position in all head postures, then people can only brux and function or parafunction ahead of that position. So that was what were you know, and I hope that made sense to everyone. I hope you can make it clearer as well. But that was to me when the penny dropped. [Kushal]Absolutely, it is both ways you and I assuming we both have full sets of teeth, we are able to go into a very reproducible intercuspal position and reasons behind this is we have this proprioception from periodontal ligaments cells, we’ve got muscles that are used to being in that position. But you and I don’t need rehabilitating. For patients who do need rehabilitating extreme examples being those with severe tooth wear, or the completely edentulous patients where there are no teeth to give you stable intercuspal positions or patients have worn their teeth away enough that they are habitually now beginning to posture the mandible in different directions without a stable intercuspal position then during your restorative phase of work, you have no reference points. And it is those type of cases where we start thinking we need to take patients to centric relation because it’s a reference point for me as a clinician or my technician to work to a point that everything we then construct is following the position of a mandible in such a way that things don’t change, smash or break. And then obviously the cases that do have teeth, which is me and you again, it won’t matter too much unless you go into the territory of para function. [Jaz]So Kush I think you summarized really well there about the cases when you would want to use centric relation point, ie in those rehabilitation cases. So most cases, day to day will be confirmative and not in centric relation. But can you think of any cases? And can you tell us about those cases where you specifically definitely want to avoid using centric relation for whatever reason? So which situations would you not use centric relation on purpose? [Kushal]That’s right. So the two big types of situations where I don’t use centric relation is from an incisal relationship position. For example, if you have a class two division one incisor patient, and you don’t take them into you’re not pursuing any orthodontic treatment on these patients, you taking them into centric relation and pushing them mandible backwards and upwards will only make the class two div one worse by doing so you’re losing more of the anterior guidance and relying on your posterior teeth for the lateral and protrusive movements. We all know that posterior teeth aren’t great for natural forces. So for dive one type occlusion not to be restored in centric relation. [Jaz]Fine. So class two division one large overjet. If you take them back into centric relation, it will actually effectively increase that overjet make them more class two. So this is a situation where Kushal saying that don’t rehabilitate that patient in CR so you for them, we would call it an arbitrary position, right? We’d call it as an arbitrary treatment position. [Kushal]Arbitrary treatment position. And you have to realize that if you take a class two div one into further class two div one, by increasing the overjet, you have you will not have you will have to use so much restorative material on the palatal surfaces of the upper or the incisal edges of the lower or combination of both. And yet, you will not be able to achieve anterior guidance when you create lots of overhangs. So for this class two div one time patients, of course, ideally, you want to do orthodontic treatment on them. But this is not always an option, both from an orthodontic point but also from a patient point, because there could be a skeletal discrepancy, and so on so forth. With this sort of cases where you’re making the overjet worse to what it is now, you would use an arbitrary position or habitual position that the patient is quite comfortable with, you have to also remember two things number one test, test test or you whatever you do allow time for you to test before you start jumping into bigger, indirect, irreversible procedures. But also think about the posterior teeth and incorporating long centrix movements in the mandible, which will be even on both surfaces, avoiding interferences on lateral excursions and protecting them from damage in the future. [Jaz]My only question now to make this tangible for everyone is okay, so we decided that for for most of the cases where we will be reorganizing, we’re going to use centric relation for the reasons that we mentioned. And also it forms like a reference point. But we’re in these cases of class two div one when we’re choosing not to use CR, we’re using an arbitrary treatment position where the mandible is a little bit further or the condyle is a bit further ahead, then how can we you know, make this reproducible for that patient? ie as a reference? It becomes very tricky to manage this in terms of communication with a lab. [Kushal]It does and then you’re then relying on what am I trying to restore? Is it for example, a tooth wear case where you’ve got worn incisal edges? Can we build these to protect the tooth structure? Think of it a patient who is in class two div one, how are they functioning? They clearly functioning because, they’re clearly eating and drinking and functioning as normal, except they have this slightly higher risk of posterior teeth being at risk of more breakages and having interferences and so on, so forth. So if we try and restore these patients, our primary objective is two things protect the tooth structure. And obviously secondary is to ensure that the aesthetic parameters are met. Functionality, aesthetics, and then it all goes down to the habitual adaptation of that patient. Now, for example, if I was doing a class two div one type case, I would choose my restorative materials to be of conservative nature. So I will use composite over ceramics as my first line of treatment, because I want to make sure if I do composites, I’m doing more additive work, as opposed to destructive or preparatory work. I’m not having to drill these down fit crowns, only to realize that in time, which could be in a short period of time for the patient smashing and breaking them. [Jaz]It’s like you said, yeah, it makes 100%. Like, it’s like you said, you know, he said test test test. These sorts of rehabilitations where you’re using an arbitrary treatment position, you want to ensure that patients come toward, you want to ensure that occlusion is working for that patient. So whereas you probably always want to put your patient in provisionals in a, in a bigger case, in this particular type of patient where you’re not using centric relation, it’s even you know, just as crucial to test test and test to make to make sure that it’s working for them. So that’s great and which is the other time that you perhaps would not use centric relation, I think you’re gonna mention another one. [Kushal]That’s right. So the second one is, which confuses everybody a lot, which is a large horizontal and small vertical slide when you go from your CRCP to ICP. Now with that, the key thing is as your mandible moves from your centric relation contact position, by definition being the first tooth contact position you make in your centric relation. That couldn’t be one tooth or multiple teeth. So going from that CRCP to ICP, the mandible moves in a certain direction usually tends to go a bit forward and a bit upward. The proportion of that forward and upward movement, the horizontal and vertical component could be either large, horizontal, small, vertical, or large, vertical and small horizontal. [Jaz]Would it be forward and down? Right? [Kushal]I think you’re talking about the condyle. I’m talking about the cusp tip fossa, [Jaz]Okay. Sure. [Kushal]..using teeth as references, so where you make your CRCP,` contact position, let’s say take a hypothetical situation, the cusp of the upper seven touching the lower seven, when that cusp blows and goes into from CRCP to ICP, because we use teeth as references the movement of the tooth, which involves a horizontal and vertical component, the condyle in itself also has a movement in it, where you have a large horizontal slide from CRCP to ICP, you want to try and avoid using centric relation as a reference point. [Jaz]Because obviously,the same issues that you know, you have the same issues as having you making someone more class two, again, you’re technically increasing the overjet. Again, right. So that’s the way to think about it. Essentially, you’re ending up in the same scenario with the class two division one patient to make them more class two, or a patient who has that very large horizontal slide, you’re technically making them more class two by the mandible going back such a back way, and you’re having the same restorative, tough challenges, right? [Kushal]When you go from CRCP to ICP in that slide, and you’re right, it’s where you’ve got a very large movement of that condyle, in a horizontal plane. This is very hard to visualize, or sort of hard to say, verbally without slides on the side. But I don’t want to confuse your audience too much. If we want to use somebody in centric relation as a reference, but going from centric relation to the ICP involves a large horizontal slide you will suddenly lose that reference point. So it is advisable in such cases not to use CR as a reference in these cases. [Jaz]An interesting thought imagine that patient now would large slide and imagine that they receive orthodontics, okay? And the orthodontics was planned in their normal starting malocclusion wherever it may be maybe some minor crowding whatever right?Now let’s say that during orthodontics this patient and this this may be happening all over the world all the time you know in orthodontics, now this patient undergoing orthodontics suddenly deprograms right? And now their mandible drops back and now they’re gonna appear more class two, they’re gonna have more of an overjet That’s right. So this to me always was very interesting something my diploma in orthodontics never really touched on I always use thing you know, Surely this is important when when orthodontists are about to put these bite ramps posteriorly, right? And completely disclude everything else and now they’ll put brackets on and move everything around. There’s a chance that a lot of patients are going to deprogram and become usually always more class two than they always start out with. But that’s very few orthodontists actually planning that and doing articulate work and checking for slides. But you know, it’s an interesting thought. [Kushal]It’s an interesting thought. Because there are two types of orthodontic patients. I’m not saying orthodontic patients per se. But there are two reasons why we have to look at orthodontics in a restorative treatment plan. So one is the patient that usually turns up to say, I just want my teeth straightened. But then there are the second type of patients are those patients were treating not only for straightening, but because they’ve got tooth wear associated with them. And this was a classic case that you may have seen in the alumni group recently. Patient is coming to the end of the orthodontic treatment, but also have associated tooth surface loss. If the orthodontist leaves them in a very in a class one perfect complete bite, canine guided relationship, which is what you would hope for you suddenly start deprogramming these patients and they’re going to class two dive one. What are you going to do to them? So we have to plan orthodontic restorative interface very cleverly. In such cases, this is not for every patient. These are patients that have got tooth wear that need orthodontic treatment before you start managing the tooth surface loss. Does that make sense? [Jaz]Yeah, absolutely. And yes, we plan jointly when you’re treating you know, cases like this where I carry a lot of baggage and need a lot of restorative work as well. Absolutely. [Kushal]On the flip side, I’ve seen where these tooth wear orthodontist will a very cautiously say I’ve left an incomplete bite so you’ve got enough room to restore that one edges with composite but actually, by the time I start deprogramming patients, which was an incomplete bites in a class one relationship turns into a class two div one. [Jaz]Yep, absolutely. [Kushal]And how do I know without going through further orthodontic work? So key point from this is.. [Jaz]This is exactly what I meant. You know, I don’t think orthodontists in my experience and please, anyone listen to this as a different experience reach out to us but I don’t think orthodontists screen for this routinely [inaudible] [Kushal]And I think it’s how we communicate from a restorative points. So prior to any deep bond of tooth wear cases. So by timeline view, I’ve seen a patient who has tooth wear I’ll put them to orthodontic treatment. I will plan my CR record Before orthodontic treatment starts, so I know where the patients’ condyle, and therefore the teeth are going to end up and I then have an indication of how much overjet is existing and how much of that I need to close, I will need to retest that before the debond stage because if I need the occlusion tightened up a little further, now’s the time to do it. Once you’ve debonded a patient and put them on retainers of some sort. Having to put the brackets on again is always never a pleasant conversation with the patient. [Jaz]Absolutely. It’s a plan B begin with the end in mind and keep checking as you’re going along as you do, you know got very good communication with your orthodontist obviously. The next question want to ask, Kush is, what happens with these patients where you rehabilitated in centric relation as you’re sort of reference point as you’re where you’re going to build your teeth into over the years? What is the what is the evidence say these a know when you look back at these cases five years later, 10 years later? Because I think from what I’ve read, and what I gather is an actually do we you know, we adapt and when we’re no longer, we may no longer be in centric, ie we may introduce or develop into posture interferences as he has go by after rehab. So have you got an experience or read any good papers about that? [Kushal]Evidence tells us that centric relation is a dynamic position, we are not buildings, which will then remain in those fixed positions. The joint, the TMJ joint is not like a door hinge. Once it’s crude, it doesn’t stay there. It’s controlled by a number of factors. Evidence tells us it is we know not even evidence but we know the neurovascular connections which will influence the joint. It is a bony component, the bone remodels and then obviously, patients’ stress, state of mind, posture, all these points will come into play and that joint will not stay in its position. We know in five years time on average, what you restored in CR will not be in CR take a classic example of the last denture you made four years ago where you did your best to take the patient into CR even if you got a gothic arch tracing. At the time of taking the jaw registration, it is very likely in 3, 4, 5 years time those dentures are not in CR and that’s a removable full mouth reconstruction by definition, the same or a fixed full mouth rehab that we do, but we’re using it as a reference and it doesn’t change on a daily basis or we hope it doesn’t because we’ve taken necessary measures pre treatment to keep it stable. And we undertake our treatments in small stages, including anteriors, posteriors, temporaries, before we move the temporaries into our provisionals and provisionals into definitives. But the key thing here is over time, four or five years down the line, the joint changes, and when it changes, you will have a new CRCP, ICP slide in a number of cases. And yes, you will develop interferences of breakages and chipping all the ceramic work or whatever restoration you’ve done especially on those patients who start parafunctioning and don’t protect those restorations with some form of a splint post treatment. [Jaz]This is why part of my philosophy and I know you have as well is that you know what patients do to their teeth when they batter them. And then when you restore them, they’re likely to do that again. So an appliance is just make sense, you know, as an insurance, because, as you say, evidence suggests and we know their joint position is dynamic, and the occlusion will not be the same five years later. And then to have a piece of plastic to protect them. It just makes sense. [Kushal]It does. And we have to remember, the average force on a molar tooth posterior is about 70 to 80 kilos. It is higher in paraunction. [Jaz]Higher in parafunction, higher at nocturnally when we’re sort of not conscious not with it, then what we can achieve in the day. [Kushal]Now that 70, 80 kilo is the average weight of an adult human being. Try and sit human being on a molar tooth every day for prolonged periods of time. What’s gonna happen? [Jaz]It’s crazy when you think about it actually. The next question I have Kush for you. And where we’re coming up to the last few is an interesting theory, you know, that used to be popularized by certain dentists and whatnot, is that when you restore someone into a CR, that you might actually be able to stop their bruxism, because actually the only reason they’re bruxing is because they’re trying to rub away that interference. Okay? So I don’t know if you’ve ever heard this theory before I heard it when I was a student from certain dentists and certain sort of things are I’d read, I now know what the answer is to that. But please, can you enlighten our listeners about this theory? [Kushal]So it’s interesting you say this, I don’t believe that taking somebody to CR will stop bruxism. And if I had to give an answer in one sentence, I would say that I can stretch to the other end and when I see my four year old niece clenching her teeth at nighttime and I she’s in the room next door and I’m unable to sleep and I see the same pattern in my sister and the same pattern in my mother. Is there a genetic component involved in this? I always say this in my occlusion lectures when we do parafunction, and we go through bruxism, why is it the masseter muscle? Why don’t I wake up with my abs muscle worked out and have a six pack to think about these factors on a logical level. It’d be great if my abs were working out I would never complain about it. Here we are in a situation where if anyone thinks that taking somebody to CR will stop their parafunction, I think they need to probably update their knowledge on this topic. [Jaz]Some historical Institute’s are used to teach this. And this used to be part of you know the program from what I read in history that this was the understanding that people had actually. I went to a lecture at the BDA, when I was a student, I was a third year student, and a guy from the States came over. And he talked about the success rate that he had in patients who had chronic temporomandibular disorder. And it’s a terrible term, because TMD is a made up of several things. But that’s the term he used, he had chronic TMD. And they were bruxism. And they’re really suffering in life. And they tried everything that actually he found that he has a one in four chance that when he puts them, rehabilitate them, in CR their symptoms will improve. And that was probably the most modest and real thing I had. So you know, he’s got an did [inaudible] and all his patients and in his website at the time was adhesion.com actually, I don’t know if it’s still up there or not. I remember this really funky American dentist. That was an interesting sort of reflective point that he actually rehabilitates his patient, he actually tells his patients, there’s a one in four chance that I might kill you. But that’s all you know that that’s such a difficult thing to test. And largely, we know that, you know, people will always brux no matter what position you put their joint in. [Kushal]What his rehabilitation involving full mouth direct or indirect work? [Jaz]Yes. So what he would do actually, do you know, what he talked about his protocols in his lecture, he’d actually chop off the sort of the, you know, couple of millimeters with molars that say, the back and then just put gold onlays on and everything in sort of CR, if you like, gold equilibratio, if you like, and that was his sort of method. And he had, you know, a lecture full of 1000 to 500,000 people that the BDA at the time, I was like, Whoa. [Kushal]I mean, if I spent 10 grand or 50 grand on my teeth, I think that in itself will stop me from parafunction I wouldn’t be worried about how much damage caused to the work paid for maybe three and four, don’t worry about the money, but one in four sets, that he did. [Jaz]Fine. So yeah, I had one more scenario where we may choose not to restore to CR. So this is a bit jointy if you like so if people’s TMJ anatomy isn’t so good, then it’s sometimes can be difficult to verbalize it, like you said earlier to someone that has an issue with their medial pole. And let’s say you can’t load them, so they can’t load their joints, then that’s another patient, I think that you would have to accept an arbitrary position, which is going to provide relief from their symptoms. And because obviously, if you load that patient, it’s gonna be impinging on retrodiscal tissue. So would you agree that I mean, but these patients is so rare, but I think if you’re going to discover another group of patients, that’d be another, someone else you wouldn’t restore the CR. Do you agree with that? [Kushal]Yes, I agree with that. And you got to obviously do your load testing on these patients before you start rehabilitating patients in CR depending on the audience that will listen to this they’ll either come out very confused thinking about what the media pole and retrodiscal tissue and CR and all these terminologies but I’d like your audience to take away one thing which is if you’re new to this game of occlusion or haven’t got too much of an understanding of occlusion, please don’t get flustered by it. You have to understand that when I was an undergraduate, everyone told me you have to restore every case to your centric relation, or at the time they were calling it RCP and RCP is now very old terminology. No one should be using it, it means the condyle’s in a very different position to being in CR. But we mean the same, we all mean the same, it has to be in reproducible position. But there are cases where we can’t restore patients in CR and as Jaz mentioned, there are cases where you, when you put patients in CR you will develop pain in the joint because it’s putting pressure on your disc at the back. And then the other two cases that I described, one of which is a class two div one or the third one being the large horizontal slide. So if I was trying to summarize this in a simple way, you have to keep your eyes open that not every case needs to be restored in CR. [Jaz]That’s brilliant. And I think I really like what you said there that occlusion can be quite a daunting confusing game, I’m still develop my knowledge all the time with this as a passion that obviously it’s a part of the density which I’m really passionate about, but everyone has their own journey and I suppose you have to spend time in the dirt and what I mean about that is everyone where you are in your journey, in your undergraduate learning or where you’ve qualified and you’re sort of going to courses and you’re developing your knowledge, you have to do your time you there’s no shortcut, you have to reflect, you have to read Dawson’s book, you have to find mentors who will help explain break cases down for you, you have to go on case courses like you know, Ace courses or [inaudible or several other courses that are out there that help us to learn more and more. So if someone’s feeling like Whoa, I really didn’t get what they said there and I can completely if I went back four years ago and listened to us talking now a lot of what we discussed would have gone over my head but like you said Don’t be disheartened because everyone’s on a journey and to keep striving and actually do the work. You know, there’s no shortcut, you have to fail. You have to reflect you have to keep updating your knowledge, spend those hours learning, listening, reading, so I think nowadays people want the information or want to know something and get on with it ASAP. But it took me years and I think that’s about right. It should take you years and as long as you’re improving getting better and developing knowledge as the most important thing. [Kushal]That’s right. And we have to understand when you get your basics right, which is from an occlusion point, and Sorry, I’m diverging from the current topic of centric relation Jaz. [Kushal]No, no, please go for it, please. Yeah, this is what we’re wrapping it up. Now. And this is a good point to bring in. Because obviously, we’ve just given we’ve discussed CR, but what you’re saying now is so important. [Kushal]What I’m trying to get across is 90%, if not more of our day to day dentistry happens in intercuspal position for the dental patients, we that a simple filling, occlusal MO, DO, MOD, whatever extension it is, direct, indirect dentistry, we do it in our confirmative intercuspal position. If occlusion baffles you, just get your single unit or multiple unit conformative of dentistry and master the principles in that. This topic of centric relation when we’re trying to move the mandible and the condyle needs most reproducible position, starts to come in when you start treating the bigger cases. So this may not apply to your day to day dentistry. But the understanding of it, especially when you start doing the bigger cases is of paramount importance. I hope that sort of puts things in context, because people start thinking of CR when they’re doing their day to day dentistry. And it doesn’t apply in whatever form or shape. You have to assess where the contacts or CRCP contact is, don’t get baffled by the fact that we’re discussing such a topic, this is very likely the next stage in your career if you’re not working outside of the remit of conformative of dentistry, and it’s when you come to start doing reorganized approaches when you need to start making this jump and learning CR. [Jaz]That’s brilliant guys. Kushal said it loud and clear, then you know, become a good conformer first and it become a fantastic and actually properly conforming, you know, don’t just look at your sort of work and then restore it as long as everything’s balanced is fine. As you truly try and conform to the best of your ability and do multiple units slowly over time, get comfortable with that. But again, conforming and only when you get to the bigger cases, like Kushal said, that’s when what we’re saying will apply and maybe three or four years later, you’ll listen back to this episode and think oh, okay, that sort of makes sense now wherever you are in your journey, just do the best you can and strive to get better. So Kushal with that. On that vein, thank you so much for giving me your time to talk to our listeners to learn more about centric relation and how in cases where you should be using and where And importantly, where you shouldn’t be using it. And of course, we’re all gonna die one day, so especially if you’re in a CR or not, we all gonna die. [Kushal]We’ve got to be real in life. [Jaz]Kushal I thank you so much, mate. [Kushal]My pleasure, Jaz. Thanks for inviting me once again. Jaz’s Outro: Thank you guys for joining me back on episode 20 which has been a long time coming. So thanks for your patience. Got so many great episodes coming up probably like once a week now from now on. A lot of these there can be video episodes as well. So I hope you enjoyed that. Catch you on the next one.

In this short episode I discuss 3 reflections from a composite veneer case: https://www.youtube.com/watch?v=JAGyIySRQUc Need to Read it? Check out the Full Episode Transcript below! 1) Communication – regarding case communication and case acceptance in an ethical manner 2) Using the Mylar Pull technique for interproximal management Full Youtube video for mylar pull technique: https://www.youtube.com/watch?v=L-fqXLi78P0 3) A bur which I LOVE to use to shape composite aka ‘the Perio Bur’ (Bur code is 831.204.012) If you liked this mini episode, please share with a Dentist friend and subscribe to my podcast. Thanks for watching! Click below for full episode transcript: Opening Snippet: Welcome to the Protrusive Dental podcast the forward thinking podcast for dental professionals Join us as we discuss hot topics in dentistry, clinical tips, continuing education and adding value to your life and career with your host, Jaz Gulati... Main Podcast: Guys, it’s Jaz Gulati from the Protrusive Dental podcast and today’s interference cast is just three tips I have to share with you. Based on my reflections of doing a composite veneer case recently, patient’s main complaint was actually different to begin with. And actually this is part of the sort of the three little tips I want to share with you guys. So let me discuss three learning points from this case number one will be communication tip. Number two will be how I managed the interproximal part of doing composite veneer. And number three will be the composite refinement tip, I’ve got a bur that I want to recommend to you to use for composite refinement, which I found really useful. So before we come on to that, if you’re listening to me on the Protrusive Dental podcast, then yes, you’re still gain from this because I’m sharing some stuff that is tangible, even though you’re listening and not watching. But it’s probably worthwhile going logging on and actually watching the seeing the images, so you get to see what I’m talking about. But anyway, let’s proceed. So tip number one I have for you is regarding communication. This patient initially came to me and she had busted her upper right five, she went on to get a vertical crown on upper right five in Zirconia, which I’ve done and as you can see, that’s done. But actually her main complaint after was that actually, I don’t like the way my crown looks at the back and she was pointing to her metal ceramic crown on the upper right six, as you can see that she didn’t like the fact that the color was a bit off to that yellow bit too warm. And she didn’t like the fact that there’s a gray line. And we all know why that is a metal ceramic crown is the metal showing through. So when you have a case like this, and you look at this lady smile after her teeth are actually framed really nicely within her lips, she’s 68 years old, she looks great when she tells me that she has an aesthetic concern, instead of replacing this upper right six, because there’s two good reasons why I shouldn’t replace it upper right six. One is that it’s still healthy. The margins still good, even though it’s done many years ago is still a good tooth. But the second reason is because she has a limited opening. And for me to do a good job back there in a limited opening compared to I’m assuming she had a better opening many years ago when the crown was first done to actually be a pension to be doing a disservice for this patient. That’s two good reasons. But the third good reason is will that really massively help her smile. So by changing the upper right six crown to something a bit nicer that says a Zirconia or just a better color with no metal, that may improve her smile and her perception, but really look at the anterior is look at the upper right one, the upper left one and upper left two. Yes, in this particular photo, I’ve just put a composite blob on to check shade. But if you have a look at this original photo, you’ll see that they are, they stand out because they’re discolored and they don’t match the adjacent teeth, which actually have quite a high value. The overall benefit aesthetically this patient might changes the upper right six crown in a very tricky area in a limited opening and a healthy crown. It didn’t make sense to me. So I suggested to her “Look, I understand that you want to improve something but your smile. But have you considered improving something about your front teeth because they don’t match very well?” And she said yes, absolutely. I’ve considered this I just never knew it was possible. So what we can learn from this is that actually, I’m usually very careful about suggesting aesthetic treatment to patients who haven’t listed as one of their goals because you don’t want to come across as salesy and you don’t want to offend the patient, you don’t want to make them aware of an issue which they never thought was an issue. It’s not a nice thing to do. So when the patient actually mentioned that they have an aesthetic concern, or one thing that’s completely fine to do, as part of your consultation, you sort of say, Are there any aesthetic concerns, anything about your smile, not happy about that’s fine, because you’re asking them, instead of pointing something out? You actually ask him you invite him to say something? And sometimes I say no, I’m happy, or they might give you some concerns. But in this case, she gave me a concern, a direct concern herself about the upper right six. So this gave me the opportunity and the invitation to discuss her smile. And I said to her, Angela, to improve the color and appearance of your front teeth, we’ll have a much bigger impact on your smile than changing this upper right crown. And she agreed. So we went on to do the three composite veneers. And when I did them, she was really happy. And she said what they all say they say I wish I’d done this many years ago. And when I asked Now, why didn’t you? And the answer is always the same. I never knew it was possible. So she’s been a regular attender for the last 40,50 years. And I think it’s something that she wanted to have done. Maybe it’s not been in top of mind for that many years and maybe didn’t look that bad 30 years ago, but if I have a long that she’s been upset or unhappy about her front teeth, I think the dentist had been seeing and I’ve been doing a disservice, because something that’s actually going to improve her quality of life, improve her confidence and smile and someone that she’s always wanted. So it’s important to discuss the patient’s smile with them when they invite you to do so, that’s my communication tip I have based on treating this case. The next case, the next tip I have for you is how I manage the interproximal area when I’m doing a direct composite veneer. Now I’ve tried various techniques in the past, including ptfe, double ptfe, or just going ahead and not really worrying about it in bonding to the sort of contours that I want. And then getting a flat plastic and soften it within the PDL, separating the teeth and then polishing and disking it off. But actually the the best technique I use now and what works best in my hands now is the mylar pull techniques. If you’re not familiar with a mylar pull technique, here is a video on YouTube, I’m gonna put the link for down below that you can actually down watch at your leisure and actually see this mylar pull technique being used. And I think it’s really good. As you can see, the mylar is pulled. And this creates a nice smooth interproximal contour. And I’ve actually known about this technique before. And I’ve probably seen this video some years ago. But it wasn’t until I went on this man’s course. That’s Dipesh Palmer. And it was the mini smile makeover course that he actually made it quite tangible for me. And at his course the tip they gave me was to use some wetting resin on the mylar. And that actually helps me to create a smoother interface intra-approximately. So my tip for you is interproximal management. Use the mylar pull technique if you’re not already. And if you are, are you using wetting resin? If not, try it. So I had this tip to Dipesh Palmer with teaching me and mentor me on that. The next tip I have for you and the final one is how I like to finish or shape my composite veneer cases or my composite, anterior composite in general. And it’s actually a bur that I have to recommend, this bur I learned about this bur from going on this man’s course as Thomas Seeley, one of the best dentists I know. And he is someone who taught me how to use his very specific bur to shape composite. And it’s been phenomenal. It’s been a real workhorse in my practice. And it gives me predictable results. So it makes even these average hands produce good outcomes because of the fact that the bur is just such a great shape. So Thomas, thanks so much for introducing me to this bur, I’m going to share this nugget with you all now. The bur is called the Perio bur. So thank you for, thank you to Style Italiano for also sort of teaching about this bur technique. And actually one of my Italian nurses Titi. She taught me that actually, it’s not Style italiano, it’s Style, Style italiano. So actually, it’s Style italiana, not style italiana. And this is the bur as as it’s shown here. And what I like to use this bur for, it’s actually it’s really great for adjusting along the three planes, incisal, the mid and the cervical planes. Because the shape of it, it makes it really easy to access and refined sort of the line angle area as well. So and the fact that you can put it into a slow handpiece makes it very, very easy to use. And it really gives you a control and the tactile feedback. So the perio bur has been an absolute game changer for me in practice. Here is another photo of it in use. And here’s the bur code, the bur code is 83120401 to contact your comment rep in your country to solve that, buy this bur. And if you’re unfamiliar with how to read bur codes, the first bit a three one is the sort of shape of the bur. The next bit the two or four is the So what kind of bur is it, so this is one for the slow handpiece. If it’s 314 that usually means it’s the friction grip, ie fast handpiece and the 012 at the end or the last three digits will always mean what is the size of that bur at the tip. So this bur is 1.2 millimeters at the tip. So that’s my three nuggets. I hope you liked them. If you liked it, please subscribe. And if you’re listening on the podcast, thanks so much for listening. And if you don’t, if you’re not listening to my podcast moment, why aren’t you? Thanks so much. Cheers.

In this mammoth episode (boy, it’s a long one but I hope you like it!) we have the legend that is Dr Jason Smithson. If you are a Dentist and have not heard of Jason Smithson, you have been living under a rock! The calibre of cases that Jason posts on Social media and lectures is always unbelievable and we as a profession learn a lot from from him, as well as the courses he runs. I went on his Onlays and Veneers course about 4 years ago and I was really engaged throughout the entire 2 days. Need to Read it? Check out the Full Episode Transcript below! We will be talking all thinks eMax onlays and vertical preparations. Protrusive Dental Pearl: for all my listeners, a group just for you where we can share content, knowledge and files for each other: Protrusive Dental Community First half we discuss all about lithium disilicate onlays including: Indications and contraindications When an onlay really should be a crown Thickness of eMax Why flat top onlays are not recommended How thin can we go if on virgin enamel? (Think of OVD increase cases) IDS (Immediate Dentine Sealing) and and DME (Deep Margin Elevation We also discussed Vertipreps in great detail! What is “vertiptrep “or “vertical crowns”? Why have they ‘suddenly’ become fashionable? Tips for temporising for Vertis (see eggshell technique reference) What to tell your technician Trouble shooting Vertical crowns (overcoming friction!) And we also discuss a gem right at the end about how I help to improve the longevity of my anterior work by a simple trick that takes 4 or 5 minutes with only with a disc….and Smithson agreed it is a good thing to do! Resources shared with this episode on the Protrusive Dental Community Facebook group: Eggshell temporary technique Loi’s paper on BOPT Bur codes for the Vertical prep burs we discuss Lots of news to share with you all: Those of you who follow me on Instagram (@jazzygulati) or like the Protrusive Dental Podcast Facebook page (I’m pretty active) will have seen the news that starting from the next episode (which by the way is with none other than Kushal Gadhia) you can get enhanced CPD! My guest and I will produce A&Os and have some questions for you to answer. The only caveat is you have to be a Dentinal Tubules member – if you listen to my ramblings, you either LOVE dentistry or you WANT TO TRY to love dentistry or you want to reignite your passion, and that’s exactly what Tubules is about and I am provide for them to quality assure and issue my CPD. This Podcast on Youtube: https://www.youtube.com/watch?v=UAEenV8Ct90 For information about Jason Smithson’s next courses, visit: Jason Smithon’s website His Restorative Program Click below for full episode transcript: Opening Snippet: Too many people start a wear case by slapping some composite on the teeth. And really what you need to do is take a step back and work out why they've got a problem... Jaz’s Introduction: Hello everyone, and welcome to Protrusive Dental podcast. This is Episode 19 with Dr. Jason Smithson. Jason Smithson is an internationally acclaimed dentist, and he’s a fantastic educator. If you don’t know who he is, you’re probably living under a rock or something because he is one of those well known dentists in the world. I went to his course around about four years ago now on onlays and veneers, and it’s one of the best courses I’ve been on. He is such an inspirational dentist in the sense that he shares so much of his knowledge. So if you go on Facebook, and you check out some of his cases, they are fantastic. Like I said, he is famous around the world raised it to Latin America and Asia. And when he has time he tries to the UK as well. So I was really excited to have Jason on the podcast today. We will be discussing all things Emaxs, lithium disilicate and particularly in respect to onlays. Cuz you know, we could talk about all sorts of veneers, I suppose we touched on that a little bit, but mostly it’s about Emaxs or lithium disilicate onlays posteriorly. And also, we’re talking about verti preps, which are very much in fashion, I think it’s it’s very poorly uncertain. And a lot of the teaching seems to be on Facebook only. Jason is the only person I know who’s running course on vertical in the UK. Usually, a lot of the dentists I know are running in Italy. So it’s great to have Jason run the flag for UK. And we’ll be talking all about the vertical preparation. So if you’re completely, you’ve never heard of verti preps, or if you’ve seen them, you’ve heard about them and you want to know more than this episode is for you. It’s packed with loads of gems, as always, especially because we’ve got Jason, he’s such a giver of knowledge. Before we join Jason in the main podcast, there’s actually a lot of news I have to discuss with you. Those of you follow me on Facebook and on Instagram. So Instagram is @jazzygulati. And on Facebook is the Protrusive Dental podcast Facebook page. But I’m pretty active on there and posting almost daily and hopefully is used usually quite useful stuff for people, I hope. And so you will have seen my post about my announcement if you like about the fact that my podcast starting from the next guest, which by the way will be Kushal Gadhia. And yes, it’s occlusion again, I promise you is going to be engaging even if you’re not into your occlusion because I think we’re going to make it quite relevant for everyone. And it’s gonna be a funny title. I’m actually excited to share that with you. But I’m not going to tell you what the title is. I’m going to keep it a surprise. But from starting on Kushal Gadhia’s episode, it’s going to be CPD, verifiable CPD or enhanced CPD. So the way it’s going to happen is there’ll be aims objectives, there’ll be some questions that you have to answer on Dentinal Tubules. And then you can actually get CPD for your commute. You know, while you commute and you listen to podcasts, you can now be getting CPD, which is amazing. And it’s all thanks to Dhru Shah and Dentinal Tubules. And to be fair, if you’re listening to my podcast, then you’re probably a dentist who’s really engaged, you’re really passionate about dentistry, or if you’re none of those two, then you probably want to be engaged or you want to be in a position where you love dentistry. And that’s why Listen to me, and that’s, that’s amazing. I love to have you on and I love you know, I love the feedback I’m getting the people are liking the content, which is the means the world to me, but I want you to know that everything that I’m about with my dentistry and my passion for it, and our podcast, is the exact same thing that Dentinal Tubules is about. So if it’s one more thing that you need to join Dentinal Tubules, to fair, you know, I’m probably certain that 60-70% of my listeners are already Tubulites, just because like I said, you know, the kind of people who invest themselves and who want to listen to my ramblings, kind of people who are really passionate and therefore you’re probably already part of Dentinal Tubules. So for you guys, there’ll be some CPD. From two episodes ago with Tif Qureshi, the pearl I shared with you is about the budget composite heater which is 30 pounds and looks like a lot of you are enjoying using it which is great. So now you can access all the benefits of heated composite, heated LA. And also my now friend and listener, fellow listener, Alan Burgin, who on Instagram is @the.cornish.dentist. Fantastic profile with lots of great cases, please follow Alan. He messaged me say that actually, you can also use it to heat your mirrors on there. So while the mirror is still in your pouch, you keep it on the heater or about you know, 60 degrees 55-60 degrees. And then once you’re ready to take your occlusal photographs or your buccal photographs, the mirror is not going to steam anymore, which is great because usually what I used to do before Alan gave me this tip was I’d be warming up the mirror in hot water and it’s wet you have to dry it or my nurse will be blowing air while I’m taking the photos. And this worked a charm. So Alan, thanks so much for that tip. And guys, you can start doing that now just keep it as pouch, you don’t need remove the pouch, and the temperatures, not an issue as it doesn’t get too hot. So thanks so much Alan for contributing. I’m also getting a lot of good vibes about the custom screen that shared Episode 18. So a lot of you guys have downloaded that and start using the custom screen and getting some feedback for it, which is great. Now, one of my listeners, and it’s a great thing about this podcast, because in a way, it’s self selecting. And what I mean by that is, you know, that phrase that you deserve the patients that you get, and sort of the patients that you attract over your working career as a dentist, they’re sort of reflective of you. So I feel the kind of people that are bothering to sort of log on to listen to my ramblings during their commute or in you know, at home or whenever you look, wherever you listen to my podcast, you guys are some of the most passionate and sort of crazy geeky people there are, which is totally cool. And through my podcast. I’ve made so many new friends and I met so many cool people. And I’ve been speaking on either Facebook or WhatsApp with all these lovely and Instagram and all the people who I never really had met before. And it’s just been fantastic. So one of those people is Richard McIndoe. And so what Richard did, he downloaded the custom screen. And he added the bit I told you that was lacking, the goals bit. So thanks so much, Richard, for doing that. It’s really, really kind of you. And he’s happy for you to share that with everyone. So I’ll be sticking that on. So which leads me very nicely to my Protrusive Dental Pearl for this episode. The pearl for this episode is that I am going to set up a Facebook group. And already the first thing you’re thinking is Oh my God, not another Dental Group, okay, just hear me out in a second. Hear me out. I’m going to make another group within my podcast page. So be like the protrusive Dental community if you’d like, right? And the reason I’m doing that is because in some of the bigger groups would like you know, 10-15,000 people, we get all sorts of people, right, you know, anyone, any dentist can join that. The idea of starting this sort of group is I’m only going to be telling the people who listen to my podcast or on my Instagram about this group, I’m not gonna invite anyone at all, you guys have to do the hard work to find it on facebook and join it itself. I’ll put the link on my Instagram, I suppose, or on my blog, but otherwise, I’m not going to be so broadcasting on the Dental Group. So the reason that’s important is because the group itself is self selecting. Now I know some dentists, some young dentists particularly who’ve been shut down before for posting something that, you know, that mean, there’s no such thing as a stupid question. And that’s the way it should be. But sometimes, people in the past have posted something in good nature than they’ve been shot down and had nasty comments, and they’re sort of afraid to post in these dental groups anymore. So the reason I’m starting this Protrusive Dental community is basically so I can share all these files with you. So not to keep going on Google Drive and stuff. So I’m gonna make it like a group where we can, you know people Richard, who very kindly shared the modified version of the custom screen can now put it on the group and I can put some files on the group says easy for everyone to sort of download things. And we can anyone can totally post cases they want. And I’m going to try and get some good people that I know as mentors on the facebook group, if they want to be particularly people who’ve been on the podcast before. So that’s what I’m, that’s the reason I’m doing it. So even if only 10 people join is totally worth it for me. It’s an area where I’m gonna be just sticking on the files that I may mention on here, any templates, PDF downloads, you know, things like that. So it’s more of a group, a community so that anyone else can post on the pages, usually me who can post but with a group, it can get all of my listeners involved. So like I said, it’s self selecting and making it look a safe environment where you’ll be posting or you’ll be reading content of people who are listeners to the podcast just like you are so that I’m hoping it’s gonna be like a non toxic if it can be non threatening sort of environment. So that’s why I’m doing that. And that’s my pearl. Please, if you like the sort of stuff I’m sharing, join the Protrusive Dental community Facebook group, you’ll probably find it within my page. And then that way you can download all things I always talk about, and then things that other my listeners sort of improve for me or share back with me and they’re happy for me to stick it on the group. And a lot of times people are sending me really helpful PDFs and then oh, Jaz, I listened to that bit. And here’s why think and here’s this paper I’m sending you that will help you. And that’s been amazing. So I want to share that with everyone. So my pearl is please join that group. And I’m hoping that through there I can be posting a lot more valuable stuff that you can download. Right enough of my ramblings. Let’s join Jason Smithson, Emaxs, onlays, verti prep. Let’s go. Main Interview: [Jaz] Thank you so much for coming on Protrusive Dental podcast. I’ve been meaning to have you on as a guest for ages. So thanks for coming on. [Jason] Thank you very much. [Jaz] Do you have had such a huge influence on my clinical philosophies, my protocols. All of the things I’ve learned about resin, you know stem from your teachings, for example, daily composite flow, I’m still using a probe and a micro brush as you told me [overlapping conversation [Jaz] I went on to your course. I’m being deadly serious what you offer on not just on social media, but through your teaching, of course. But if you just hone in on your Facebook posts that you do with all your lovely cases, I think every one of them have such great learning points. So I know loads of dentists who gained so much value from your posts. I’ve learned heaps and heaps and heaps from from you. And also you’ve got the time to comment and reply to people and answer a question. So that’s amazing, my laptop almost feel there. [Jason]That would not be good [Jaz]Would not be good at all. So that’s why I’m so happy to have you on because I think you have so much to offer and share. In terms of previously how I’ve done it, I usually introduce the guests a little bit. I do like a crappy introduction about myself, but I let I let you add in. But you know, if you don’t know Jason Smithson, then you’ve been living under a rock is gonna make you blush a bit more. Obviously, he’s one of the rock stars of density in the world. He’s famous for lots of things. He’s famous for lots of things, including the photo every time he goes into international course or something he’s got his shoes, fancy shoes always, up in a train station, legs up. So that’s one of the things he’s famous for. So Jason Smithson is a massive inspiration to me, Jason, anything want to add to that? [Jason]Not really. That sounds good. [Jaz]Let’s just go in. I want to get, I’m gonna give the listeners a lot of value because we have a limited time with you. I was taught Emaxs onlays by you. I hadn’t placed a single Emaxs onlay. Into fair, I was doing NSH style non precious onlays back so many years ago, but when I came on your course, a few years ago, I think it was in. Was it? Was it Wakefield or? [Jason]Wakefield. Yeah, with Prem. [Jaz]That’s it. With Prem. [Jason] Lunch, if you remember? [Jaz]That was the first thing I always think of lunch when I think of Prem. [Jason]Yeah, [Jaz] amongst other things. So also Jägerbomb, I think of when I think Prem, that’s when I learned about Emaxs onlays from you. And honestly, your protocols, I use them daily. So that’s great. So let’s just talk about do you think Emaxs onlays are an over utilized restoration? [Jason]I think I was thinking about this earlier, actually, I think it’s over utilized and underutilized. And it really depends where you’re coming from. We see, when we look on social media, particularly because that’s nowadays, where we look at them Stream Map, most of us don’t look at journals anymore, you tend to see quite a lot of onlays done, where perhaps, maybe you ought to be thinking of doing crowns. And that comes from the new minimally invasive concept. And perhaps sometimes we’re a little bit too minimally invasive. And then you also see direct resins done where really, they should have onlays. And I think the main reason for that is really money and perhaps to some degree, a little bit inexperience. So my answer to your question is yes and no. [Jaz]And I totally agree. And I remember a few years ago, I went through space, maybe I was, you know, when you go into courses, and you just want to do that techniques. Of course, I may have gone through a period of over utilizing Emaxs onlays, somethings I should have been a full crowns. I think I was doing Emaxs onlays. So I mean, another way of saying is that in too many situations, I was having to do deep margin elevation. And when that sort of sentence comes along, then you know, you may be over utilizing it. So before we come on to teach our listeners or educate them about what deep margin elevation is, and you’ll do much more, much better job of that. And I will do, we’ll just talk about just the indications in your books. What percentage of your posterior indirect work is lithium die silicate onlays as a as a sweeping statement, I guess? And what are your, what’s the ideal tooth to require an Emaxs onlays in your books versus At what point does that switch to a different type of restoration, crown? full veneer crown? Yeah. [Jason]So I mean, we al learn at university the restorative cascade, so obviously, we’ve got direct resin, amalgam maybe. And then we’ve got an onlay and then we’ve got a crown. When you switch from doing a direct resin to a ceramic onlay, well, really when you’ve lost maybe a couple of marginal ridges, because the marginal ridges hold the tooth together a little bit like the rings on a barrel. We call that the peripheral rim theory. Basically the enamel around the periphery of the tooth, it can be used on still marginal ridge at other rings on a barrel and it stops the cusps from spreading out. When you load it when you buy time. When you lose that, the cusp could be more and you’re more likely to fracture it. The other thing to take on board is the amount of dentine underneath the cusps. So what we do is We measure the thickness of the cups. In other words, we take out the existing restoration, remove the caries. And then we use some calipers something like an Iwanson gauge would be good. So thing you might measure crown thicknesses with and just measure at the base of the cavity to the outside of the tooth. And what we’re looking for is a thickness of three millimeters or more. So is there’s a bit more to it. But there’s a basic for two slots to marginal ridges. And the cusp bases are three millimeters or less than you should if you’re doing an onlay [Jaz]Just on that point, Jason because I’ve seen some photos on social media where Dentists have removed the restoration, remove the caries and then they get in there once engage out and they’re measuring the the cusp thickness but they might they might be measuring the wrong part of the tooth. So you’ve made it measured a good point, then, you know, you’re measuring the base of the cavity where if someone’s gonna, some people are measuring, you know, the higher, you know, the actual coronal part where it might be one and a half millimeters, but that’s supported by that three millimeters base. So is that a point worth exploring? [Jason]It is. really the base of the cavity. But it is only really important when you go beyond the kind of half the depth of the crown of the tooth. Do you follow me? Because if you’ve got if you’ve got a quite a shallow cavity, maybe a millimeter and a half depth, you just reached maybe one two millimeters deep and you’re barely reaching into dentine and you’ve got thing cusps, you may not need to do an onlay in that case, because of the height of the height of their residual cusp comes into action as well. So it’s basically a whole day lecture on biomechanics cover or [Jaz]Absolutely. Fine. So you decided, Okay, so if you’ve got like an MOD situation and your cusp is looking a bit thin, and you’ve measured it, at that point, you’re looking to go for the onlay, but then what makes an onlay into the crown is what I like to [Jason]Yes, so, an onlay is retained, conventionally with a gold onlay, we have our retention form, which is parallel walls, near parallel or 6-20 degree taper. Potholes, maybe grooves, something like [inaudible] made show, one you may have seen on Facebook this are very, very obvious retentive features. And that’s because those restorations don’t adhesive. Nowadays, with adhesive restoration ceramic onlays, we use extra enamel as a retentive feature. So what we’re looking for is to have a decent amount of good quality enamel to bond to. So what we don’t want to do and what I see quite commonly on Facebook, for example, is people doing an onlay when they have a mesial cavity that’s on dentine, distal cavity that’s on dentine, and then a class five, so perhaps about 270 degrees on the margin is dentine that’s probably not a very good risk for an onlay. What we’re looking for is a decent thickness. There’s no research to tell us what the decent thickness is, but a decent thickness of good quality enamel. And if you don’t have that, then maybe you should think about being a crown and using standard potential resistance form parallel walls and taper to retain that. So that’s your decision making process, really. When I was younger, as you kind of alluded to maybe about, oh, about 10 years ago, I was doing onlays on everything and saving everything. And what it found was if you don’t have a reasonable amount of enamel, there’s no data on that, but perhaps about 270 degrees of the tooth is enamel. They come off at about three or four year down the line. So for that reason, we do crowns with those, because it’s a crown. [Jaz]Fine. And I’ve got two questions based on that then what I mean is deep margin elevation, something that you’re doing a lot of nowadays in terms of your posterior restorations, or is that something that you really are doing on rare occasions, but it’s good to have like a trick up your sleeve. And then you can also explain about DMV to our listeners as well. [Jason]Okay, so DME is well, it’s kind of heresy really. I mean, when I trained we which was late 80s, early 90s. We were sort of taught to finish on sound dentine or sound enamel and if you didn’t finish on sound enamel is a problem. So nowadays with an adhesive restoration, what you can do is particularly in the mesial distal box, you can fill the mesial distal box and in a conventional way with direct resin and then you finish your ceramic margin on that correct resin. And that’s called gingival margin elevation or nowadays deep margin elevation. I do it quite a lot, but I do quite a lot onlays so but as a percentage of the onlay as I do I, I wouldn’t say I do it a massive amount, because often if you lost a lot of enamel for the reasons I discussed earlier, you’ve probably got to do crown. Yeah, I think again, it’s probably over utilized. The other problem with it is, the idea of deep margin elevation is to elevate the margin out of the sulcus. So what you’re doing is you’re dealing with a tooth that has usually mesial, or distal caries in the mesial distal box within the sulcus, but it isn’t breaching the epithelium and it isn’t breaching the connective tissue. So you do the margin elevation to raise your margins supragingivally. And the reason why you do that is because when you come back to the patient’s cementation, a couple of weeks later, I don’t know, 2-3 weeks later, you can isolate more easily with rubberdam. Because the margin is supragingival. That’s the advantage of doing the gingival margin our deep margin elevation. However, nowadays, quite a lot of people are using the margin elevation to deal with biological width invasion. In other words, you’ve got caries which is breached [inaudible] in the connective tissue. And that’s good medicine really. Really those cases need to have surgery or something like that for extraction. [Jaz]Yeah, absolutely. I’m glad you mentioned that. Because the next question I was going to ask you is in order to do deep margin elevation, what tissue management do you do, but I think what you’ve alluded to in that sentence is that actually, if you’re having to do a lot of gingivectomy then in that case, probably that’s not the right case, would you agree with that? [Jason]Well, I usually end up using, I’m the old school I still use electrosurgery. But you usually have to do a tiny bit of electrosurgery just to get the bound on. And usually if the patients have caries within the sulcus, that usually got some degree of gingivitis in that area anyway, so often, there’s a little bit bleeding. So we do a little bit of electrosurgery usually just taking spaces. But if you finding your cutting with your like, you know, when you cut with electrosurgery and so going black and just something finding the bone, that’s probably a tooth that needs to go in a bucket or be crown lengthening, one or the other. [Jaz]Right, let’s hold that thought for when we talk about verti preps later. Come on. So the next thing I want to ask you is about immediate dentals dentin sealing. If you can describe that for listeners, what IDS is. And do you still I mean, I know you’re taught it on your course I went a few years ago [Jason] Yeah. [Jaz]Has there been any advancements in the literature suggests that actually, it’s not so much well worth doing or what are your thoughts on this? [Jason]Well, IDS for Immediate Dentin Sealing basically classically, when you do ceramic prep to prep the tooth and then impress the tooth and then send the impression away for lab work, then the lab work would come back you would hybridize the dentin. So, you would etch, prime and bond the dentin then you would cement the onlay or crown with a veneer cement or heated composite, one or the other. Immediate Dentin Sealing is slightly different what you do is prep the tooth and then you etch, prime and bond the tooth prior to take an impression. And then you take the impression of the practice which has been etched, primed and bonded, get the onlay fabricated or crowd and then the crown onlay comes back and you’re cemented that. It does offer some advantages, higher bond strengths, sealing of the dentinal tubules so you get less sensitivity etc. So yes, it’s kind of funny because I do it all the time when I do my onlays because commonly when I do my onlays, I block out all the undercuts anyway. So I have to etch, prime and bond so I kind of do it. When I do my crowns, most of my crowns are vertical. So I cement them conventionally with resin modified glass ionomer so I don’t bother with immediate dentin sealing. And I also don’t bother with them anymore with veneers because most of my veneers are now mainly in enamel. So there’s no point because by definition immediate dentin sealing is no guarantee so [Jaz]Okay, so an Emax onlays you are obviously because it makes sense because you’re when you’re blocking the undercuts with resin, it just makes sense when most of them [Jason] but you’re going to do it anyway. [Jaz] Yeah, that makes absolute sense. What I think you’ve touched on is ready. But are there any common mistakes that you see dentists make either with immediate dentin sealing or with Emaxs onlays in terms of case selection or execution. [Jason]In case selection we’ve talked about quite a bit. I’m not a massive fan of the flat onlay preparation. I like to see I used to do those again a while ago. But there is a concept called [forms first the band], which means that if you give a little bit of a resistance form, if you cut into box form a little bit of a different height in the preparation, you get more resistance format. And when you bite on the tooth, it stops the onlay from twisting on the tooth. And it reduces the amount of stress the bond is under, therefore the onlay tends to stay on better. [Jaz]Yep, that’s certainly what you taught me at your course. And that’s why I’ve been doing another thing. It’s just more for the benefit of the listeners. But when I place the onlay on, it’s nice to have that resistance form that is not going to be twisting around, it’s got that positive seat. Yeah, might not have some retention, because it’s gonna be getting the retention from the resin cement. But it’s nice to have that resistance form. So I’m a believer in that. And in terms of thickness, what you taught me at the course was two millimeters thickness of lithium silicate. Are you still following that? And how about in cases where you may, for example, if you are increasing the vertical dimension, and you are able to add, additively posteriorly, can you go down to a millimeter? If you’re let’s say bonding to virgin or near virgin enamel? [Jason]Yes, is the answer. I think the guidelines are somewhere about 1.8. We do 2 because 2 is enough. Basically, if you’ve got a tooth that is pretty much intact, in other words, it hasn’t got an MOD cavity. The enamel covering the two thirds remaining, which you might get, in quite rare cases usually wear cases or erosive wear cases would be quite common. So the patient has a virgin tooth, which may have some enamel wear but the majority of the enamel is left. The enamel covering the tooth gives the tooth some rigidity. Because enamel is a rigid material. So when you bite on that tooth, it doesn’t bend and flex so much. In comparison, if you have a tooth that has an MOD cavity when you bite on it because it’s lost that peripheral rim which I talked about right at the beginning the tooth bends or flexes more. Now because with a tooth that has all the enamel remaining isn’t bending and flexing so much you can put onto that a thinner onlay because the onlay is better supported. It’s a little bit like laying paving slabs on to hardcore rather than on to sand. If you lay on too hardcore, which is a firmer base, that are much less likely to crack if you put it on sound that’s more likely to crack. So if those, if you have in those unusual cases or the enamel remaining, you can actually go down to a millimeter on the cusps at 0.7 in the fissures that the researchers by Matthias Kern in Germany. [Jaz] All right. [Jason] So there you go. So you can open the vertical with less distance. Some people now get down to 0.3 and I think it’s possible but it’s hazardous. I think if you stick around one it’s for the average GPS [Jaz]and anteriorly we’ll see that’s completely different to Emaxs onlays and whatnot anteriorly for veneers is that where you can go contact lens thin quite thin anteriorly or is that, are we still using lithium disilicate in those cases if we’re going ultra thin? [Jason]To be honest, if we go ultra thin I go stacked feldspathic veneers because there’s no substructure in it so you get a better aesthetic. But if you go below 0.3 you tend to get fractures. My findings were I got quite a few fractures in the box when they’ve been sent to me. And then quite a few fractures on the seating and then quite a few fractures after sitting out for 24-48 hour period. I think if you can push them up to 0.5 it’s a lot safer and you just make your life much easier. I mean, 0.3, 0.5 is a huge difference. But there’s a massive difference in predictability, just by jumping that 0.2 millimeters. [Jaz]Brilliant. One more thing that you taught me, which I think a lot of dentists may not appreciate or know about was and something I started to request on my lab docket was exactly which [Jason] which ingot? [Jaz] Yeah, which ingot of lithium disilicate to use. So, you know, you taught me about HO, MO, MT, LT. So no low translucency, medium translucency. So, did you mind just doing a quick recommendation for mostly on posterior onlays, which ingot would you recommend in which scenarios? [Jason]Okay, so, here we’re talking about Emaxs, which is an Ivoclar product, which is what most people do whether they use, whether they realize it or not. And it comes in varying translucency, HT, high translucency being the most translucent, and HO, high opacity being the most least translucent. So you would tend to use the HT when you’re replacing enamel. So that would be a good solution for a very thin veneer. There are some other ingots, which may be a good option for that as well. Most people, whether they realize it or not, tend to get the LT which is a next one up, low translucency. The reason is because it’s easier to use in the lab. So the lab technician, if the dentist doesn’t ask for a certain ingot that’s probably the one they’re going to get. The HO is used where you need a really high opacity situation where you’ve got maybe a discolored core, maybe a metal post, or maybe an implant to block out discoloration. But I don’t tend to use that very much because I tend to do full crowns, when I do full crowns I used [inaudible] So I don’t tend to use Emaxs in that situation. The other ingot, the medium opacity, which is kind of in the middle. We use when we’re doing Emaxs crowns. And this might be a situation where you’re doing crowns on the teeth that you can bond them. In other words, there’s an enamel margin. So we may do Emaxs crowns and bond them. But some people may have noticed Emaxs can look good in the mouth. And then when you photograph it looks great. You’ve been noticed that? [Jaz] Yeah, I have [Jason] Occasionally. And that’s not a problem with the material. It’s actually a problem with materials selection. So if you use the LT ingot, it’s a little bit more translucent. So if you make the whole crown with an LT ingot, it tends to look gray. Whereas if you make the whole part of the crown with the MO ingot, which is less transfers and more opaque, and then layer over it, you don’t have the frame. So that’s just a little tip if you do full crown, not always for veneers, although sometimes we do veneers with MO as well. If you got somebody who has got discoloration, tetracycline maybe or one discolored [inaudible] teeth, or they want a particularly bright kind of Hollywood smile, that might be a good indication to the CMA. [Jaz]That’s important because when I do speak to dentists, and it you know, we’re discussing about which prescription of, you know, lithium disilicate ingot for, they don’t really appreciate. And that’s something that was unique about your course that you went through in good detail about that. So [Jason]On the Ivoclar website if you have a look, [Jaz]Jason, we all know no one has time to read nowadays. This is why we need you. [Jason]It’s not on Facebook, though. I think it’s on. [Jaz]It’s not on Facebook, it’s not going to get absorbed. Awesome. We’ve covered Emaxs onlays. Now to get to the sort of the main fashion trend over the last couple of years, which is vertical preparations, verti preps and I love that title of your course. I think I saw it was vertical preparation. It was old tricks for new dogs? [Jason]Yeah. Because it’s not new. [Jaz]Yeah, absolutely. And when I read in to it Holy crap, you know, this has been like from the 70s right? [Jason]Earlier. way. You know, it’s all very fashionable now. But guys, particularly in Italy have been doing it since the 70s. Definitely, and maybe the 60s. So really nothing new. [Jaz]Yeah, when I saw it first on Facebook, and let’s be honest, that’s where I saw it first. And then I went on to read the paper by Loi, which, you know, a lot of people who will see on Facebook, they won’t then actually go search for lithium. I thought, No, no, I gotta read up more about this. I went to read the Loi paper, is a brilliant paper. And in fact, I’ll put the link on my blog page for the Loi paper for those who want to read it. So that’d be a good thing to do. All right, a reminder. So you mentioned that most of the crowns that you’re placing nowadays are vertical. Was that, were you also doing that 10 years ago, five years ago? Is this a shift that you’ve made as well? And why have you made that shift? And now let’s talk about, can you educate because you know, a lot of people every time you see vertical preparations, or vertical crowns being post on Facebook, it’s still something new that we don’t get taught at dental school so people like, what is this doctor? Is it going to work? Is it going to fracture? Question mark, question mark, what the hell is a verti prep. So let’s get into that. [Jason]Well, it’s nothing. It’s nothing new, really, it’s just a knife edge margin, really. So it’s actually the oldest form of margin because historically, we didn’t have very good handpieces we didn’t have very good burs. So we cut knife edges. Because we’re dentist, we’re lazy, it was easier. And then when the turbine came around in the 70s, and we put quality down on burs, we started cut chamfer margins because it’s easier to cut a chamfer margins, get a good aesthetic. And so the knife edge died out because you couldn’t get a good aesthetic with a ceramic margin on a knife edge. However, nowadays, we’ve got a Zirconia so you can finish Zirconia down to a very thin margin 0.3 millimeters. And it still has the attentional strength to cope with that. So nowadays, we can do a good quality durable margin with Zirconia. And actually, there’s quite a bit of research that shows you can do it with Emaxs as well, although I personally wouldn’t do with Emaxs because Zirconia is a little bit stronger. And I’m going to cement it anyway. I’m not going to bond this [Jaz]subgingival, yeah. [Jason]Yeah, exactly. So, you know, it’s kind of just been reinvented. But the thing that people are getting involved in now that’s slightly different is historically we used to spin a bur and round the tooth, there’s a paper by Ingraham, which you may know on “gingitage”, so you tape around the tooth and the tip of the bur would trough the sulcus as well. And then you impress that day. Whereas Loi’s paper, that you’ve read talks about how to condition the tissues, over usually a 40 day period. So you can take an impression at 40 days with really decent quality tissues. So I do quite a lot of vertical in my practices, really, because my patient base is quite old. And those patients in their 70s 80s have got crowns that were placed maybe in the 1980s 1990s, quite deep subgingival, quite broken down teeth. So I do the vertical because it helps me recover the margin. And also it’s more conservative. [Jaz]Brilliant. Can you talk a bit about how you recover? So you’ve got an old crown that you’re dismantling which had a shoulder? How do you, What’s your protocol and converting that, now, old crown prep into a verti prep? [Jason]Yes, so what we do is, it’s not always possible because if it’s really deep into the sulcus and it’s quite heavy shamfer or heavy shoulder, you can’t do this. But rather, when I first trained we start off with a crown with a prep margin and just made the margin a bit bigger, basically a bit deeper and it’s quite destructive. So nowadays, we do the exact opposite. What we do is take your crown off, clean it off, maybe air abraded and then etch, prime, bond, place regular composite, and then just prep on to the composite with vertical I will finish the margin on dentine. Often there’s quite a bit of core in the tooth and that’s not really a problem [Jaz]Brilliant. The biggest issue I’ve had with the verti prep when I’m doing it is initially as a learning curve and I made this one want to get to is training your technician because a lot of technicians are uncomfortable so and then the technician I now work with an Oxford I’ve sort of had to encourage him and send him the Loi’s paper and you know some health diagrams and what we’re trying to achieve here and he’s done really well but the initial issue I had was that there was friction in seating these crowns, right? So then Jason I read this on Facebook look I’m so sorry. But then I read the actually the space that should be placed cervically. Is that the best way to do it? I mean, because I think that’s against the principles of what we’re taught, right? You know, you want a less base cervically, nice tight seal. So how do you train your technician to overcome the issue of sort of friction so that would prevent your crown from fully seating? And what is the role in dye spacer in this, if any? [Jason]I think the first thing that will happen when you send the impression to the technician and [inaudible] for it, they’ll immediately call you and say, I can’t see a margin. That’s for somebody. And your answer should be Well, no. And that’s the whole point. And then you say to them, the technician will say to you, so where should I put the margin, and you say to them, you decide. And that’s like a whole different ballgame for technician because historically, with a linear margin, or, for example, margin, we’ve, as dentists of practice chamfer, or shoulder or shoulder with a chamfer, or whatever, we’ve defined where the margin wants to go. And the technician that has followed our direction, whereas the vertical, within limits, the technician can choose exactly where they want to put it to get the optimal aesthetic outcome. And that’s a bit of a game changer for a lot of technicians. Because commonly, particularly with things like for example, a diastema closure, or a discolored tooth, perhaps the technician with a standard chamfer the technician may call you and say actually, the margin is not really deep enough, I can’t get a good emergence profile, I can’t mask this discoloration. Whereas with vertical, they can just make it a bit deeper if they want. Obviously, you haven’t got to make it so deep that you get a biologic width invasion. But it gives the technician a lot of flexibility. So often, the interesting thing is you would imagine most technicians will be thrilled with that to be given the choice of where to put the margin, but actually quite a lot of them aren’t, they find it quite challenging, because you’re just throwing the ball into their court. And they’re not used to that. So you kind of have to, we, the technicians I work with, we choose to tweeners, where we’re going to put the budget. And it’s to give us the optimal aesthetics but without invading the tissues, usually about a maximum of 0.5 millimeters into the sulcus. But maybe palatally, it might be equigingival, just because it’s better for the tissues. So we didn’t touch on, which is a common error and a common mistake is technicians will then finish the margin down to a knife edge, or the ceramic and that’s when they break. I had a my mother I did one of my first vertical crowns on about seven, eight years ago. And it was an upper right first molar. And she had an endo problem. And the guy who builds those seven upper chest filled is good endodontist did her endo and Okay, I think he spent about three or four visits during the endo made a really nice job with the endo and all settle down. And then I decided I was going to do a vertical crown on it of the crown prep. I didn’t really know what I was doing to be honest. And I got my technician to finish the margin down to a knife edge. And she came in and tried it and look good, fitted well, good contacts. Nice occlusal scheme. I then fitted it because I didn’t space it well, hydrostatic pressure give a big halfmoon fracture on the palatal [Jaz]Immediately? Then and there? [Jason]Immediately. So I seated in with my thumb. I immediately hear that [breaking sound]. And I was like, Whoa shit, I’m going to get this out. So I’m trying to get this out with juicy crowns forceps not going anywhere. So there it was. But the reality is, what you should do is have about a 45 degree angle emergence profile on the crown a little bit like you might see on an implant and that technicians find, a lot of dentists actually have quite uncomfortable with that. And certainly a lot of technicians are you know, when I first started doing it, the technician would be saying “what we, shall just finish it right down? So it’s really nice and flush,” the answer’s no, the tissue reacts quite well to a 0.3 millimeter margin. With a 45 degree emergence profile, that’s a maximum of 0.5 millimeters into the sulcus just not a problem with that. And because he’s at 45 degree emergence profile, you get a degree of stress. So that’s something you need to teach your technicians. [Jaz]That’s something I definitely take my teach my technician, you made me both very happy to learn that but also very, very nervous. [Jason]Well, that’s just life happens on your mother or guaranteed relative [Jaz]Yeah, absolutely. That’s a fantastic tip to get a train your technician to have that 45 degree bevel. So what about the overcoming the friction because obviously, by the nature of this verti preparations they’re going to be very tall and the taper is to your control. So they’re very vertical in nature. So there’s lots of friction. How can I overcome that? [Jason]I think that a lot of the preps we see are under tapered. I think that’s a problem. I also think, actually, it’s not so much the fit, because to be honest, we talk a lot about dice facing, but let’s be honest, most of them is a Zirconia, and they’re milled, so they’re not going to fit perfectly anyway, a lot of the problem that you see, and I see this on cases, people show up when they show the model work, because they take the margin into the undercut, in the sulcus, and not many people discuss this, but if you’re not careful, you can scan into the undercut and you can work even if you impress the technicians gonna make a model scanner and then you’re gonna mill into the undercut. And then when you sit it, [Jaz] it’s not gonna sit, yeah. [Jason] It’s not going to sit and that’s a common problem. And not many people will take the time, what we do is, before we trim the die, either digitally or analog, we mark a line at a level of the tissue. And then we trim the dye. And then we mark another line at the maximum apical extent of the impression, bottom of the sulcus, give or take. And obviously, if we go above the line, above the gingival margin, there’s going to be, you’re going to have a visible margin. So you want to go below that. And obviously, if you go below the line to the bottom of the sulcus, you’re going to have a biologic width invasion. So you want to be above that. So you’ve got this kind of sweet spot between the two lines. But unless you’ve marked those lines before you trim the die, you’re gonna have a problem. There’s also a problem. It’s very difficult actually to prepare something particularly pre molars, upper fours and upper sixes into the furcation on the mesial of the upper four. And often on the distal of the upper six, it’s quite difficult to prep it to there without getting some degree of undercut. So sometimes you have to accept you’re going to be slightly supragingival there or going to destroy a lot of tooth. And that’s, I think, a lot of the time you need retention or try to tuck it in to try and get a better aesthetic. And that’s when they don’t sit. I don’t think [overlapping conversation] dice faces a bit of a red herring sometimes. Because they’re milled and whatever people tell you the milling process is quite accurate, but not, it’s not as accurate as the PFMs as we used to do. So I think it’s more margin position than dice facing to be quite honest. [Jaz]Okay, so margin position and taper is the main take home point on that [Jason]Taper. Yeah, if you look at, Well, there’s a lot of research on taper, I mean, Goodacre, the classic research on paper and they talk about somewhere between 6 and 20 degree taper, I would suggest a 20 degree taper for zirconia crowns, probably a good idea. Because if you don’t have a reasonable amount of taper on top TLC, you can’t see too because of the hydrostatic pressure. Of the cement. So for that reason, we, I would tend to taper as a Zirconia crown, vertical or a little bit more than I would taper for example, a PFM crown. I would tend towards that maybe 6 to 10 degree taper for PFM, personally, but maybe more like 20 for the Zirconia or vertical? [Jaz]Okay, that makes perfect sense. And Yep, I am also thankfully following that as well, which is good. It’s always whenever you say something, I’m doing it. I’m like, so happy inside. So that’s good. Can you give us some tips on temporarization of vertical preparation. So the issue is that, yes, it’s so thin, you know, at the margin area that, you know, sometimes when I’m making a temporary, it can fracture. So what I’m doing actually is before I’m prepping sometimes I’m adding a bit of flowable to tooth to beef it up. And then in my index, I’ve got a thicker sort of temporary crown coming. Is that a good way? Is there a better way? [Jason]It’s a really good way. No, no, if you just use some flowable I don’t like to mention brand or something like GC universal flow would be good because it’s the thing, heavier flowable. If you will just go around the margin and then when you take your PVS putty wash, for if you attempt that will work better. So I think we also use is upper four to four particularly I use those 3M Ion Crowns, which are the preformed plastic [inaudible]. Like shell crowns and you know, you’ve got the cost involved in buying those, but actually, it’s a lot faster. Anyway, it’s a faster procedure with one of those, you’ve got a lot less work to do and finishing them and mocking around with it. So we do that. Another thing we do is, if I’m doing multiple units, I just get lab temps. We get shell temps me so there’s a paper by a guy called Gregg Kinzer from experience shoot [inaudible] called the egg shell temporary technique. So what we do is we take about an impression of the patient’s teeth beforehand, we get a diagnostic wax up that’s processed, this is done to she now. Then we take the stent to that, putty stent to that and then a teeth prep. And then we fill that stent with some acrylic. And we see seated over the cracked teeth on the model. To do this, you need to be minimally prepped and we take it off and then thin out the inside of the egg as a crown till that eggshell thing, hence egg shell crown. And then we take out to the patient prep their teeth, and you can just fill that with snap or trim or something like that. [Jaz]But not bis-acryl. It has to be acrylic, not bis-acryl? [Jason]It could be bis-acryl but the problem with bis-acryl is snap set. So when you fill it with, and sometimes if you’re not on your toes, you have trouble getting it out. The other problem is it doesn’t trim so well. So when you trim the margin, it’s quite tricky to do the margin, I guess. So yeah, not bis-acryl. Generally, I just use snap for trimming something quite old fashioned drill. You get a those seated from pop it on and off. Particularly with multiple units, six or eight units, you want to be able to pop them on and off. So you get a good fit, but they don’t lock in place. [Jaz]Is it true that the vertical crowns that come back, the reason that they’re not chipping in the margin where they’re so thin is because you need to have an adequate thickness occlusal thickness that may impart the strength to the crown? Is it? Am I making sense there? [Jason] No. [Jaz] Okay. So [Jason]It’s the 45 degree angle, margin, that’s what makes them not break. If you see them right down. And again, this is a Facebook problem when you look at a lot of cases on Facebook and a lot of cases done by gurus on Facebook, the margins are correct. It’s usually that sinned right now. [Jaz]Absolutely. I mean yeah [Jason]Which is a problem. Yeah, you need, if you look at Loi’s paper this really nice pictures to show the emergence profiles, like a 45 degree angle, give or take 30-40 degree angle, and it’s quite a fit. So it’s almost an overhang. But it’s a thickness of tissue will tolerate. [Jaz]Fine. And then speaking of gurus now, this can be controversial a bit. So. It’s gotta be done, Jason. Come on. You can’t mention much. And you know, this is, let’s have a respectful conversation. There’s a whole backbar, philosophies so if anyone who’s not familiar with this, there are you know, there’s the battbar is like an endo Z bur, if you like, diamond with a non cutting edge, and that can supposedly do your gingitage at the same time as prepping your feather edge if you like, whereas in Loi’s paper they use the is flame shaped burns, right? The thin flame shaped bur? [Jason]862 or 863 for years [Jaz]So tell us about, obviously, I know you like the 862s and 863s, but do you see any issues with using that bur? [Jason]Yes [Jaz] please tell us [Jason]Well, first of all, I use the 862 or 863, undercut problems with using that, right? So I my hands off [Jaz] the wrong hands [Jason] in the wrong hands. And the problems are is basically a flame. And if you don’t hold it at the right angle or modify the angle, you can end up gouging the root. So when again, when I first started doing this, I was just picking up spinning around around looked like a great prep. And then on some of the cases, I’d end up being Perio surgery on them. So I prep them, put them on temps, and then I do perio surgery, either receptive or grafting. And when I raise the flap, all those roots look terrible, you know, the loads of dents in the roots. And that’s really due to poor bur angulation. Now, there’s a group called Tomorrow Tooth on Facebook. And I’m very friendly with Pasquale, who is the founder of it, he’s very good friend of mine in fact. He wants to give me some olive oil from his olive oil farm. Very, very good, very good. And they recognize that was and the other problem with the 863 or 862 is it’s quite tricky to prep a margin without getting an undercut just goes back to what we were saying before with seating issues or fracturing issues. So 862 and 863 are not without their difficulties. So they came up with batt, B-A-T-T to counteract this and it’s so much chunkier bur that I would agree in inexperienced, you’re much less likely to gouge your root. And you’re also much less likely to get an undercut, the problem is quite a fat bur. So you do a little bit more than gingitage to make a massive, whacking great trough all the way around the tooth. And if you look at the cases, there’s typically quite a lot of bleeding. So as soon as, if you just remove epithelium from the sulcus, you get tissue healing within about 7 to 14 days. And it’s pretty predictable. If you trough away a lot of connective tissue. Let’s be honest here, we’re all going to remove a bit of connective tissue, irrespective of how careful or how good and great we are. But if you remove a lot, the patients get more pain afterwards for sure, and healing is going to be a lot less predictable. So for that reason, I’m not a big fan of the battbur. However, the battbur has an advantage in such as it has a safe tip. In other words, the tip of it isn’t Diamond Coated. But you can and again, I’ll mention brands here from Meisinger, you can get an 863 with a safe tip. So I actually use a Meisinger 863 or 862 safe tip. So I get I’ve just actually putting the slides together for next year’s lectures. But that I’ve been using that for about 10 months now and I’m really sloughing off first time i’ve admitted it publicly. But that is kind of the best of both worlds. You’ve got a safe tip that doesn’t gouge, it’s a much finer bur. So in answer to your question, I think both techniques are have their disadvantages. [Jaz] Yep [Jason] Let’s say that [Jaz]Which is why the sort of flame shaped with a non cutting edge makes so much sense. So that’s [Jason]Because it’s a very slim bur, particularly if you use a 012, which is what I use is that’s 1.2 millimeter diameter rather than 016. Lot less tissue damage. It’s just a bit more sophisticated way of doing it. It’s a very well publicized bur, not many, I mean, I’ve been involved in writing the book, and I didn’t know anything about it. And I just kind of fell upon it when I was dealing with Meisinger. But it’s a nice book. [Jaz]Brilliant. Now it’s a great tip. And I started using the 862, 863 like you advise. And then because I didn’t trust myself, I moved in the battbur. So the way I the way I prevent the way I sort of learned, prevent really destroying the gingiva is just packing lots of ptfe in the sulcus. And then that way I’m not destroying the sulcus and it can give, it makes a little stock for me. [Jason]Yeah, but then that’s fine, but it takes time to prep the ptfe. So it’s time consuming, very time consuming, actually. And you’re not getting any gingitage which is the whole point of the procedure. [Jaz]Yeah, I see it means so it essentially it all almost makes it a supragingival or equigingival technique by doing that, I appreciate that. [Jason]And that’s probably very good for lower molar, you know, you have a knife edge finish is slightly equi or supragingival. On a lower molar, that’s fine. That’s gonna give you reasonable outcome. Look at the X ray, because you’ve got a notch and then you margin but on an upper central incisors, it’s gonna look like grey. I don’t think [Jaz]You’re right. So everything I’ve been saying to fair, I haven’t done this technique anteriorly just because I mostly use it for premolar is fractured, maximizing ferrule posteriorly. Whereas I think you’re right to have the sort of tissue control and thing to wrap up on verti preps is, yeah, well, that was one of the main questions I wanted about verti prep. Is there anything else that you want to tell the listeners about vertical crowns? [Jason]No. Well, I would suggest, and this is not advertising myself, I would suggest that you don’t learn off Facebook. [Jaz]That’s a great advice. But I was gonna ask you actually just now, can you? You know, you want to do anything on vertical preparation? Can you please tell us about that? [Jason]Yeah, we do. For various courses, we have a website. And I think the thing with the vertical is bur angulation, it’s really all about bur angulation whether you use batt bur, whether you use 863. You can’t really learn about bur angulation from pictures on Facebook. So you actually physically need to see it done, demonstrated, whether it be by me or whoever, you just make sure you actually see it done. And then actually do a course where you physically get some hands on component because actually, it’s quite tricky to do. It’s much better to learn on the plastic model, there’s no GDC involved in that. Nor is there’s bleeding, before you test out on a patient. So that would be my take, that message out that the fact that’s slightly in my lecture, download this technique on Facebook, because it’s something that’s tactile, and you really have to learn it by seeing really. [Jaz]And if you don’t mind, I’ll put the website for your course on my blog along with all the other sort of things that you mentioned, I’ll put Loi’s paper, the egg shell technique, your website for your courses. When’s your next main course coming along? [Jason]The course in Russia next week in Moscow [Jaz]No for UK. So my listeners are UK based if they’re looking to come in Smithson [Jason]I don’t even know. I think we got work coming up in about march in Glasgow. I think it’s my first few [Jaz]Jason, thanks so much for coming on Protrusive Dental podcast. I know my podcast is quite clinically focused. So I’m going to try and put some supporting sort of information for our listeners. But if anything went above anyone’s head, please send in some questions if you’d like. In fact, that reminds me, someone did actually send in a question for you. I posted on Facebook, and you gonna come on the podcast. Are there any questions for you? The problem is it’s questions like you know, this question you could probably give lecture and I know you do lecture about this, like five days in a row about this one thing and he wants you to know about composites for free rehabilitations, and managing the occlusion, and I just don’t think you can satisfy. But if there was one tip that you could give to someone, just any random tip, I’ve got one tip in my head, I’ll give them as well. But is that, what would you say is the one tip, any sort of scope domain of have that sort of question? [Jason]For wear, Steven begin with the end in mind. Too many people start wear case by slapping some opposite on her teeth. And really, what you need to do is take a step back and work out why they’ve got a problem. Work out where you want them to end up. And that usually involves having some deprogramming, and usually it’s some articulated models and usually the wax up. So actually, the composite is the least important, is the most important part is actually diagnostics and deciding where you’re going to go. So that’s the main message there otherwise, you’re gonna get really burned. [Jaz]Brilliant, and one thing that Jason I’d like your opinion on this is something I do quite a bit it’s fun restoring a chipped or worn upper anterior region. And if I noticed that the lower anteriors are sharp and chipped and broken and I smooth the opposing sharp bits of enamel to get nice, flatter, rounded, opposing contacts to distribute the force better. Is that a valid approach? [Jason]We call it incisal edge grooming. [overlappin conversation] Incisal edge manicure, it was called by David, oh gosh, there’s a guy I saw on dental town maybe 15, 20 years ago. [Jaz]I love it. Incisal manicure. That’s fantastic [Jason]Incisal manicure. It’s a soft flex disc about two or three minutes. But it makes a hell of a difference. [Jaz]Yeah. So yeah, I mean, I’m doing this, but you’re happy that I’m doing this. And it’s a good thing too. I think it makes a difference in terms of education. [Jason]And patients, you know, I say to patients, you know, because I think of basically touching my lower teeth, at the top is fix and say, Look, why don’t we just level these out and make them a lot prettier and a lot smoother on your tongue? It’s less of a soaring effect on your upper teeth. [Jaz] That’s a great way to put it. [Jason] Yeah. Because, you know, if I was having some upper centrals fixed in composite, and somebody starts banging away at my lower teeth, I’d be like, What’s he doing? So you’ve kind of got to some degree sell it, but it’s a positive thing. Most people sit up and go, Whoa, that feels better, you know, they don’t feel so sharp. But they didn’t realize it was sharp because it accommodates? So yeah. That’s good. [Jaz]Brilliant. Thank you so much, Jason, really, really appreciate you having on. [Jason]No, Jaz. Thank you very much. Jaz’s Outro: So thank you, again, for listening all the way to the end. I’m sorry, if it was a bit echoey. Jason was recording it in a large room. So I’m hoping my editor managed to get rid of that echo, magically. But if it was still above echo there, I apologize. Not the usual crisp quality that people told me about. So next episode is with Kushal Gadhia, I’m not going to tell you the title, it’s going to be a funny one, it’s gonna be a good one, a very relevant for daily practice, but it is on the theme of occlusion. And it may or may not involve a certain joint. A lot of you’ve also been recommending guests to me that you think will be good. And I’m starting to contact them and everyone said yes, so far. So I’ve got a great lineup coming up. One thing I’m also very sort of forward thinking about, I suppose is, or rather I’m mindful of is that a lot of the speakers I’m having on, you know the beginning had lots of female speakers, which is awesome. Then I had lots of male and now it’s getting a bit male dominated. And I think there’s such great women in dentistry. So I’ve already contacted some really, really inspiring female dentists. Is that political correct? Female dentist? Women dentist? Women in dentistry. I think they have so much to offer. So that’s gonna be happening in my podcast future episodes as well. So please tune in. And I’m sorry, if there was any confusion about the sort of splint course I’m doing in Patcham. It’s actually two dates. So you can either come on the 1st of February, or the 29th of February. They’re both Saturdays so it’s not a two day course or a one day course. But if you want to come along, you can do just give me a DM, message me and I’ll send you the link that you need. And lastly, if you liked what you heard, and you want to go to one of Jason’s courses, I’m gonna put the link up in my blog post which will be on www.jaz.dental underneath this podcast episode, so you can go and went on this video prep course which I’ve been dying to get to. I can’t make the April dates, it’s my sister’s birthday, but hopefully we’ll do another one the UK if not I’m on heavy travel because you know I love mixing travel and dentistry, it’s tax deductible, holidays to me at the end of the day. So yeah, you could check that out and thank you so much for listening.

I am joined by Dr. Stephen Hudson of Dental Law and Ethics Blog Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Download my EXACT examination Custom Screen for free! (I had to move the link to the Facebook group where you fill find all the custom screens – wait for group approval) Once you are in the group, this is the post with the download: In this episode we cover: Who can call themselves an ‘Expert’ and why it’s stupid Who was Montgomery and why did they have such an impact on our profession? Where do you draw the line in terms of ‘explain every single option’ If you feel uncomfortable treating this patient – how can you tell your patient? Consent forms – are they really necessary? What happens when a child attends with the father, not with the mother? Under age Teeth Whitening – would you do it? Do you always need a PA for extractions? The GDC says you should make a recommendation – what happens when the patient says ‘No’ to the recommended treatment? The over arching theme of this episode is the importance of building rapport with your patient! If you like what you hear, please Subscribe, leave a review on Apple Podcasts and share with a friend who may find it useful! https://www.facebook.com/protrusive/videos/589415178518912 Click below for full episode transcript: Opening Snippet: So there's been a lot of hoo ha about Montgomery because initially we were afraid about it. But what's happened?... Jaz’s Introduction: Hello everyone and welcome to the Protrusive Dental podcast, it’s Jaz Gulati here. Today, I’ve got Stephen Hudson on the show, we’ve been talking all things about like consent forms, notetaking, how not to get sued, the relevance of Montgomery, Who the hell is Montgomery? You’ll find out today, like I did, I thought Montgomery was a guy, right? It’s actually a woman. So there we are. I’ve noticed that actually, a lot of my listeners are starting to message me with recommendations for who they think that should come on the show next, and I’m actually loving it. So please, if you’ve got any suggestions for topics, I’d love to hear it, I’ve got a good list of speakers coming up and guests on the show lined up for you. But if you think something would be beneficial to the audience, then please come with the suggestions. Before we dive into the episode I will give you the Protrusive Dental pearl for today. And that is going to be a gift to you guys. It is my custom screen for taking comprehensive examination notes. So for my new patient examination, I try and make it fairly comprehensive. It’s not ott it’s pretty detailed. And you know, you can fit in what you want. But basically the the benefit of a custom screen, if you never heard of a custom screen is on Exact, Software of Excellence , Exact. You can actually have a way of collecting notes where instead of having to have like a template where you’re adding and deleting stuff, I’ve converted it into like tick boxes and drop downs. So it actually makes it really easy for your nurse to follow what you’re doing. And like for example, molar classification, you can just drop down click class two whatever, you can select your sort of incisor classification, you can have the BP code within the custom screen, you can take where the radiograph is grade one, two, or three on page two of the custom screen. So basically, custom screen is a fantastic way of collecting notes efficiently. And also notes of very good quality. So I’m going to share with you my custom screen, the story of how I got to make my custom screen was basically I was a bit poorly last Christmas. Basically I hate doing nothing right? So I was in bed, I was super sick. So what the hell can I do anything I can move. So I got my laptop, open our log into exact. And I was able to bust out for hours and make this custom screen. So I know I worked really hard on this custom screen. But it’s not perfect. I realized that for example, if I could go back in time when I get some time. The next thing I’m gonna add on this custom screen is patient’s goals. Patient’s goals are so important in treatment planning, and I’m always having to add it on somewhere, I’d like to have a dedicated place. So it’s not perfect, but I’m hoping it’s going to really improve the note taking. So if you’re using software of excellence or exact, then you can download my custom screen, and you will probably find a way. I mean, I can’t tell you the top my head how to do it. I’ll probably include this in my instructions on the website and how to actually install a custom screen and use it and maybe like a video, that’s a good idea. Actually, I’m gonna put a video on how to install and use this custom screen. So I hope you like it. That is the pearl for you today. So let’s join Steve Hudson for today’s episode. Main Interview: [Jaz]So Steve Hudson, welcome to Protrusive Dental podcast. Thanks so much coming on, I wanted to have you on because amongst all the episodes I do, for example, you know, the dahl technique or Tif Qureshi thinking comprehensive, and we’re talking about all these techniques and stuff. But none of this is valid, or it’s borderline dangerous if our consent process isn’t there. So that’s why I’m having you on. I’m gonna do a little bit of introduction for you. But I’d like you to do a bit yourself. So Steve, I know that you are a sort of author in apocalyptic books. And that’s what you’d like to do. You are I believe, a retired dentist who does a lot of medical legal work, you have a blog called GDP resources, which I find very useful. And I’ll link that for my listeners. Can you add to your crappy introduction I’ve just given you [Stephen]Well, the website has changed its dental law and ethics now. [Jaz]Okay, brilliant. [Stephen]Yeah, the apocalypse is mainly zombie fiction. [Jaz]Okay. Zombie fiction. That’s, of course, and when did you retire it clinically? [Stephen]This year. [Jaz]Congratulations. [Stephen]Literally this year. Yes. It’s true health though. [Jaz]Okay, fine. And so now, am I right that you do a fair bit of medical legal work? [Stephen]work through probably for another year, because there’s only a certain amount of time you can carry on doing it if you’re not practicing. [Jaz]Okay, fair enough. [Stephen]The courts like to think well, you’re not really practice, you’re not really going to keep current. [Jaz]Okay, fair enough. So it’s a shame because I think I obviously I know for a fact that you’re full of a lot of knowledge when it comes to this field. But you know, if that’s how it is. So that’s exactly what I want to talk to you about. You know, I was gonna call you a medical legal expert, but I you know, I’m scared this current state of affairs, Steve, I’m scared to call you an expert. And the reason I’m afraid to call you an expert is about a year ago, there was a leaflet produced with my photo on it. And it said, I’m some sort of expert in discipline I was using at the time, right? And then one of my good friends, my dear friends, I won’t name and shame him, but you know, he was one out for me, he messaged me saying, look, you know, I think just be careful with that term expert. And you know, then I reported back to the guy who made the leaflet and you know, he’s not a dentist and he’s like, well, what the hell if you’re not an expert who is an expert? So Steve, Who the hell is an expert? I [Stephen]I have no idea. But if you’re actually on the specialist register, it might be alright. I’m not actually convinced that GDC or that word with that? [Jaz]Okay, I’m glad you said that. Because an expert for me, someone who you know, I love reading self development books and that sort of stuff. And what I’ve gathered is you’re an expert, if you know if you’re in the top 5% of a population who knows about something that’s, you know, that’s why think so, for example, compared to a layperson, I’m an expert in dentistry. I’m an expert in composite resin. I’m an expert in a lot of dental things because the lay person wouldn’t be but if asked to call myself an expert in orthodontics, then you know there’s a gray line that yes, I have a diploma in orthodontics, or maybe I do have a right but you know, maybe you know, you have lots of experience in orthodontics. So you know that, you know, I don’t know if it’s worth exploring this topic or not. But so you think it’s not something worth worrying about too much? [Stephen]I think you have to be careful. If it’s like, if there’s an official specialist field like restorative,. [Jaz]Then I’m going to be very controversial and say, who can call themselves an implant expert? [Stephen]I don’t think there is a implantology specialties. [Jaz]There isn’t. So if I’m on someone’s website, and dentist, I said, I am an expert in placing dental implants. Is that cool? Is that kosher? Is that Halal? [Stephen]I think what the CDC doesn’t like to do to make yourself sound better than anybody else. I think that’s why they don’t like to use it. You know, if you get your BDS with honors, that’s why they don’t like using with honor. But [Jaz]That’s BS, because you know, can I worked really hard to achieve my honors? Right? I didn’t i think [inaudible] if everyone gets honors, correct me if I’m wrong, but no, I think generally the degree you get is with honors, but I might be wrong. I don’t know. But Look, I know a lot of dentists work hard to get the honors, and you know, you stick it on because you’ve been awarded it. But anyway, that’s a different topic. Look, Steve, let’s dive right in. Okay, I want you to tell me who this one Montgomery person is. And what are they done cause such a massive stir in our profession. And if you can, please clarify in terms of in relation to bolam. And if you can make it tangible for the listeners. [Stephen]Okay. Well, Montgomery was a legal case brought in Scotland, it was a woman who was pregnant. Because she was diabetic, she had a certain risk of giving a natural birth. And she wasn’t given that the warnings about that risk. So what happens you have the birth and that risk materialized in the child, the child’s got some shoulders, or some sort of shoulder scares. Yeah. And so she went to the court to sue, because she said, if you if I’d been given the risk, [inaudible]. And the Scottish court said, No, no, no, no, no. And they kept throwing the case out. And it wasn’t until they went to the Supreme Court that the judges agreed with and awarded a quite a large amount of money. So there’s been a lot of hoo ha about Montgomery, because initially, we were afraid about it. But what’s happened is the court take this kind of case law, and then they interpret it themselves. And I don’t think they’ve gone down the road, we were afraid that was, to be honest, all Montgomery has done is brought the legal side of negligence to the same standard as the regulatory side, because we look at the standards. Standards are saying this since 2013? [Jaz]You mean the GDC standards, right? [Stephen]Yeah. They’ve got a whole Principle number three, obtain valid consent. And it’s all about you must obtain valid consent before starting treatment. [Jaz]So it’s what’s changed, make a tangible to dentistry you know Monday morning, or you know, whenever I go practice because of Montgomery, what do I have to do now to make sure I’m doing things by the book? Is there anything any specific scenarios? Make it tangible. [Stephen]The Montgomery requires patients to be given the choice. So it’s not enough to advise of the risks and benefits of a recommended treatment, you must also have the risk of any other alternative. So generally, if you’re doing a composite and you give them the risk of the composite, you kind of got it to let them know about the option of amalgam as well, as long as we can still do amalgam [inaudible] [Jaz]So option and the risks of the amalgam as well [Stephen]Yeah, cuz it’s a viable treatments, because the composite has risks and benefit, and amalgam has risks and benefits and so on. So patients will, believe it or not, [Jaz]It’s true, but you know, I’m really airing the frustrations of our profession because where do you draw the line? Because there’s about as Lincoln Harris one taught me there’s about seven different ways to treat a cavity. For example, do I now need to also discuss Okay, I can also put a sandwich I put a GIC at the base, then put the composite okay? And that’s another way how I could do an inlay. Okay, so do I need now discuss inlay? That’s a viable choice, clinically, that’s a viable choice. Okay. So where do you draw the line? This is ridiculous. [Stephen]Well, that’s where the the next bits come in draw the line? This is ridiculous. requires a doctor or dentist take reasonable care to ensure that patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or varying treatment. So it’s reasonable word is what comes out, though, it wouldn’t be reasonable for you to have to go through that because I actually figured out was 48 ways to fill an occlusal cavity. So it would not be reasonable for you to sit down because the patient wouldn’t understand it. If there was absolutely so the problem is the only body that can determine what reasonable is a court. So you should be reasonably aware that the particular patient would like to take significance in it and that comes through the conversation. You have the patient before treatment. [Stephen]Okay, so what should that conversation involve to make sure We get the right fee to the patient. [Stephen]Yeah. So you basically got to make sure the patient is on board with you that you’ve got rapport. If you don’t have rapport, we probably shouldn’t be treated. But yeah, if you can tell is that that sort of hesitancy the probably don’t like your conversations not flowing, you know, when the patient’s not on your side? [Jaz]Absolutely. [Stephen]You just shouldn’t be treating those. [Jaz]So I’m gonna jump straight to question seven because I made a list of questions to ask you. So we’ve gone from Montgomery, which question one, I’m gonna go straight to question seven, which is exactly about the situation. So let’s say we’ve encountered this patient now. Okay. And for those who listen to the basic implant occlusion episode with Ivan from the US, he talks about red flag patients. Yeah, so he’s got a system of, you know, you know, two yellow cards and red card and this is, he’s trained his staff to do this, right? So I have a red flag patient in front of me, just from the history that they’re giving me and I’m feeling uncomfortable in doing any treatment for this patient, how can you let them down in a way that is respectful and courteous, and within the law. [Stephen]Basically, with experienced, you’ll find a way to get rid of patients [Jaz]Commonly, there’s some tactics employed, I’m not endorsing these tactics as quadrupling your fees, which I don’t think is really a great strategy. But, you know, it’s very tricky. [Stephen]Yeah, I mean, things like that quadrupling your fees, if you’re doing this, just because the patient is annoying, or might sue, what if they take your product? What if they still go ahead with the treatment? Because they can still complain afterwards. And they can still cause problems with payment, and they can still complain to the GDC. It’s much better, in my opinion, and my opinion, may well be flawed in to get that patient to go to another dentist who may have a better relationship with the treatment, [Jaz]But it’s having that difficult conversation, you know, with the patient be like, look at you know, I don’t feel I’m the right dentist for you. I guess that’s the only way to do it. But you know, I don’t know, based on what he said, I’d love to help you. But I don’t feel I am the right sort of a match as a dentist for you. If you’ve got to do it, case by case, but it’s a tricky conversation to have. [Stephen]The ways I’ve done it in the past are exactly that, just to be honest. So I’m not the dentist for you. And half the time they were ‘Yeah, you’re right’, which can be a bit bruising to your ego. The other half of the time, the last one, and you’ll just look at me. I said, ‘Well, you know why? Because we’re not on board. We’re not on the same page, you’re gonna be better served most likely by finding a dentist who’s more tuned to you psychologically.’ [Jaz]“Mr. Smith, I want the best for you, I think I’m not the best dentist.” I think that Yeah, fair enough. Honesty is the best policy. And I think that’s as best answer as we can possibly get into this sort of question. [Stephen]What I’ve just said is obviously for entertainment purposes only because I’m not a lawyer. I can’t give legal advice. [Jaz]Absolutely. Anything I ever say on any of my episodes is for entertainment purposes only. I’m just putting it out there. [Stephen]If you look at the principle, one of the GDC standards, it says put patient’s interests first. So if you’re going to treat this patient, you’ll be able to give them the result they want. You’re not doing it. [Jaz]Perfect. Love it. [Stephen]Though [inaudible] Parliament’s been buttoned up for years. Yep, they’ll treat patients who don’t like because they invariably don’t like you. [Jaz]Yep. And don’t treat patients you can’t have a laugh with. And it’s something I’ve said before, and it’s a good way to practice, actually. So next question, my friend, Steve, is consent forms, they aren’t worth the paper, they’re signed on. What is your advice in being involved in the medical legal field, being the expert. Consent forms? You know, is there a minimum threshold or procedure? For example, look, I’m being very honest. And I’m exposing myself, okay. I’ll be careful what I say, consent forms are not my favorite thing to do in life. All the things there are to do in life, consent forms aren’t highest priority for me, but I know that’s certainly my wisdom teeth, always. Oh, my gosh, wisdom teeth always. Now, can you give me some advice? Can you mentor me in this way, that should I be doing consent form for everything? Is there a limit? Photography? What was the medical legal take on consent forms? [Stephen]Well, as you said, they’re not really worth anything. The GDC only get insist you do them in very few circumstances, like general aesthetic sedation, that kind of thing. So I mean, you can do them, but they’re not going to prove anything, because you can give them a 27 page treatment plan, which they sign, and they can turn around and say, I won’t understand what it was, I just felt pressured to sign it. So again, it comes back to the patient, you must have the patient on board before you do any treatment. Now, that variable, you then have still have to do the treatment plan, because that’s the GDC requirement. But I wouldn’t get too concerned about the consent forms, to be honest. [Jaz]Amazing. This is music to my ears, but then you know, the type of some dentists are very fond of it. And you know, that doesn’t mean you change your practice overnight, stop doing it, whatever you find a comfortable way to build rapport and get your patients on board, do it that way. For me, I just look them in the eye and I tell them all the risks and I take my time I show them radiograph and as long as I feel we have an understanding and sometimes that what I love doing is I love quizzing my patients, you know, I say Okay, so what did I say the risks were from last time? What did I say on this? And half the time they remember but I remind them and I write in my notes patient, quizzed and reminded and it’s and patients you know, like that they’d like that interaction I found so that’s great. So consent forms to your discretion everyone there you know they’re not really the worth of paper though. You know the wrote on so I’m glad you said that. Anything else want to add to that before a move to next question? No, I think that’s it amazing right. So next thing is a children’s act. So when the child attends with their because a common scenario child attends with their father. There’s a whole Act about the father, if they’re not married must be on the birth certificate, blah, blah. Can you just clarify that scenario? [Stephen]That is quite a very complicated piece of law, the shoulders occurs. It’s all about parental responsibility. And if we get a second, am I able to pull something up from my computer? [Jaz]Yeah, go for it, please. Because I think this is a daily scenario for GDPs. And every time a child patient attends with their father, I feel like I know this stuff. I feel like I know, but every time I have a doubt, in my mind, I just feel so basically, I feel uncomfortable when a child is there with their father and not with their mother, because I’m not like 100%, you know, medically lead the best way, which is a shame. You know, as someone who’s became a father recently, myself, it’s a shame but you know, when a mother is there, I’m relaxed. With anyone other than the mothers there with a child. I’m on edge a little bit. [Stephen]It’s also good to worry about grandparent bringing, [Jaz]Oh, absolutely. Which is a common scenario. If you can shed some light on this for our listeners, that’d be amazing. [Stephen]I think if the husband, the father is on the birth certificate, then they’ve got parental responsibility. I think that’s what it is. But then how do you ask? [Jaz]Yeah, I’ve had to ask before and it’s just a terrible thing to ask. Very insensitive. [Stephen]There’s also things about children’s consent because the child has Gillick competence, then they can consent treatments, but they can’t refuse treatment. So generally, I would have the parents on board with until the kids 16 because then the 16 becomes an adult, it gets even more complicated then just have to find this thing I’m looking for [Jaz]No worries, but I’m gonna jump in as the now a 15 year old Gillick competent patient comes Okay? and they need some teeth whitening and I don’t mean they want teeth whitening, I genuinely means they need teeth whitening they’ve got yellow brown teeth and they’re being bullied at school. Okay? And I see this on the dental forums all the time. “Oh, I’ve got a 17 year old”, “Oh, I’ve got a 15 year old”, “Oh I’ve got a 12 year old patient” and by the letter of the law you can hack these teeth down for a minute you can slap on some composite which is going to need replacement events for the rest of your life and I don’t care what anyone says composite veneers they will need maintenance and replacement. So that’s all kosher and fine but then the teeth whitening bit so what is medical legal stuff because I you know, I hear it banded around that actually, if there is a psychosocial element to it, ie the child being bullied then whitening is allowed? Is that written anywhere? [Stephen]That the problem with that if they’re below the age of 18. There’s European law. So he can’t be, he can’t do the whitenening. [Jaz]Hashtag Brexit. [Stephen]Yeah, well, it’s probably gonna be still in British law for a good while. Yeah, even if we do leave, which I don’t think we will. I’m still don’t see that happening. Because if the states just pushing everything to try and stop Brexit from happening, despite what you hear from the Tory MPs. Yeah, so that’s gonna be interesting. [Jaz]But in the young person scenario needing whitening, I mean, my stance is this. And again, please guys, it’s for entertainment purposes only if I have like a 15 year old, 16 year old and I had the parents on board, and I have the child on board. And they genuinely are like, I haven’t had an encounter this scenario. But if they’re generally are really discolored, and the child’s being bullied, I would probably do it. [Stephen]Because you’ve also got the GDC principle, you got to do what’s in its best interest. [Jaz]Yeah, absolutely. So it’s a whole minefield, but that’s my true thought. And I would do that. [Stephen]So it’s not in the child’s best interest to pack their enamel off and rectify their porcelain deficiency. But it’s also is it in their best interest to do something that’s technically illegal is only a decision the practitioner can make based on their own judgment. And that’s going to be based on the relationship you have with the patient, the parents, because again, if they like you, and the wind goesw well, you’re not likely to have any problems. [Jaz]It’s true. So again, there’s a whole rapport thing again, with the parents and the child so it stick always goes back full circle, but I actually know a good friend of mine, restorative dentist, a fantastic clinician, I won’t name them just because I didn’t really agree to this. But in the one or two times they’ve had to do this exact scenario because it’s a referral practice. And they get referred the sort of cases he or she has actually written to the child and under parents to an explicitly written in the letter I will be carrying out illegal tooth whitening on you. This is illegal, in the letter, and it’s everything’s like really transparent. [Stephen]I can tell you what the ddu say, [Jaz]Yes, please. [Stephen]So this is under the law patients must be aged 18 or over. Although the GDC makes an exception for whitening the teeth of under 18 when used wholly for the purpose of treating or preventing disease. The DDU cannot envisage any circumstances where this might be the case, our legal advice is that there are no exceptions to the rule, and all patients must be aged 18 or over. [Jaz]Wow, that is very strongly worded. Today goes DDU says no, we’re not in any circumstance because they can’t envisage that scenario. But what is the definition of disease? You know, once again, you know, is it completely ignoring the mental side of it, which I think I’m sorry DDU, but I don’t like that. [Stephen]Yes, as well. I can’t go with DDU. I’d like to. [Jaz]Yeah, I think we’d all like to, but that’s not good. Okay. So we’ve talked a bit about the whitening to your discretion. I know some people who would some people who wouldn’t, but you know, that’s your discretion and it is what it is until the law changes. So next question is there’s an extraction that’s booked in, the tooth is grade two mobile, it’s a new patient to you, the diagnosis, whatever the diagnosis is, the tooth needs to be extracted. New you and the patient have come to terms with this, I would take a PA because make a medical legal world we live in even though in Sheffield, the way I was trained, it was actually a common, you know, it has two roots, you know, as you know, you don’t really need a PA. But nowadays, I don’t know a single clinician nowadays where we’re at, you know, and practicing, who wouldn’t take a PA in that scenario. So any comment on taking PAs prior to XLAs? [Stephen]I think you take a PA. I think that’s the way to do it now. Personally, I would also do a PA. [Jaz]Fine. So it is what it is, you know, take a PA, everyone. [Stephen]You can get, very rarely going to get some bizarre, apical pathology that makes you get [inaudible] that you know, some it’s like one in a million kind of thing. Some bizarre squamous cell carcinoma or whatever, they’ll ask me about all pathology [Jaz]but I think you’re right. [Stephen]I know one or two times I’ve heard dentist talk about what they discovered on a [radio]. So yeah. [Jaz]Yeah, I think in this current affairs, yeah, [Stephen]it’s like on peri I mean, you have to do your periapicals. I’m not convinced but I really need to, but that’s what the British regulation states [Jaz]Everyone, please take some PAs prior to XLA. Sorry. But that’s how it is. [overlapping conversation] [Stephen]This is literally wafting in the breeze when that when they breathe in and out. You probably be alright with that to not do a PA but don’t quote me on [Jaz]Of course not. But you know what I do in that scenario, I’d get my intraoral camera out and take three photos of that tooth in extreme buccal position, in the middle position and extreme lingual position, just so it’s like crystal clear. The degree of mobility. [Stephen]I think what you’ve highlighted actually, is there’s no proper guidance. There’s no, this is how you should do it written down on a piece of paper somewhere. Everything’s a bit vague. It’s a bit wishy washy. And there’s a reason for that, because dentistry isn’t the kind of thing you can have set rules for. But the drawback is everything’s open to interpretation. When it’s open to interpretation, then you get some fancy lawyer on the stand, who’s got his interpretation that it might sound completely wacky, but if the judge goes for it, then yeah, [Jaz]It’s a both a blessing and a curse in dentistry, that everything is obviously open to interpretation. But there are upsides to that as well, obviously, cuz you can, you know, justify and argue and that sort of stuff. So so that’s cool. Next question is, I used to work with a male nurse, right. And I’m terribly sorry, to my listeners if I have said this story before, but it’s a funny one. So I work with this male nurse, right. And he was taller than me broader than me. And he was a Sikh guy. And he had a bigger turban than me, right? So this is really is in private practice that and I know he’s listening to this probably right now. And I’m just gonna say, hey, champ, I hope you doing well. And anyway, so he’s actually a dentist in India, and now he’s just done his ORE and stuff. So patient comes in, female patient, okay? And obviously, he’s my nurse, and I’m the dentist. And quite a lot of times a patient would assume that he’s the dentist because he’s got, you know, a bigger turban and stuff and more authority and stuff, which was always a funny scenario. And the other funny thing was, when I’d been sort of leaning in the mirror and the handpiece and he’d be leaning in with the suction or turbans would clash, which is like a completely like, unprecedented scenario in clinical dentistry in the UK, I imagine. So that that was that’s my funny story done. But okay, in this scenario, I feel in this current climate two male nurses, female patient, that’s a no go. [Stephen]I think you might be right. I can’t quote you the law on it. And people will say there’s no problem. But the [climate] is so very driven. Now that I think you have to have a if there’s a female patient, you have to have a female in the room. [Jaz]Chaperone. [Stephen]But yet, but then that brings in all the other issues about transgender and all the different other genders that are now coming out. It’s a minefield. [Jaz]It really is, you know, women want equality. And we know I’m a big fan of equality and stuff. But what about this scenario, when you have a female dentist, a female nurse and a male patient? I know it sounds stupid, but you know, how is that different? Really, if you want equality? [Stephen]I don’t know the answer to that. [Jaz]It was just a stupid rhetorical question. Anyway. So Fine. So next question, thank you for that. So you’re allowed to make a recommendation, I mean, under GDC, you are allowed to, you should make recommendation to your patient, which I think is a very sometimes a forgotten point. And it’s a useful thing to have, when you’re explaining to patient that you know you’re allowed to recommend a treatment option. And then when the patient says no, and they’re completely within their right to refuse treatment for any reason, what would you recommend us, gdps do when a patient you know they need an extraction and you’ve had or they need a splint even and this, you know, you’ve come to the conclusion that, that’s what’s gonna be the most appropriate thing for their health for the prevention or whatever. So and the patient declines, it all you have to do is write at the notes for a patient declined and risks won is that as much as we need to do and or do we get in writing, that’s the sort of direction I want to explore with you. [Stephen]Well basically explain to the patient why you recommend the treatment, the benefits of the treatment and the risks of not having and the risks of the treatment and also the benefit not having the treatment and the risk of not having the treatment and then you record that in a clinical note, because the patient has the right to make what we think is foolish decisions because it’s their body. And obviously they’ll then turn up at [inaudible] on a Friday before Christmas. But yeah, just let them decide for that. And then when it then eventually happens that the face blows up on the middle of the transatlantic flight or whatever, then you’ve been seen to be the wise dentist warning them this might happen. As long as you’ve got the report and the relationship with the patient where they trust you that shouldn’t happen by and even if it does, you’ve got, you’ve told them and recorded it and then even warned them. And it was their decision not to go ahead. [Jaz]Yeah, this is always a tough thing. It’s a tough thing for all dentists. But I used to almost get like a flight or fight response inside me when like, for example, you know, oh, you just need two bitewing x rays, or you need two x rays in your routine x rays. And if the patient refused, and then I’m like, Oh, my God, I mean, this is, it becomes confrontation sometimes. So what I’ve adopted now is just don’t make the patient’s problem, your problem firstly, okay? Relax, and I just smile. And now I’m really, you know, I try and be real with them and say, “Look, I totally respect that, I respect your decision just to agree with them respect, I respect that, the main reason why we do it is because you know, you might have holes between your teeth, and I can’t see them in my eyes. And this is why we take those x rays, if you’re cool with it, I’m cool with it, as long as you know, there might be some holes. Is that right with you, Mr. Smith?” Are you saying that tone, and that really lightens the mood. Because, you know, there’s no point once they’ve made up their mind, okay, they’re not having it. And they’ve got their preconceptions or whatever. And sometimes it will, Oh, I didn’t realize that I’ll have the X rays. And but you’ve done your bit, and you’ve done it in a non confrontational, non judgmental manner. And I think that’s the most important way to do it. Would you agree with that? /-Yeah./ – And one thing that David Winkler taught me, you know, guys who work with him, he patients who need extractions, and, you know, they because the tooth gonna blow up, okay, he just smiles them and says, “Just don’t call me on Christmas Eve, just don’t call me on Christmas Eve”, you know, patients get the point. I love that. It’s so straight and real. So that’s a great communication tip to just smile, Yeah, that’s fine, Mr. Smith, but just don’t call me on Christmas Eve. And they sort of get it. So that’s mine. And I’ll get there. Shared. Steve, those are the questions I had for you. Tell me is there anything else that you’d like to mention that the microphone is yours to GDPs. Mostly, you know, I’d say 80% of my listeners, young dentists between the age of 25 and 45. So any anything you want to send out to them. [Stephen]Don’t be afraid of Montgomery. What we’re seeing is since it’s been brought in, isn’t that the court are kind of feeling their way with it. And they’re generally going down a more sensible road than we considered they would. I think, if I remember that in two legal cases, recently, I think it was A) versus East Kent hospitals university NHS Foundation Trust and Tasman vs. Bar. And both those cases, the case was thrown out because the risk patient was complained about that they weren’t warned about was considered immaterial, it was to support some really rare thing. And it was the risks of it happening were less than one in 1000. So generally, the resists or it’s not set in stone, and the courts might turn away and go down a different route sport, I think if the risk is less than one in 1000, it’s not classed as material, which means you probably don’t have to worry about it. [Jaz]That’s interesting. [Stephen]There’s three kinds of risks. There’s the general risks, so you know, do an injection, you’re going to be numb, that’s a general risk. Treatment specific risk, you can take out a six and the root [inaudible], but it’s also patient specific risks. And that’s where the gray area is, it’s a rare risk that might be relevant to a specific person based on their their lifestyle. So a trumpet player might consider the risks of paraesthesia, for lower lip more relevant than, say, someone who works in a factory, [Jaz]Even though the risk might be again 1000, wherever it becomes more patent, [Stephen]Because if they have paraesthesia [inaudible] and that’s their life, that’s their livelihood. [Jaz]So the message there is have that rapport because you would have no idea about the trumpet playing if you didn’t already have rapport built in and a social history. [Stephen]So that’s where the conversation in the chat comes in that will then come out. [Jaz]Because when you mentioned that about the 1000, I was thinking well hang on a minute, oral bisphosphonates the risk of you having you know, [bronch] from a tooth extraction on someone who’s, you know, on oral, you know, an uronic acid or whatever, without any steroids, nonsmoker, that sort of stuff is like one in 10,000 to 100,000. But you’re right, that’s a very patient specific risk. And you know, you should discuss that with the patient. [Stephen]or we shouldn’t even be the ones that were warning them about that should be the medic. [Jaz]Yes, true. And so many times a patient have no idea or maybe the, you know, maybe the medics have told them, they just forgot, who knows [Stephen]The medics generally don’t tell them. I mean, I’ve had a bit of interaction with medical question the last few years and their consent process is woefully inadequate. [Jaz]Oh, absolutely. I mean, I’ve had some medical procedures and the way they’ve gone through stuff with me and I’m there saying Whoa, this is consent? [Stephen]But the thing is litigation side because the patients don’t pay, there is this for medicine, there is this because you lack of need for all this. But if you look at the NHS, it’s putting some money aside for future litigation. I think something like 60 billion it’s a crazy amount of money. It’s just sat there to fight off future litigation because the lawyers are really getting clued up on this and so the patients. Patients are realizing now that negligence can be a good way of earning a little affair trust [Jaz]So very sorry state of affairs. [Stephen]But patients won’t sue you for like, you know, there’s been study after study that shows that if the patient likes you, they won’t sue you. When I’m sure you read the book, blink. [Jaz]Yeah, read blink. Yep. [Stephen]Yeah, the As a gold chaplain in that book, [Jaz]I’ve also read your book, the dentist Survival Guide. There was that chapter. Oh, gosh, is it by [Amin Armenian] Is that right? Fantastic. Really, And it was that book wasn’t a dental Survival Guide. Or was it masters? Message for masters? Which one was it? [Stephen]Dental Survival Guide [Jaz]Okay, so what I loved about his bit, and it’s worth mentioning here is that if you do too, and correct me if I probably recall this wrong, Steve, if you do two of the following three things, right, your patient probably won’t sue, okay? So A) if you’re nice to the patient, and have rapport B) if you do the correct treatment plan, and see if you do the treatment plan well, so for example, you could be nicer to the patient, and you can do some really good treatment, but maybe it wasn’t the most appropriate treatment, then you probably should be fine. Or you could you know, do some, the correct treatment plan. It’s not, look amazing, whatever. But the patient likes you, you sort of like also be fine. So I really like that way of thinking about it. [Stephen]Yeah, the problem is, no matter what you do, there’s always going to be that risk, there’s always gonna be the patient that can slip through the whatever systems you put in place. So you just have to keep good note. And again, there’s the other thing, when, where’s the guidance on how to write notes? [Jaz]I’m hoping you write a book on that, mate. [Stephen]Well, does this mean you remember? I got some guys from dentinal tubules. And we did the examination. what’s right for examinations? What five restorative procedures? Which is given away free on my website, just like I mentioned that, [Jaz]no, absolutely. I’ll link everyone as well. Because this is, you know, people always like, you know, “templates” or whatnot, because it really helps you as a signpost to make sure that you’re consistently recording notes at a high standard. [Stephen]Because there’s guidance from the faculty of general practitioners on what to write for examinations. There’s guidance from the various society on what’s the right tone of treatments, and there is a little bit of guidance. I’m not sure how it can be called guidance, but it’s everything we’ve got. It’s a position paper from the European endodontic society or something, which I think that’s now classes what you should record when you’re doing endodontic treatment. But apart from that, I can’t really find anything for MLS manual surgery, like take your teeth out, what should record obviously, there’s going to the implant societies will have guidance for what to record with an implant. I know. You know [Jaz][Kara?] [Stephen]Yeah, he’s got a website, I believe [Jaz]my implant plan, [Stephen]Yes. Which has everything he needs to record and everything to tell the patients which is very good. And that’s free as well, I think, [Jaz]Wow, I didn’t know it’s free. I will contact Parven with I’m sure would be fine with me sharing that with our listeners, because anything to help everyone would be good. So thanks for raising that. [Stephen]Just record everything. [Jaz]Good luck. [Stephen]When are you having a conversation with the patient, your nurse could be typing away? [Jaz]So I’m so glad you mentioned that. Yeah. So my nurses, I try and train them as much as possible that when I’m done with my patient, there should literally be like, you know, like a transcript like Jaz said this, patient said this. So yeah, fair enough. Some nurses are better than others. But hey, this is an in service I’ve seen an advert for it’s like [Hiroku] or something it’s called, it’s where apparently, it’s like an Amazon Echo that’s listening to your conversation and converting into notes and stuff. So if anyone’s got any experience with that, and once it gets feedback, how that’s going, please let us know. Because that’s, you know, anything that can help everyone record notes better, faster, quicker, that sort of stuff. So that’s interesting as well. [Stephen]There we have databases and patient conversations teacher is a whole server forms full of these. Now, I don’t think we need to go to that level. I think just because if it’s in the note, the courts will generally say that’s what’s happened. Promise, you can’t rely on templates, because I’ve actually seen this in legal cases where you’ve got the notes, and it’s the notes of Mr. Smith. And halfway through the record of that day patient warned about pregnancy. So it’s been cut and pasted and they’ve not actually read through your notes can have a certain degree of templates applied to them, but they still have to be bespoke. [Jaz]This is why I like custom screens. Are you familiar with custom screens? [Stephen]I try to avoid computers as much as [Jaz]You are so old school. No, Steve, custom screens are amazing. And this is actually give me a really good idea, I use a really good custom screen, which I made myself on SOE and I’ll try and sort of share that with everyone. It’s like, so on a custom screen you’re actually taking things and your drop down menu, select things so you never sort of writing or using like a template, you have to actually manually choose something which means that you would have had to go through it. So I love that. I think that is more, you know, medical, legal proof if you like. [Stephen]Yeah, I think that’s really good. The only thing that makes me pause is how that looks when it’s printed out on paper. [Jaz]True. I’ve never tried it. That’s a great point. Actually. Worst case scenario just open up exact. You know, it’s all there. I just buddies text screen shot [Stephen]Simon factory did his LLM, his law masters and his dissertation was on bias and expert witnesses. And he found that expert witnesses are very biased if I remember and one of the thing that occurs to me if you’ve got notes that are hard to read, let’s say let’s make it easy, you’ve got handwritten notes and you’ve done spider scroll. If you give that to an expert witness, he or she’s going to be like, you’ve got legs? So the expert is already against you. Because you’ve made it difficult for them, if you’ve got a good notes with everything, then it’s going to be easy for them. And that bias might slip in your favor. It’s just a thought it just occurred to me. [Jaz]No, no, it’s true. So make sure your notes are clear and legible. Because if shit hits the fan, Excuse My French, then they won’t be able to read your notes. [Stephen]I mean, I teach dental students, and they do like to write their magnum opus, every time they see a patient, slightly less patient that the site don’t need to go to that level. But if you do want to go to that level, then at the end of it, just do bullet points of what the actual treatment was. So you can skip all that anything. Okay, that’s what’s actually been [Jaz]So the notes have to fulfill the benefit to use so that when you actually go back next time, and you look, you know, you’d have to read through all that stuff. So that’s a good point, you know, have you made notes and have a little summary to help you. So, Steve I think that’s all we’ve got time for today. Thank you so much for coming on. I will share your law and ethics website. So because I know it’s got a lot of helpful resources, the templates that you mentioned, I’ll reach out to Pam I’m sure be happy for me to put my implant plan out there, I try and get a exportable version or importable version if you’d like of my SOE exact template, which I think is a pretty good and thank you for covering really pertinent key points, which actually confused dentist and finally, I realized that Montgomery is a woman and it wasn’t a man. So thank you. Jaz’s Outro: Thank you very much, guys, for listening all the way to the end. I really appreciate it. I hope you like my custom screens. I’ll make it available to download on my website will be on www.jaz.dental/customscreen. That’s all one word custom screen. So now you’ll be able to download the custom screen. It’ll also be on my normal under the of the blog post for this episode. I hope you find it useful. Give me some feedback. See what you think. And if you guys have got like, if you guys in the Protrusive community have got good custom screens and you want to share them with everyone, please send them to me I’ll happily like make it make a page on websites we can all share our customer screens because look if we can all help each other, record better notes more efficiently, then that’d be amazing. Apologies if you’re an All for though, I realized that I haven’t really given you guys anything. Sorry. Once again, thanks for staying at the end. And next episode will be with Jason Smithson. And we’re talking Emaxs onlays and vertical preps, vertical crowns, which is really really good episode obviously pre recorded. We’ll be launching that soon. Tickets for occlusion 2020 are pretty much almost sold out. So hence why I’m not really promoting it that much anymore. You can be seen a massive drop in the ads. I’m running on Facebook. So thanks so much for those who’ve booked and I’m looking. We’re so stoked for May. It’s gonna be the best occlusion event ever. So we’ll see you then.

Dr Tif Qureshi is back for Dahl Part 2! Need to Read it? Check out the Full Episode Transcript below! We build on that awesome first episode (Episode 16) and discuss: Contraindications of Dahl Technique Maximising success Uses of splints during Dahl Technique – is that even possible? What type? When? Communicating with our patients Assessing the Envelope of Function What if Dahl fails? Deprogramming prior to Dahl What if the Dahl wears down years down the line – how to ‘recycle’ Dahl technique Influence of Digital on Dahl technique? On the show, I promised Tif I would share a full protocol case with him – you can see this on my Protrusive Facebook page here. *PROTRUSIVE DENTAL PEARL* A £30 composite heater! This mug warmer looks really posh and can be used to heat composite and local anaesthetic.   https://www.youtube.com/watch?v=Y6WuuHI__oA Check out this full episode on YouTube Click below for full episode transcript: Opening Snippet: I actually seen quite a few cases have been posted online on one or two articles written, you know, people have said Oh, it's not sure if it's gonna. Actually, it's not gonna work. And the way I view it is if someone's got an in standing premotor and they need a dahl, because why not just have you know, a few mouths or a couple mouths of ortho, you know, it's not a rocket science to move that tooth, that's the point if you've got a little bit of, you know, dahl is effectively like doing some ortho. It's like doing some ortho but we're talking about biplane... Jaz’s Introduction: Hello, everyone, and welcome to Episode 17. The one that so many of you have been pestering me about. I sort of teased you with the first episode with Dr. Tif Qureshi Dahl part one, and then I threw in the 12 rules of dentistry which was please say greatly received. And then a lot of people got value from that. And now to continue on from that cliffhanger I left you on with Dr. Tif Qureshi. I’ve got dahl Part Two for you today. So this will be the spicy part. Now, before we get into an excellent conversation with the top man that is Doc Tif Qureshi some important things. Firstly, a very Happy New Year to all my listeners. Thank you so much for tuning in in my first proper year. 2019 was really the first year I started podcasting. And honestly, I really, really appreciate you taking your time to listen to it. I struggle to listen to myself, you know, I make myself cringe. But the fact that other people are listening to me is just it blows my mind. So thank you so much. A massive shout out to one of my listeners. I’m not gonna ask him but he messaged me to say thank you. Because somehow the episode with Druh Shah and myself episode 3 transition to private had such an influence on him that he decided to change his environment, change his mindset. And he thinks that good things have happened because of it. So now he’s in, his goal was to be in full time private practice, and now looks like in the coming months he’ll be able to achieve that. So if I’ve had that sort of influence on him, that has literally made it completely worth my while. And that’s exactly what I like to do for as many people as I can. I love sharing my enthusiasm and my love for dentistry. And it’s so great to hear stories like that. So thanks so much for reaching out to me. And thank you Dhru Shah as well for a great episode that we did in Episode Three. Secondly, I’m really sorry that I didn’t give you a Protrusive Dental pearl with the last episode to make up for it. I’m going to give you today a really, really awesome pProtrusive Dental pearl which can save you hundreds of pounds potentially. Okay, so Hear me out this pearl or this hack will save you money on buying a composite heater. So the first question that some people ask when we talk about heated composite or a composite heater is why would you heat the composite in the first place. So from my understanding from in-vitro studies, it’s suggested that there are improved physical properties, high percentage of cure, micro mechanical details of that sort apparently heated composite is a good thing to use. However, I like it because of the physical changes that happens when you heat composite, it becomes much less viscous. The wettability of the concert significantly improves. So people use it for bonding, Emax onlays, for example, posteriorly I use it also for injection molding ala David Clark, ie the bioclear technique, which I love, I’m huge fan of bioclear. So to use heated composite ensures that it will flow into all the nooks and crannies of the bioclear matrix and prevent any air gaps and air voids. So it’s a great thing to use. So that’s why you would essentially use heated composite. So what is a less expensive way to heat composite you know, these composite heaters can cost a significant amount. I’ve tried the following methods before over the last six years, I’ve tried a cheap three pounds Chinese make coffee mug heater like a USB one that worked well, you know, actually did work and you know, broke few times just buy a new one, it’s really cheap, you know, buy cheap, buy twice, and all that sort of stuff. So it would work well. But the only issue is that I had no control over what temperature I was achieving. And apparently the literature suggests, and when I mean the literature, I mean Jason Smithson and wrote on Facebook, so it’s gospel, it should be about 55 degrees. So I didn’t know if I was hitting that 55 degrees or not. Another thing I’ve tried is by putting the compule up by the operating light, so you know you’re operating like a lot of these lights have like a little gap like you can almost get your finger inside this little gap, it’s difficult to explain. So you can put your compule inside this little gap and our light gets really hot. So the composite compule can get really hot through that method. And that worked really well. The problem with that is what happened to one of my patients once I was moving the light around and the composite compule becomes, you know sort of fell on his head, which was funny at the time I guess but in the patient is cool about it. So that can happen. Also, again, there’s no control over what temperature I’m actually hitting by using the compule up in the light. The hack I have for you, the pearl I have for you is to buy a really posh coffee mug heater, so it’s a really posh one it’s by a company called COSORI and it’s sort of available on Amazon, I’ll put a link to it on my Facebook page and my blog www.jaz.dental under this sort of Episode 17. So you can click through. And it is phenomenal. If Tesla made coffee mug heaters, that’s what it would look like. It just looks really Swish, it connects to your mains, and you can actually control the temperature. So I’m going 55 fix degrees and I can be confident that we’re hitting that so it looks really nice in front of patients it looks professional, and it doesn’t actually look like coffee mug heater at all, you can you can make it what he wanted to be. So it’s in that using that which is just 30 pounds is fantastic. So that’s my major Protrusive Dental pearl to make up for lack of a pearl last time. I think if you haven’t got a composite heater and you like to use heated composite, it get it, it’s just fantastic. The Gold Standard obviously is to buy a proprietary composite heater, but these can cost upwards of 400 pounds to 1200 pounds. I’m not against buying it I just you know so if you please buy the best you can afford. But here are a few reasons why I am not in a position to buy a 600 pound composite. Number one, I’m an associate that’s pretty self explanatory. I’m taking my gear to different practices. So I don’t want to be you know, moving around such expensive gear all the time. And number two, the money that I don’t spend on equipment I get to spend on courses and you all know how much I love going on different courses. So you know for me I value courses way more than paying you know, apologize saying but over the odds for some materials. So I mentioned about this composite heater on a Facebook group and Steve walked in from Optident big shout out Steve, awesome guy, awesome company, which is Optident. He actually made a counter argument said, hey, look, if you’re undercutting the UK, dental suppliers, and you’re going to Amazon to buy this tool to hit composite instead of buying a proper concert heater, then I might as well go to Turkey and get my implants done. Well, you know, I respectfully disagreed with him. It’s very different to that. What I’m not recommending here is to go on eBay and buy counterfeit hand pieces. I’m not saying that. What I’m saying is where you can save money on things that you know, you don’t actually have to put in a patient’s mouth? Do it. Why should we pay over the odds for something that we can achieve in simpler and cheaper means? I know plenty of people that use a baby bottle warmer to heat their local anesthetic or hypochlorite. So same principle, really. So I’m totally cool with that. If you think it’s immoral, then go ahead, buy the expensive composite heater. Can afford it, do it totally, that’s the best thing to do. I hope that pearl was useful to you. And now we can jump in and join Dr. Tif Qureshi, what you’ve been all waiting for. Main Interview: [Tif] And this is gonna be one of the questions that we were sort of thinking about here was, Why do people not appreciate it and one of the biggest problems is I think a lot of people use dahl on the wrong patients when it’s too late. And dahl is really for patients that you’ve had a relationship with you, they understand what’s going on. And you actually say to imagine to brand new patient who’s got a bit of wear on the anterior teeth. Imagine trying to say to them, right? “I need to build your anterior teeth out to improve your anterior guidance and disclude your posterior teeth blah, blah, blah.” This guy talking about [Jaz]I’ve been that, Tif, I’ve done that. So you must teach me and my listeners that hopefully I’m better at now than I was. But tell me about how you would approach that. And then how to actually communicate to patients Oh, you’ve lost your canine guidance interseptally, you’d benefit from a interceptive dahl technique. So how do you approach that? [Tif]It’s all part of a, for me, a much more everyday comprehensive checkout. And I don’t mean a comprehensive checkup as in our comprehensive exam. I mean, you have your comprehensive exam, which you know, you deal with a new patient, but actually, every chapter, there’s lots of little things that we can also be looking for, talking to the patients about, explain to them, that then helps them understand the dynamic picture what’s going on. So, you know, we’ve already mentioned tooth surface loss, you know, looking very carefully at dentin and making sure we understand that, you know, this stuff is six to eight times softer than that stuff. A lot of people don’t understand that when I actually give a lecture and I asked dentist and I talk about dentin, enamel and I say, you know, what do you tell patients about how soft that is compared to I mean literally one handlebar in the room. So it’s not something dentist potentially confident in saying but actually patients need to know that that stuff is a lot softer. And as a result it will wear, erode and whatever quicker. That’s one thing [Jaz]I tell my patients but only because I went on your course in Sydney. So I do tell to patients, I show them because I take my DSLR photos in a comprehensive new patient examination. And I showed him that yeah, that you know what that is? And I say, No, is it well, you know, that’s a dentin that is seven times softer, that’s what I’d say I just leave him with that. So it’s co diagnosis [Tif]Exactly. But then the key thing is, you know, if you do that on a check up, you then reshoot that image six months a year down the line, what I’ll say to the patient is okay, that’s there is some wear there. I said it’s not that’s not how it should be but don’t panic because you know, the tooth isn’t gonna fall out for being like this. But what we want to do is to see how it looks in at you know, in a few months time, see if your bites change, see if you any of the anterior contacts. And critically also, of course, see if your teeth are moved. Because if there’s if you have a combination of anterior crowding, and wear then you have this whole kind of concept of potentially constricting envelopes, not every patient but if some patients and I found that a really easy concept for people to understand And you know, if they see a lower tooth sticking forward and and then an upper one subsequently sticking forward as well. And an upper one sticking back and a lower one sticking back doing a very simple this is a thing that I do every checkup. I do a very simple fremitus check on every single check every time to make patients aware of the tooth position. And the very simple way of doing it is I literally put my finger on their teeth, I lean on their teeth from four fingers on the front eight teeth, and I’m literally squeezing the ligament and I just say, you know, it’s going to lock the complaint piano on your teeth. I said, Now I want you to bite fully on your back teeth. And actually, what often happens is a tooth that’s out of position, one tooth or two teeth that are out of position, they start to knock more heavily against one of the lower teeth. And I think that both Can you feel that? And they’ll say yeah, so Well, that’s probably happening, not 100%, but probably happening because that lower ones drifting forward a little bit. And it’s the key point is it’s continuing to slowly drift, but it’s slow. So we’ll look at again, in six months or a year, we’ll take a photo, now I’ve got a scan out, I’m telling him, we’ll scan it and then I said you don’t, what we’ll do is we’ll look and see whether we have to change it. You know, what usually happens one year, two years out, it’s happened five years later, and patients come in and said, you know that you’re telling me that those wear and I think that tooth is moving. And I’m sure that he’s darkening a little bit as well. Then we say, Okay, this is what we can do, as we’ve discussed, and we go from there. And that I mean, in a nutshell, a lot of those cases described in that way and not even with tooth position but just tooth surface loss. You know, it’s come back a little bit later becoming a bit more aware of the color, the shape, the edges, the sharpness, and then they say, yeah, let’s get it fixed. So [Jaz]Hats off to you, Tif, because no one actually talks about, I mean, no one ever talks about, oh, five years later, I’m then gonna give him the treatment plan. No one talks about that. So ultimate respect for you for for having such a long term view with that. And also that’s it you know, that’s a great clinical tip to use your two hands, four fingers, front teeth push down, ligaments squeeze, bite together. And that really makes it tangible for the patient. [Tif]The key thing is not you know it You mustn’t panic people it’s about I just say I always reassure them that this is normal. This happens with a lot of people, you know, tooth movement, and wear it’s a normal thing. Some people might call it aging, But actually, it’s preventable. So, the key thing is that the problem is so we go back to what we said earlier, you know, there’s this whole kind of selling pressure people have, and there’s all the gurus that teach you how to sell and somehow if you don’t make the sale on the day, you’re upset at the way I described, it is what you should actually do is tell don’t sell. If you tell people what’s going on with me. A lot of dentists don’t tell, you know, they talk about caries, they talk about perio, but they don’t look at occlusion, they don’t look at slow occlusal changes, they don’t look that slow tooth positional changes, if you tell people about that patients are not as stupid as we think, okay? You know, patients do understand I talked about envelope with function every day in my practice in Kent, and every single day, one patient walks back into the door and asked me how their envelope of function is. And I’m not joking. And then that comes from literally a two minute demonstration of how their teeth should be moving. And then how their teeth are actually likely moving and how much overjet they’ve got and how much overbite they’ve got. And that is a normal patient. [Jaz]I feel sorry for these patients who when they geographically relocate, and they find a new dentist, and they ask their dentist, how’s my envelope of function? And how startled the [Tif]You know, the thing is, yeah envelope of function, it’s quite an interesting one, actually. Because it’s theorized, you know, Pete Dawson’s work on Frank Spears work on it, there’s not a portion of it that needs to be, there needs to be real good clinical data on it. Because what I found quite amazing is that inside our profession, some people not even heard of it. Right? You know, in orthodontics, there are some orthodontist who’ve never even heard of it. Never. [Jaz]It’s true. I’ve just finished my ortho diploma. And that was not mentioned. And this is quite a comprehensive diploma. You know, and there was not mentioned once about envelope of function at all. And I think it’s a key concept. But you know, we have to be honest, Tif, And you know, there’s more than anyone that there are some camps who believe that actually, there is no impact and they believe it’s purely parafunction, whereas other camps in a believe that yes, there is no element of that constriction, the teeth knocking together more. So, you know, technically, we will never know when we can never make the study. But it just makes sense in terms of clinical observations we all make we can see this. [Tif]That’s exactly right. And you know, what the way the way I would say those in doubt, please show me your case follow ups. 10, 15, 20 years later, please show me that. You know what, they haven’t got them. There’s a lot of people that love to talk the talk, but they never see that patient again. And this is the thing if you don’t see your patients again, but you think you’re you know, a real hot shot, got no position despair. That’s the problem. And it goes back to what I said, what’s the core problem in our profession? I think actually, our professional curriculum has been created for our own convenience, not for the patients. So people you advance through your career and you get all these labels, but you’re not necessarily actually doing anything better for the patient. What would be best for the patient? Is it you looked after that person if you carry out a complex treatment, and even if you can’t, you made sure the work they had carried out gets looked after? And, you know, let me tell me anywhere in our profession where that occurs. I think the only area it does I believe is a perio. I think perio has just got that long term mentality to it, but it’s quite controversial. [Jaz]And the studies in perio, you know that x was on paper 30 years and stuff, and that, you know, they’re really into that. So I agree that’s probably the area of density. We have such beautiful long term [Tif]As well, but for different reasons, basically. Yeah. You know, and I think a longitudinal view on everything is a good thing, because it teaches us if not everything, we do works, and that stuff changes over time. So, you know, and it’s GDPs always going to be the person that’s going to see that [Jaz]True. Next question I want to ask you is do you routinely deprogram your patients before starting a dahl case? [Tif]I have to say, my dahl buildups are my deprogrammer. So once upon a time I never did then once upon a time I started doing and I started learning about splints, the deprogrammers. And then actually it sort of dawned upon me, why am I doing this when actually the thing that I’m bundling in their mouth is a deprogrammer. Okay? And so actually, now, if it’s appropriate dahl case, I mean, come on to that what’s an appropriate dahl case, because there are a few things that aren’t appropriate. But if it’s an appropriate dahl case, actually, the dahl build ups are the deprogrammer, so I, what I tend to do is I tend to just build them up so that my initial point of contact is just slightly posterior to maximum intercuspal. And you could say, Are you guessing, and actually, for years and years, I guess, and then actually, I started to try to take records. And I then started to set my dahl up to my supposed CR records, and it doesn’t, it made no difference whatsoever. So the key thing is you put the dahl, you put the buildups in, but then it’s critical, you get the patient back two weeks, four weeks later, because at that point, you may well find the patients now reprogrammed and suddenly you develop there’s an interference posteriorly, I have to say. [Jaz]Fantastic and I’m glad you’ve said that. So how many times has that happened to you? Because you’ve done dahl more than anyone probably so how many times that happened to you? [Tif]Well, I’d say is quite rare because it’s probably 1 in 25 cases, maybe something like that. And the reason why is that if you think about it, you’re actually separating the back teeth and so therefore Yes, of course the jaw can receed and then it can find a new position but because the back teeth are separated, what effectively then happens is a process of you know, in inverted natural equilibration so it’s quite rare I have had to you know, there’s been your tooth or you find a you know, a cusp of lower seven or upper six or something is knocking where it wasn’t before, but it’s not that common and [Jaz]It’s happened to me in my fifth, probably the fifth dahl case I’ve done and the patient of deprogramming I was Oh, okay, this is interesting. So I’ve had to follow that up and treat it and there’s a really good dental update paper actually put on as well were these clinicianss I think Leeds Dental hospital had a case where they just went ahead, wax it up, did a dahl, and then the patient deprogram to a quite a significant horizontal reconcler repositioning so that now they were extremely class two div one, they’ve lost all that anterior guidance. Yeah. So it’s rare, though, I agree with, I was in a postulate 2-3%, you said 1 in 25. So that we don’t have any, I suppose we don’t have any data on this, but that’s, you know, coming from you, I totally respect that. So this is why Personally, my philosophy is I do deprogram, but I’ll tell you about the Okay, how about you tell me if there’s anything else you want to tell me? But also tell me that Okay, once your patients have dahled in, what do you, how are you managing them with splints or not with splints. [Tif]Okay, just come back come to that in a second. But basically, another thing just to say and you know, all the papers that are written on these, if you look at the patients that have been treated, a lot of the train wrecks already, this is the key, you know, brought the cases end up in universities and hospitals cases that Dentists have left far too long. And so a lot of the patients are you kow the patiens have proper sort of severe occlusal issues, if I showed you and I’m not saying that those patients shouldn’t have been treated, and of course, they need to treat it. But if you look at a lot of the cases that I’ve treated, their patients that are early phase, you sort of get my point? So what I and that’s the thing, it’s quite a difficult thing to kind of explain and I’m not saying that you The point being is that the patient that was treated in Leeds or wherever should never have probably got that far. That’s the point and that patient has ended up there because the dentist you know, couldn’t do anything about it. Dahl is a treatment for everyday for your patient, it’s a treatment that I actually believe virtually every single person no you put it at a high percentage of people at some point in their life will benefit from if it’s only used to treat the train wreck. If it’s used to treat the train wreck it will be unpredictable and it won’t always work for it should be for preventing a train wreck. That’s kind of the way we think about it. It’s preventative treatment it should not be as severe I have used it in cases where they you know there is a lot of wear already but they’re just about the patient now just starting posterior wear because you can see there a really heavy bruxist, they are quite young and they’ve gone through the tip quite quickly. [Jaz]And that’s exactly the patient that had the condylar repositioning quite significant in my case, actually so that’s why now since then, I’ve started to deprogram but I take your point that actually maybe when we’re using it appropriately interceptively, the need for that may not be as significant as those sort of train wreck patients who have had severe occlusal issues, severe bruxism, that sort of stuff? [Tif]Exactly. And actually one you know, when I teach in my courses I’m actually just I’m appreciate a lot of people that come in and listen to that are kind of looking at this for the first time I want to actually tell them it’s in those patients don’t you can identify proper TMD or, you know, some of the massive shifts. I said, don’t do it on that case. I do use it on that case. But I wouldn’t start with a patient that’s got no restricted opening and huge clicks and all that sort of stuff. And masses amount tooth surface loss. Really this is for somebody we build the discussion that with over time, they’re losing their guidance, they’re trying to prevent them through a combination of dahl and potentially ortho you’re trying to prevent canine width collapse, lots of OVD, earlier rather than later. That’s really the key. Now, I guess I do use it on patients who do have kind of more severe tooth wear they’re more into anything, it’s just not got a posterior wear and I’m just about okay to do dahl, but if they’re heavy bruxist, then it might, in my strategy is this, I will dahl them exactly the same way, we go through a period where, and there’s a little bit of worry and risk when we’re waiting, because obviously, actually one issue is when you’re waiting dahl to occur, you can’t really wear full mouth splint or anything to protect it, because you’ve got to try to wait for that compensation to actually occur. [Tif]I’m going to come on to that because I want to think about splints. And so at the moment, when you’re dahling in, you’re leaving them new, no splint. [Tif]No splints. No, I do sometimes [Jaz]like an anterior only splint, maybe? [Tif]But that has to be given to a patient that you trust that and you know what I mean by that, it’s a patient that you trust to follow the instructions. And the instructions are, of course, that as soon as they’re back teeth start to touch, when they are eating, and they removed it, they must remove it quickly. And that’s also means that you follow them up quite quickly. Obviously, the last one is leave it there and then end up with an anterior open bite post treatmen. Which is possible, of course, it is possible. So sometimes, if I’m worried about that, I will protect them. But actually, so what I used to do for years and years and years ago, I would dahl them, okay, and then if I was worried about teeth tripping Well, back in those days, we gave them a rubber bite guard, which we know are, well some people actually don’t believe in. But I think they completely useless. Anyway, again, I used to get rubber bite guard. And then I started getting into splints and started, you know, learning how to be splints, you know I use splints, I can still use splins as I use this. But actually, I have to say the vast majority of my more severe wear cases treated with dahl. And now, dahl and an essix retainer. And that’s it. And I found that that in most patients is enough, I can kind of think of the last five years, there’s only one patient whose teeth who kept going through the assets and then ended up giving them a splint. And I think part of the reason being is that actually having the dahl buildups bonded in your mouth is it’s quiet, it will go no one really understands how to why people brux, there’s loads of reasons for it. We know that loads, but it but actually opening the bite, building the anterior is it’s as I say, the way I describe it, it’s like having a deep, anterior splint bonded in your gob that you can’t remove. And actually I found patients, I’ve got loads of examples of patients who I did treatment on who had severe bruxist, and that I dahl them. And actually, somebody didn’t come back for five years, and they came back. I didn’t have no splint, no mistakes, and all the composites still there. And you think, Well, you know, lots of examples, it’s not like one or two but lots. So actually Now, of course, life circumstances might change, the stress levels might reduce, they’re might be sleeping better at night, they might, you know, [Tif]But if you think of the mechanics of that situation, I mean, you build someone, you rebuilt the anterior guidance, so even if they are bruxism, the fact that it’s anterior contacts and muscle contractions are less and that’s part of the theory. [Tif]Exactly. And then just as a point, you know, even if you’ve been negative at all, you think, well, what are you actually doing, you’re just adding something to the teeth, you’re not spending a fortune on it. And actually, it’s quite simple to do, it doesn’t take very long. And we’ll talk about that perhaps as well, but how to do it. But because I think some people some of the techniques that I’ve seen become so complicated, that actually almost puts people off from doing it. But actually, it’s not that difficult, not that simple. But what the worst can happen, there’s no preparation, I’m prepared to teach at all. So even if after who knows three years, it all wears back down to nothing. The way you look at it is, you’ve got three years where none of, let’s say there’s been no further tooth surface loss. And I take the view really that if I can get anything for five to eight years out of it, even if not all patients, you know, the way you think about it is the five to eight years, your teeth are going to be the same because there’ll be no theoretical aging of those particular teeth. And when it comes back, [Jaz]Oh, I love that ageing of your teeth. That’s a communication gem, because patients need to be you know, hear it in a way that they can understand. So I’m writing that one down aging of your teeth. That’s really good. [Tif]Because you know, a tooth aging is, it’s tooth surface loss. It’s taken up of color, it’s chipping, it is movement. And you know, and I think another thing people don’t appreciate, is how particularly I think when you see it over the years, you see a patient over the years you notice a tooth that has dentin exposure. If you look at patient over the years, just watch how dark their teeth go. You know, it’s again, it’s a thing that no longer true nor kind of view on it. But teeth go dark and it’s because dentin absorb stain massively and at that particular, some drinks tea, coffee, smokes, you just know that someone with an open dentin have gone to what’s called dentin lesion, the permanent with open exposed dentin, they’re going to get darker teeth and that all contributes to aging. So yeah, the point being is that [Jaz]No, I like that very much. And the reason I asked about the splints and basically when you when you’re talking I wish we were videoing actually because I was smiling it because this is a huge part of my I mean I’m massively into splints and I do all types of it but my go to splint for someone and I’m glad you mentioned it who has no temporomandibular issues at all, healthy, who has no muscle issue. Okay? I am totally happy with a passive fitting and actually for me it has to be passive fitting, I get the lab to block out the undercuts essix retainers, so that they’re really comfortable and easy because you don’t want to give someone a really tight essix retainer to put them, you know, the compliance of it. So I’m so glad you mentioned that. And that’s, I use that as a protective appliance. So not really a therapeutic or diagnostic, it’s a protective of go-to appliance, because it’s cheap and cheerful. It works. And it can be comfortable when it’s made the right way. So I’m so glad you mentioned that no one talks about that. [Tif]Exactly. I mean, this is the thing, and I’m just, you know, it’s this is kind of what I’m using, I’ve gone through a whole spectrum of usage of various devices. And I did go through a whole period of experimenting Michigan, Tanner, soft splints, and you know, what, I’ve had great results from various things. But what I do find now is that the vast majority of cases if they can be, and remember, these are those appropriate dahl cases. And those are the most of the cases I’m treating, I don’t treat massive train wrecks, because I’m trying to prevent them. That’s the point. I get patient comes in who you know, needs a lot dahl. And you know, I deal with that, and I deal with as I need to deal with it, but most of them end up with build up, which I know have an effect and then vast majority with essix retainers and the ones that break through those or, you know, keep parafunction or who knows begin parafunction later for another potential reason those are more than happy to go on to some other type of splint for that they need to but they’re quite, but it’s quite rare. And you know, the thing is, I think you can only really judge us if you’ve been seeing people for long enough to know it’s very difficult to make an assumption of what how someone’s thinking of a change 5, 10, 15 years later unless you see them again, or you have the intention to see them again. That’s really the key [Jaz]Tif, have you heard of a flexi orthotic splint? Have you heard of this FOS appliance by any chance? [Tif]I have actually but I don’t [inaudible] know a matter of match. But I had heard a little bit. I’ve heard I’ve heard and [Jaz]So I use this in my protocol and I use this in my dahl protocol. And what I’ll go ahead and do is I’ll share a full protocol case on Facebook and I tagged you in it. Okay. I absolutely love this splint for dahl cases. Basically the acrylic that you mixed actually bonds to the polyester copolymer of the splint itself. So I actually use it as an anterior only deprogram appliance first, okay? And then once I’ve done the buildups the patient doesn’t need a new splint, I just gouged out the old acrylic. And I realized, [Tif][inaudible] that sounds quite Yeah. [Jaz]Which is amazing, which is so good. And then when the posterior contacts reestablished, I then will convert them to an essix or if they’re really heavy bruxist, because one thing you could do with the splint, you can color in black with the Sharpie pen. And then you can see their parafunctional patterns. And when they come back, they’re like, Oh, my gosh, yes, I’m grinding. So I think you really like this splint I’ll show you. I’ve got quite a few cases with it now with dahl. I’ll put one on, see what you think I’d love to hear what you think about that. So I’ll stick that on and I’ll tagged as part of this episode, so I’ll be sure to them. So make a note to do that now. [Tif]Sure. Sure. Yes, please do that sounds really interesting, actually. Yeah. [Jaz]Okay. So I think we’ll have to wrap up soon. But there are some honestly, that’s been brilliant so far, I just want to say, Have you seen any dahl cases? No, actually don’t want to talk about that. Let’s talk instead about, Okay, so in those cases, where dahl may not be successful, no, it’s incredibly successful, especially in the cases that you’re doing case, because you’re doing, Tif, because your case selection would be quite good. And so in those cases, where it might not go to plan, I tend to have that discussion beforehand, as part of my consent process, I might say, okay, in a small, very small number of cases, it may not work, what this means for you is more time, a bit more money, and you know, that sort of thing. So how do you have that conversation with patients upfront? And how many times have you had to then sort of add composite or posteriorly, or other restorations posteriorly to actually do more like a full mouth rehab [Tif]What do I have to say, honestly, genuinely, I don’t think that ever happened. And I’m not kidding you. [Jaz]It’s because your case selection is really good, I’d say. [Tif]I mean, then yeah, there must have been your case where maybe I built the tooth up to get into contact or something. But I think part of it is I mean, the case selection is really important. And I think it’s probably important, I’ll run over a couple of things or cases not to do that’s important, because this is where I see. And I have seen some people who are very well known in the industry, and they talk about dahl doesn’t work and you know, you know, and actually even showed some case presentations or write blogs and stuff. And I’m looking at the case of getting those with the wrong cases. Now the problem is, who am I to say that the wrong cases? I think the problem is, there is a lot of luck dahl theory out there. There’s a lot of evidence and whatever it may be, but there’s nothing really that talks a lot about case selection. There’s nothing about, particularly about protocols. And no, I don’t think anyone’s ever done the studies on it. So what I would say is, you know, fundamentally, number one, obviously, we’ve already talked about patients with worn posteriors, it’s not a patient for one with worn posteriors. I’d also say any patient with perio issues is just a no no. And certainly any patients have got you know, significant bone loss or anything like that is out of the question that isn’t [Jaz]But Tif you find that your bruxist patients or your you know, extremely parafunctional patients, you know, they sort of select themselves because those who have periods extendibility they would have experienced it in a big way. I think there’s obviously there’s no evidence to support perio, occlusion, parafunction and stuff, but you know what, you know, the client that got like massive exostoses and stuff that might be either medical commodities or those cases to avoid dahling because maybe their teeth [Tif]Not necessarily I mean it, what I would say is one of them Most important things also is to avoid a heavily misaligned posterior arch or arch forms that are heavily tilted. This is a really important one because I found [Jaz] Do you mean like a cant like a maxillary cant? [Tif] potentially or posterior arches were just heavily misaligned, where you’ve got a lot of crossover on the lowers. You know, you’ve got like an ending premolar. And I’ve seen that I’ve actually seen quite a few cases have been posted online, or one or two articles written, you know, people have said, Oh, it’s not sure if it’s going to, actually it’s not going to work. And the way I view it is, if someone’s got an in standing premolar, and they need a dahl, because why not just have, you know, a few mouth, or a couple mouths of ortho, you know, it’s not a rocket science to move that tooth. That’s the point. If you’ve got a little bit of, you know, Dahl is effectively like doing some othro. It’s like doing some ortho, but with it’s like a bacteria about biplane, and I think anyone that’s got, you know, misaligned arches, it the way I think about it, you’re expecting this segment to sort of move. Now, in the study Syed eruption. I think there’s a degree of compensation and potentially a touch of eruption. But the way I view it is that if you’ve got [Jaz] and maybe some joint repositioning, maybe? [Tif] yeah, definitely. I mean, the jaw reposition has been shown and actually, it’s of benefit anyway. But no, absolutely you’re right. But if you think about how the teeth actually move, I mean, I’ve looked at teeth slowly, over the months that they moved, actually, they, you know, they kind of if you think about two teeth touching each other, two molars touch, I think with tiny mesial distal rotations, you see what I mean? Almost tilt a bit. So, it’s much more predictable if a patient’s got a well aligned arch, that simply, quite simply it. So and if the patient’s got really bad arch, so there’s like huge instanding premolars, canine tipped out to the side, then that’s not a dahl case to me. And that’s really, really important. And I don’t think enough people say that. And I’ve seen you know, a few occlusion gurus do cases like that, and then they complain, it’s unpredictable. And reality is it doesn’t work in those cases. Another classic one is the sort of example of a static occlusion, we’ve got someone who’s already had, you know, they’ve got, you know, they’ve basically got a hugely already over compensated three to three region. And I’ve seen people do [Jaz] like a massive curve of spee. [Tif] Yeah, that again, you know, that was 10 years too late backache needs ortho to basically intrude those teeth and level the art in might, you know, you might then do some bonding, whatever, afterwards. Obviously, anterior open bite cases as well, you know, there’s no point as well, yeah, [Jaz] of course [Tif] it’s those sorts of cases that I won’t do Dahl and what I would say is, you know, it’s really, really important to think about dahl. And this kind of what I hope this podcast will help people do is to start to think of it as as interceptor treatment. And if you’ve seen my presentation, but the cases that I show that I’ve used, Dahl at, they’re not crazy cases, these are patients who were starting to get tooth wear, lots of anterior guidance, they’re some of them are combined with ortho, there’s a bit of crowding and stuff as well. But what I did is I treated them hold their teeth in a better, more functional position and critically, a retained position in a better anterior guidance, you know, in 5, 10, 15 years later, you look at the teeth, and you think, well, if we hadn’t done that, where would those teeth be now? You see what I mean? That’s really the key. The key is to try and use it in interceptively, basically, it is not a tr it should not be a treatment that when you see a traditional, you know, heavy tooth wear case, oh my god [inaudible] patient, I’m not thinking dahl, you see what I mean? [Jaz] Yes, I agree. [Tif] Dahl is the alternative to occlusion? No, it’s not. It’s not and actually, it’s an adjunct. And, you know, I know Ian Buckle really well. And it’s a really good friend of mine. And we’re actually [Jaz]I’m doing the Dawson modules with him. I’m on module three in January. So yes, Ian’s a top, man. [Tif]Exactly. And, you know, Ian and I meet and talk to him all the time. And we, you know, he’s doing running a course with IIS, and is doing some case with us. But he came in and sat, watch my lecture. And he basically said to me, you know, this is the bit that content is missing from a lot of traditional approaches, because what we end up doing is fixing a problem which could be could have been prevented or a lot now, what you’re doing and what you’re learning within your need to learn because there’s always going to be patients that never go to the dentist, you know, there’s always going to be patients who never go their teeth wear they get to that point where what you are learning from it, and you will be able to offer the patient a very viable treatment. But the point being is there’s a lot of patients who go through their whole life seeing a dentist every six months, their teeth are gradually wearing, anterior guidance is reducing the bite potentially could be deepening there may be getting more loss of anterior, loss of canine width. And dentist says nothing and says nothing. [Jaz]And dentists don’t diagnose. And I can say this because I didn’t used to, you know, so my story is and I’ve said it in a podcast, Episode Four is when I was a first year after DF1 associate part time, I’d read the prosthodontist notes and the patient’s Not in front of me because the previous practice owner was a prosthodontist. And he’d said there’s a line wear facets you know, upper right five, upper left four, lower left six. And I’d look at the teeth that way. I don’t see anything. [Tif]Yeah, I know. [Jaz]Oh my goodness. And when you when you start seeing them, you start seeing them and so now on my exact coding, there’s a code we make a TW it’s an orange, tooth wear for me and my system, that’s it and maybe you have a better system, Tif, I’d love to know other than photos, your system of photos is very comprehensive, each individual tooth that’s as comprehensive as it gets. But my charting system is a poor, one tooth wear if there’s been any degree of tooth wear from attrition if you’d like or erosion, but if there’s denting expose, I put two wear times two, there’ll be two TWs on that tooth code. So but I’m the only one I know, especially in my circle of friends, dentists, other associates, principals I work with no one does that. [Tif]Well, I think, you know, the problem. The problem is, I mean, we’re actually getting into political territory. And I’m not afraid to do that. But I think the problem is, is that our system has kind of encouraged us not to. The system the way it is now, particularly with UDA it almost gets to the point where if a dentist identifies this problem, you have to tell the patient and then what’s the solution going to be, is that I don’t understand how UDAs work, but I do understand is it from my understanding, the dentist identifies a problem offers a solution to a patient, they’re probably gonna have to spend a lot of a lot of time on it, and they’re not going to get the fee to justify the time is that correct? Or am I incorrect? That’s correct, isn’t it? So actually, our system is sort of dissing discouraging people to actually even talk about it. And you think about it, that is just astounded. I find this particular being in private dentistry for a while. And I think about, you know, you think about what the NHS offers, in my head, if the NHS was fee per item, and actually was a core service, I’d go back to in a heartbeat, I would, you know, I actually believe in it. But I think the biggest problem we’ve got is we’ve got a system which has been created by people. And you know, I’m not going to point the finger in individuals here. But it’s been created by people who actually don’t understand dentistry, they don’t understand long term dentistry. It’s all about fix. And it’s all about politics. And I think the problem is, whenever the reality is, when it was a fee per item, it’s a lot easier to do. It was a long term period. And I came from a very kind of privileged era, or actually, we had fee per item, we had NHS patients, we could talk about the difference between private dentistry and we could offer them different things. UDA meant that became very difficult and actually pushed dentists into a corner. And you know, the way I think about it is those people that thought that UDA was a good idea, I actually think they need to be made accountable for, because the damage they’ve done to the profession over the years is actually spectacular, because it’s made it very, very, very difficult for dentist to actually talk honestly, with their patients. And actually, it’s created this whole, I’m either private, or I’m NHS. And this is kind of one thing, it’s harder for young dentists to be able to convert their patients, it can be done. But the problem is, is, you know, you’ve got this scenario that makes it hard and kind of going off subject slightly. But the but the reality [Jaz]No, not at all, this is important. This is the real world issues that we face. [Tif]This is why I think that you know, Dahl is something to, it’s difficult because it can’t be offered. Now, the what I do 32 [inaudible], actually a lot of cases that have dahl sometimes an ortho and the best thing at ortho is, if you know, you don’t have any title, actually, it’s a conversation quite a bit easier. So you can, kind of say, does the whole ortho restorative treatment plan, and you could potentially take your conversation that direction, but I mean, fundamentally, dahl is should be an interventive treatment based on people who you’ve been speaking to, and you’re identifying sort of slow changes. And as I said, you’re trying to prevent, the way I look at it, dahling, is for me to try and prevent a full mouth rehab. And actually, I actually take a view that if I see a full mouth rehab, it’s not something to celebrate, it’s actually an abhorrent reflection of the fact that our profession can’t cope with those patients and failed to prevent those patients from getting there. And our goal should be to always stop it. In my practice, you know, I didn’t really say any patient that’s come to see me and stayed with me has never ever gone on to the need of full mouth rehab, you know, so I treat them I’ve treated some, of course, to treat some because they walked through the door, but no patient who’s I’ve got, actually the patient yesterday is lovely at age 86. And she’s on her fourth dahl recycle and nearly 26 years later. Okay, I want to say, I mean, obviously, they take the material off and put the same material back on. But I mean, as we strip some of the last like questions, I said the term recycle. But I’m getting a bit better thunberg here with recycled stuff. But basically, yeah, it’s when the dahl cases were down and start to look bad, and start to fail. And you know, they’re not guiding anymore. You literally strip it off, start again and deport me that just let it no evidence has nothing to say how many times you can do we do it or what’s actually happening, but she said I’m on my fourth. You know, who knows? Hopefully, we’ll get to my fifth better. But we’ll see. [Jaz]That’s interesting, actually. So you know, when we’re doing repeat, will the sort of mechanics of dahl continue to work? And obviously they do because you’ve been doing it? So that obviously works. And I think it’s a great philosophy, it’s a great way you run your practicing life. And obviously, you’re a massive inspiration to young dentist, if I just wanna leave you with three little reflections. I want to hear your views on this and then we’ll go into interest of time for today. Yeah, so first thing you mentioned about the in the in standing premolar sort of scenario. So in that scenario, I’m thinking okay, this patient would benefit or in “benefit from orthodontics” or it’d be an alternative plan. So in that orthodontic plan, would you then be intruding the anteriors to then create the space to then rib in the guide? Is that sort of where you’re getting to as well instead of doing a dahl? [Tif]Yep, definitely. Because actually, you know, one of the best ways of fixing the lateral anterior space is with ortho and if ortho is appropriate and if there is actually anterior crowding or anterior tooth movements that need do it. Then that needs to be offered to the patient, the patient may not choose it. And I probably say some patients don’t. And if they’ve only got an instant in standing premolars, and it can be fixed very simply, sometimes they say just fix that. We’ll do the rest of it with the build up. You see what I mean? So but the option has to be a table, as with every option has to be comprehensive, has to be on every you know, [overlapping conversation] the decision really so but yeah, it may well be and it’s happened, you know, it’s happened in many, many cases that I’ve come across in the past, what we’ve done is, we’ve done that, or actually, in many cases, deals that don’t refer to have done that [Jaz]Brilliant. And the next good thing, last of the two I want to talk about is now with the advent of an accessibility of digital dentistry. And you mentioned scanners, are you doing this thing whereby your dahl cases, you’re seeing them every couple of months, and then scanning them and doing like little time lapse, because if that, that study needs to be done, we would learn so much from that. [Tif]No, I am. I am actually at this quite interesting. I’ve got a new scanner, I had a scanner for about 18 months online, which was wonderful having online, and I did quite a lot of scans on those cases that we’re trying to do now is actually marry up those original scans with those same patients. But anyway, we had a new scanner for about about six weeks or so now, scanning so many patients now for the basis of patient monitoring but Yes Also, I’ve been doing a couple of Dahl cases where I’ve scan those. And now I’m actually going to plan is to then see the patients in a month and then rescan and see the patient three months, [Jaz]We had learned so much as a profession from that, and also about the mechanics of it, which was, you know, a little bit disputed, I guess. So that’s amazing that you’re doing that. And I can’t think of anyone better who’s doing that. [Tif]I got to give a call out to one of my friends Andy Wallace, who’s been who’s even further ahead on the curve than me on that one, because I know he’s got a couple of cases at the moment. He’s sort of mid scanning. So you know, be interesting, I’m actually waiting to see his [Jaz]Andy’s a top guy and part of the tubules sort of a crew and I went to his Inman course actually. So yes, shout out to Andy, thank you so much for the work you do. The last reflection is my theory on why some dentists are against dahl is it because it means that it their big tickets will not come through. So basically, you have to charge the patient way less, you’re being way more minimal, and you don’t get to do the posteriors. And that could be a reason why maybe dahl is not favored. [Tif]I think it is one reason. It’s definitely similar. The only reason I think what we’ve covered some of the reasons in that perhaps a lot of you know, the view the term gurus, those gurus are seeing those patients way too late. And those gurus perhaps also don’t have regular patients, perhaps, you know, they’re acting like pseudo specialists, you know, it’s like, [Jaz]They’re in a niche area where they wouldn’t see the sort of interceptive opportunities, [Tif]Exactly and they’re seeing patients who are already too far gone. And that’s completely understandable. But I do, there is definitely an element. I don’t think so much in this country, I really do believe in this country and most of Europe that I think that really our health professionals first and business people second, I appreciate there are other areas of the world that may be a little bit different. But I do think that ultimately, you know, we do hopefully think what’s right, for patients is best. But yeah, there is definitely I mean, I have sort of given lectures on on dahl in various countries around the world. I’ve had a couple of people sort of say to me, you know, well, this is all well and good. But you know, what about the milling machine I’ve just bought? And what about this? And what about that? [Jaz]And what about the bottom line? [Tif]Yeah, and I you know, that’s fair enough, I kind of it’ll be very easy for me to get angry about that anymore. You know, you’re speaking about a patient, but ultimately, I can understand why they’re thinking that. But I think that’s a very short kind of narrow minded and perhaps short term view. Because, as I said, if you know, if we were all less focused on this big ticket, new patient walks through the door, I’m gonna charge him 5 or 10 grand type of thing. And you’ve thought about a patient about keeping that patient for life, you thought about all the people they were going to refer into, you don’t have to kind of fight with mentally and drive and worry about getting sued by them and all that sort of stuff. You think about, you know, that sort of enjoyment you get out of seeing your worth 5, 10 years later. And you know, I think perhaps that’s the problem. I don’t think enough dentists do because they don’t do enough dentist think that’s the thing to do. And then actually, I think there’s a much this sort of long term view, and I call it a lot of my lectures now call it the lifetime patient. That’s a term that I use. And I think that the more we think about that, and the more that word and that process gets put out there, the more hopefully people will realize that dentistry is not just about, you know, it’s not just about big ticket, it’s not just about Instagram, it’s not about here’s my before and afters, it’s about actually, it’s about here is before, and after five years later, here it is 10 years later failing, and this is why it’s failing and is it failing, you know, the patients don’t have the patience to have loved me. And you know, that’s just a different view. And so I think that there’s a lot, you know, I’ve kind of come away from it helped being a cosmetic dentist, you know, it helped with me being that sort of person that thought I was like this hotshot walking around in the white suit with my name written on it and all that. And I thought, Oh, yeah, I’m a superstar. But over time, I realized, actually, I learned a huge amount from that. And I don’t mean to belittle anyone that does that. But a massive amount from smile design impression taken, but actually, what I didn’t learn was ethics. And I’m not saying that they need to learn that but I think being a general practitioner and seeing the work that you did that you probably realize you shouldn’t have done come back to actually haunt you and you’re having to fix it and you haven’t to, you know, a case I sold with smile design technology, you know, 20 years ago, we had a version of digital smile design. And I remember setting cases like that. And I kind of looked at it 5 to 10 years later thinking, why did I do that? You know, and actually, that’s I think it’s probably the one, you know, for my generation dentist is probably the one it is hot, it’s a terrible thing to go through. But actually, it’s one advantage of way of learning what not to do. I think that’s really, really valuable as well. [Jaz]And you’re so honest to talk about these matters. And honestly just highlights your ethos, and everything you’re about. And you know, with this episode, it’s so many gems in there. And even though it’s been, I think, two or three years since I did your course, I retained It was good to see I retain a lot of information. But again, there are some few things a few gems that you gave me that I can implement Monday morning and [Tif]that actually so it’s a comeback, as it’s changed quite a bit since then. I’ve kind of restructured it. [Jaz]Brilliant. Okay, well, I’ll have to and I’m looking forward to sharing that case that I told you about with the FOS appliance, I really want your input on it. I mean, more than anyone, so I’ll put that on as well. [Tif]So does that appliance? Wher it’s come from? Who created that. [Jaz]So Gary [Tif]Yeah, that was the day I remember missing a lecture is I think it damn I wish I pushed it because then everyone was talking about it after that he might he might be in at BACD or somewhere that I missed it. Anyway, that’s thank you for that. Yeah, [Jaz]No, no, I’ll tagged you that when I can. But Tif, thank you so much for coming on and inspiring everyone, as always keep doing your thing. You know, what you’re doing for our profession is amazing. And again, I’m so glad that you’re getting this prize, which obviously means so much to you. And I’m so glad that you’re a dentist from the UK. And we have we have someone to look up or look up to. So thank you so much. [Tif]Thank you very much, Jaz, take care speak later on. [Jaz]Thank you. Cheers. Jaz’s Outro: So there we have it, folks. As a dental geek, I absolutely loved having Tif Qureshi on the show. I hope you gained a lot from this two episodes. That case that I mentioned to Tif, the one that I would tag him in it of me using the FOS appliance and my dahl protocol. I did actually post that on Facebook with about 60 photos step by step. I’m a huge fan of doing step by step photos because you know I’ve done it before, obviously, but I don’t like the whole thing. Here’s a before and after, look how awesome I am. I like to teach and share. And I’m open to getting criticized and scrutinized, I feel like if someone can criticize me and scrutinize me, I will gain, I’ll become a better dentist from it. So I actually posted my entire protocol of a dahl case on my Facebook. So the way you can easily access it instead of me giving you a long sort of URL is you just go to www.jaz.dental/dahl as D-A-H-L, then it will redirect you to my Facebook page to the album that has all the 60 photos. Let me know what you think. And you’ll see that the FOS appliance and action which has just been fantastic for my dahl cases. And if you want to learn more about this type of splint, there is a hands on course happening in February. If you want more information, please message me. I mean, it’s me who’s teaching on it, but it’s mostly being marketed internally to the people who use this lab. But there might be a few places available. And if you’re interested in that Chim near Reading up anyway, so please message me if you’re interested in that, you know, hit me up on Instagram. So thank you so much for listening all the way to the end, and I’m really looking forward to next one. Thanks so much.