Protrusive Dental Podcast

Jaz Gulati

The Forward Thinking Dental Podcast

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Dec 10, 2024 • 1h 3min

Principals vs Associates – How to Foster Positive Relationships and Flourish – IC054

Why are principals and associates always at loggerheads with each other? Why can it be almost impossible to find the right associates to work at our amazing practice, but also almost impossible to find that amazing practice to work at as an associate? Join myself and Dr Sarika Shah on this episode where we learn more about self leadership and the ways to prioritise our values to help us find the right working relationships and places of work to be a part of. Let’s figure out how to bring all members of a team together and create the zen we are all in search for while working in our day to day lives. https://youtu.be/-ua1PAB6A90 Watch IC054 on Youtube Protrusive Dental Pearl: Be willing to accept rejection. A ‘no’ from a patient today is often a yes tomorrow. Plant seeds for high quality dentistry and you will find yourself harvesting many of these seeds at a later date. Those who fear rejection routinely offer less than their best, which cheats patients out of rightfully making their own economic decisions – inspired by Dr Lane Ochi (the ORIGINAL Dental Geek!) Check out Flourish as a Female: https://www.flourishasafemale.com/ Use discount code ‘protrusive’ (No financial interest) Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:02:18 Protrusive Dental Pearl04:30 Introduction – Dr Sarika Shah10:10 Transition to Private Dentistry13:40 Practice Ownership17:20 Managing the Practice24:55 Internal Leadership29:40 Principals vs Associates Friction41:56 Women in Dentistry47:15 Supportive Partners55:25 Top Advice from Sarika58:28 Flourish This episode is eligible for 1 CE credit via the quiz on the Protrusive Guidance App. This episode meets GDC LEARNING OUTCOMES A and B AGD Subject Code 550 Practice Management and Human Relations Aim:To explore the importance of self-leadership and effective communication in building successful relationships between dental associates and principals, enhancing teamwork, and optimising practice performance. Dentists will be able to: Identify key principles of self-leadership and apply them to improve personal and professional development within their practice. Understand the impact of effective communication and aligned values on maintaining strong, respectful relationships between associates and principals in a dental setting. Develop strategies to enhance emotional intelligence, ensuring improved patient care and better collaborative relationships in their practice environment. If you liked this episode, be sure to check out IC025 – Parenthood and Dentistry Click below for full episode transcript: Teaser: And when this respect is gradually lost, that relationship is most likely going to break down within three years. Okay, there's research behind this. I've read a lot around this. So what it there is, is there's three phases to this. The first phase is like- because even when I went out there to approach women, to approach some of these women are still around. And I think they're awesome. They're powerhouses. But when I went to them to ask for help, I got nothing. And it's not like I just asked once. I asked a few times. I asked several women and I got nothing. So the majority of my mentors and coaches have now been male. Jaz’s Introduction:Principals versus associates. Why is there so much beef? I’m constantly seeing on the dental social media groups that principals are bashing associates. They’re saying like, where are all the good associates gone? I’m really struggling to find a decent, honest, hardworking associate. On the flip side, the associates are searching for trustworthy, kind, caring principals that are willing to mentor and provide an environment where you can flourish. That seems to be a bit of a pipe dream. So who’s right? Are they both right? Or maybe all the associates and principals that are happy, that are in very, very happy teams. Maybe they’re just having some popcorn watching all this unfold. I don’t know. I personally have had some wonderful principals throughout my years. I’ve also had some not so good ones, so I can totally resonate with some of the things that I said. So in this episode, we will cover how do we promote a good relationship between associates and principals? Where does it begin? How do you know if a principal and an associate are a good fit even at the interview stage? And if you lead a team, especially if you own a practice, I’ve got Dr. Sarika Shah, who’s all about the systems, and I really admire her. Like, Sarika’s one of these dentists who I seem to always bump into at courses. It makes me think, right? Why is it that I always see the same people at the courses? Why don’t I see any new faces at courses? It’s as though there’s like a 20% of the dentist population that goes on all the courses and everyone else is not going to the courses. I don’t know. But Sarika is someone who I’d always see around. Well, hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Some of the other themes we discuss are leadership in dentistry, particularly self leadership. And if you’re thinking, hey, I’m not a leader, I’m just an associate, then you are totally wrong. We are all leaders. We also talk about starting your own practice and the challenges particularly faced by women in dentistry who are looking to start their practice. Why is it that the lecture podiums have less women? Why is it that less women end up owning practices? But these are very worthy themes that we discuss towards the end as well. So make sure you make it all the way to the end. This episode is eligible for CPD or CE. And as we are a PACE approved provider, the subject code for this one is 550. That’s practice management and human relations. We also, as ever, satisfy the GDC’s criteria for enhanced CPD. So all you have to do at the end is answer a few questions on the quiz. The quiz is accessible from Protrusive Guidance, which is our platform. Dental PearlAnd speaking of platform, it’s the platform that gives us our Protrusive Dental Pearl today. You’re going to love this piece of advice. On our app, on our community, I asked our community, what’s the best advice you ever received in our profession? And I talked about not owning the patient’s problem. Like, I’ve talked about this a lot. But so many of you chipped in with such brilliant pieces of advice. I’m going to highlight one from Dr. Lane Ochi. And in his contribution, he gave like five or six absolute golden nuggets. But the one I’m going to share with you today is where he learned to be willing to accept rejection. He said that most who practice dentistry successfully recognize that a NO from a patient today often is a YES tomorrow. Plant seeds for high quality dentistry and you will find yourself harvesting many of those seeds at a later date. Those who fear rejection routinely offer less than their best, which cheats patients out of rightfully making their own economic decisions. So another way to make this tangible and explain it is sometimes we know that a indirect restoration may be the best for that patient, but for some reason, whether we think the patient is just not going to say no, or we think we have this silly perception that patient can’t afford it, while the patient’s just unlikely to go for this treatment option, we give them something suboptimal. Maybe it’s a cheaper option, maybe it’s a direct restoration, but really you know that this tooth would scientifically benefit from an indirect cuspal coverage restoration. Now, if you think bigger picture, think of the patient with generalized wear, and you are concerned that one day the wear will get so bad that it’s going to become even more expensive to fix, and maybe the patient may need more root canals or more complex treatment. But maybe you don’t suggest a comprehensive plan. Maybe you don’t suggest any treatment for that wear. Why? Because you’re afraid of rejection. I think forget about rejection. And if you treat every patient with your best intentions, and I know we always have our best intentions, I truly believe you have the best intentions, but don’t hide your cards. Just show, well actually, ideally, Mrs. Smith, we should be doing A, B, and C. And it will cost this much, but the benefit of this treatment for you will be X, Y, and Z. And having some of those difficult conversations, even if you know you’re going to get a no, but once you get that no now, just as Dr. Lane Ochi says, when it’s the right time for that patient to have the best and the correct treatment, they will come back to you. So start planting those seeds today, Protruserati. And it’s another good reason to join the app. There’s so many good things in just that one post alone. Anyway, let’s join the main episode. I’ll catch you in the outro. Main EpisodeDr. Sarika Shah, welcome to the Protrusive Dental Podcast. How are you? [Sarika]I’m really well, Jaz. Thank you so much for having me on. [Jaz]I’m very excited to cover these topics because it’s a little bit about the animosity that we feel and we can sense between principals and associates. But actually what I want to do is just take a step back and learn about a bit more about you as a business owner, a practice owner, someone who has a team, because I feel as though the podcast hasn’t covered those themes as well as it should have yet. And so I’m hoping to do that. But also you as a strong woman, a leader, we need more women in dentistry who are leaders, who are practice owners. And I feel as though, even like when you look at the courses, you know, you see all these males, males, males, and very few women in dentistry. And so I feel as though what you’re about, you’re changing that as well. So I think there’s a lot of themes to cover, but before we dive into that, Sarika, tell us a little about you. [Sarika]Brilliant. So, thank you for the introduction. And I guess a bit more of my professional background. I graduated from Manchester in 2006 and I was an international student then. And I remember one of my first memories was final exams were looming in year five. And just a few months before we had to look for our first job, it was called vocational training at the time VT training. And because I was an international student, I had to apply for over 120 jobs. I wasn’t prioritized over UK residents, so I had to work extra hard, and I just went all over the country applying for jobs. And then I finally found a job, and I graduated, I moved outside of London, I had my first job in Norwich. And it was VT training, I was an associate there in that practice. It was a large group of practices. There were four partners in that practice and it was brilliant. I gained so much experience. I think not just from working on the NHS and the dentistry, but also the experiences that I had with working with a big group of dentists as well. So I learned so much in that time. And then I quickly realized that I wanted to do more. I wanted to be better. So I did my MJDF a year later after my VT. And then I realized that, you know what, I’m going to go out there and I want to potentially specialize in something. So I first looked at perio, that kind of decided against it. And then I went and did my part time MSC in restorative dentistry at the Eastman at UCL. So I did that. [Jaz]I feel like at that stage of career Sarika, I feel like we’re all a bit starry eyed and a lot of us want to specialize and stuff. And so I’m glad you had that bug as well. For me, it was restorative specialism. So I wanted to be a restorative red straw and consultant at that stage of life. And then life took me down a different course. I had these experiences in the hospital. I thought, hmm, perhaps this is not the best environment for me. And so when you look back now at that Eastman training that you did, was that like a thing? The two year, three year, five year. Cause they got lots of different programs, right? [Sarika]So I did the full MSE, which was five years, part time. And it was tough because you know what, Jaz, I think that there wasn’t a lot of guidance then. There wasn’t all these courses that we have now, the level of kind of external education that you have postgraduate now is crazy. It’s immense. There’s so much more. [Jaz]Too much now. It’s gone the other way. It’s like tiring in terms of what you see now. So it’s actually gone the other way, but yeah, back then, there wasn’t as much help or extra additional thirst that we had for knowledge wasn’t being catered for. [Sarika]Yeah, I think there wasn’t guidance and I don’t think there was enough choice at the time. So anyway, I did it. I have no regrets. I absolutely loved it. It was super tough because I was working five to six days a week in Norwich and then commuting to London to do the MSC and then slowly. [Jaz]Can I ask you a bit about the MSC? Just a little bit because look, my wife’s on MSC in Paeds. It was three difficult years for her, but it was great feeling when she got through it. However, and we talk about this. A lot of MSCs, they are very academic and the dissertation years, they’re not very hands on clinical. How much of that applied to your MSC? Was it all reading papers and critiquing and writing a dissertation? Or did you actually get to treat any patients? Because usually that’s more of an MClinDent then. [Sarika]Yes, absolutely. So, I think with a part time MSc, you’re obviously not in clinic or in hospital treating patients. So you have to be in an environment where you can take all the knowledge and then go and apply it in practice. I think there is an advantage to that as well, because you’re doing it in a normal practice setting. If you don’t want to work in hospital, I think it’s great because you’re doing the whole people management side of thing, you’re problem solving, you’re holistically treatment planning, and these are all huge skills that you need to provide optimum patient care. So, it was brilliant and I was in that environment. I was given the opportunity where I could treat my patients holistically and I had the whole array of like dentistry that I could do. So it was brilliant. I got a lot of experience, but it was tough. You take the information. You go and you apply it, you come back, you’ve got to take all your photos, you’ve got to have your case presentations, and then you’ve got to overcome that fear. You’ve got to ask your tutors for help. You’ve got to ask them to critique or give you feedback on your work as well. And I think that’s how I learned, I kind of overcame that fear and I thought, well, I’ve just really got to take this feedback, learn from it and improve. So my experience generally was brilliant. I loved working in practice, you know? And so in that sense. I took a lot on. Also at the same time, this group of practices, they opened a small group of private practices. Now I was quite a young dentist then, but because I had all this knowledge, this new knowledge, I again, took on the courage and I went to like the main owner of the clinics and I said, look, I know that I don’t have as much experience as all these other dentists, but I would very, very much like and appreciate if I could have a day or two in your private clinics. And they offered it to me. I was maybe like three or four years in and they offered it to me. So that was brilliant. [Jaz]But you made that happen. You asked the universe and the universe gave it to you, right? You forced your way in a good way, in the sense that had you not asked the right questions, knocked on the right doors, opportunity doesn’t just come to you. You have to kind of fight for it. [Sarika] Yeah, absolutely. And something I’ve suffered from my life is really having that fear to speak up and having, I had a lot of good like external confidence, but I didn’t have a lot of internal confidence and I had this massive fear of judgment from other people. But I think that, circumstance put me in this position where I had to slowly learn to overcome that. And I realized that if I want to grow, if I want to learn, if I want opportunities, they are on my doorstep. They’re right there. They’re there for me to grab. It’s my choice and my decision on whether I do it or not. So it’s great. It put me in a great position. And then, in my final year, I met my partner, we plan to get married and then I moved to London and then, oh my goodness. I was like, great, now I have to look for another job. I wanted to work in private practice. I wanted to move away from the NHS to do the dentistry that I wanted to do and work in the environment. [Jaz]So at that point you were part time private, right? [Sarika]Yeah, I was part time private. [Jaz]At that point you moved from Norwich to it? [Sarika]Yeah. And you can say it was maybe like 20%, 30% private and the rest was all NHS. So moved to London, had this transition. And then I don’t know if I was just naive, but I thought I could find a job in a private practice five days a week. It’s clearly not the case. And there was nothing out there. You know, I remember like being on all these job sites and really looking for a practice to work in, but there’s just nothing out there. There was no choice. And in the end I decided- [Jaz]Is that because the usual channels nowadays, I feel like Facebook has a good presence in terms of finding associates positions and stuff. Is that because that was lacking? Or do you feel as though the market at the time didn’t have positions? Cause I see all the time, principal and maybe you have this complaint. I don’t know. We’ll find out. But principals complaint that where are all the good associates? And their associates are like, well, where are the awesome principals? And like, is it a fact that they’re all out there and they were just not able to connect them? What’s going on? [Sarika]Yeah, I really think that there needs to be more platforms and there needs to be a little bit more collaboration. So, I feel like, I think that problem still exists, to be honest with you, Jaz. And there’s got to be something wrong, right? If principals can’t find associates, associates can’t find the practices they want to work in. There is an issue there. And I think that maybe it was that time, like back in the day, that a lot of people, it was word of mouth, and people recommended other people. I don’t know if that was the case, but I was someone that came from outside of London and there was nothing there. So in the end, I just accepted this job outside of London. They took me on as a private clinician, but it was kind of like a little bit mixed practice and I had to kind of convert, had to start my own list. And I grew it and I was there for about five years. And then, in between my brother’s a dentist as well. He’s five years younger. We were having conversations and he said, you know what, I think, what about owning a dental practice? And I said, well, it’s been on my mind for like years. And he said, well, it only makes sense. If we do it together. And so we started to look for practices. Now he lives in the Midlands. He lives in Manchester and we were looking at practices in around London. And then my partner who was then in banking, we would go to him to ask for like, oh, can you have a look at the financials of this practice and what do you think, and his opinion. So he’d like tag along to all these like viewings that we’d see for all these practices. And also we were looking at option of like setting up a squat as well. So we were keeping everything open. In the end, it didn’t work out with my brother. Logistically, they wanted to stay in the Midlands. And then I said, right, I’m just going to continue. I’m in this too deep now. I’m too excited. I’m too hungry. I’m just going to like, go for it. And so I started, I kept looking, my husband, Rishi was tagging along and then he got excited and he got hungry, I think he caught the bug. And he said, you know what? This looks really juicy. This looks so interesting. How about we do this together? So I said, yeah, a little bit hesitant because I was thinking, gosh, we’re like newly married and I’m not sure if we can live together, work together, how’s that all going to be? So yeah, we came across the practice that I currently own. I fell in love with it. I sometimes think- [Jaz]So it wasn’t a squat. You didn’t start a squat. You bought an existing practice. [Sarika]Yeah, it was an option. I was looking at both options and I had prepared for both options, but, in the end we bought an existing practice. It was a very kind of small two surgery practice. It had a team of, I think, seven people, including the whole team, the whole team, seven. And, we took it on, we grew it, we’ve owned it for seven years now, went through kind of two refurbishments in that time. [Jaz]And we went through COVID. [Sarika]I went through COVID, had a baby in the middle, like went through all this stuff. I was going through, you know, I had seven years of IVF treatment, so I was kind of going through all that in this phase as well. And yeah, now I lead a team of 28 people and I’m super happy. [Jaz]How many surgeries now? [Sarika]We’re four surgeries, busy four surgery practice in Canary Wharf in London. So yeah. [Jaz]And did you have to like, were you able to extend quite easily? [Sarika]So there was space, there was one surgery which was plumbed or wasn’t used. So we expanded into that and then there was like this empty space. So we kind of had to do a little bit of interior architectural, get some interior architectural advice on how we could like reposition and kind of like redesign some of that, the rest of the space. And so we created another small surgery on the side as well. So four surgeries. [Jaz]And how many days at the moment are doing clinical, being mom, being principal, being team leader, being all the other things that you do, how clinically involved are you still? [Sarika]Yeah. So, it went from working six days a week to then five, then to four. And then I was going through all this health issues and like all my IVF treatments and I went down to three. And now I have, it’s taken a really long time, but I put systems and processes working a lot more efficiently. And so now I work two full days clinically, but a lot of my consultations, things like that, I’ve started to now do online. So I’d say. It’s kind of three days of work, and then the rest is kind of around admin, practice management, things like that as well. It’s a seven day a week job. [Jaz]Do you enjoy it? [Sarika]In my practice. [Jaz]It’s a forever. When you’re a practice owner, it’s a forever job. And you could tell me about the first few years about the fear. And I mean, people always say that the first few years aren’t going to be very profitable and people accept that. And then people think that, okay, they’re off. There’s a lot of stresses, staffing issues, which is the number one thing that principals complain about staffing problems, getting the right staff, dealing with sickness, getting locum cover, that kind of stuff. How have you navigated all these usual stresses and have you had a different journey at all? [Sarika]Yeah, absolutely. You know what? I think owning a practice is like going into a relationship or having a child. There’s so many unknowns and I think it’s a steep learning curve. You just have to experience something, learn from it, grow from it, and then like build on it. And that’s exactly what we kind of went through. We were lucky that, it was being run fairly well because of our location. We have really a great demographic and really nice patients, but we had to really bring a lot of systems and processes in place. I’m a very organized person. I don’t like mess. I like everything clean and needs and everything kind of organized. So I kind of did a full clear up processes in place. So that was first thing, because you need the practice to work efficiently. So that’s like the first thing that we started to do. And then it was just about ideas for growth. How do we kind of grow this practice? And as you kind of grow the practice in terms of more patients coming through the door, inevitably you have to grow the team. So, slowly, we inherited a team, by the way, when you buy a practice, you kind of inherit that team. And obviously you come with new ideas, like a new vision. You want a new culture, you have new values and existing team might not always align with what you’ve come in with. So they did stay with us for a few years and then slowly that team started to dissipate a little bit. We were recruiting as well. So we were growing. So, recruitment and people management was probably one of the toughest things that we have experienced. I think- [Jaz]I’m sure you’ve learned a lot of lessons along the way. [Sarika]Oh my goodness, so much. Because that was so new to us. And you think as being a dentist in clinic, yes, we’re managing people all the time. Even as an associate, you’re managing your nurses, your team, you’re working with them. But I think this is management on a different level. And you’re not just managing one or two people. You don’t just like turn your computer off and go home. You have to continue managing those people. Out of hours on the weekends, and it can be a lot, it can be very, very stressful. And for very, very long time, we’ve gone through a recruitment crisis, not just in dentistry, but overall in health care. In fact, you hear it everywhere, in retail, at restaurants, in corporates. So we’re going through a recruitment crisis. And I think it started off with Brexit with a lot of staff potentially a lot of dental nurses and reception staff kind of in that sector leaving the profession. Then we were hit with COVID and then post COVID, there was a lot of external SOPs management we had to do. But then again, we had a lot of practices had major growth after COVID as well. So again, we had to then recruit, but we had to take so many not necessarily risks. I remember when it came to recruitment sometimes that you almost feel like you’re desperate. Like if you don’t feel a position that it’s going to affect the rest of your business, it’s going to slow your business down. And so you almost like recruiting out of desperation. But we slowly realized that actually by taking people on that weren’t aligned with our culture and weren’t aligned with our values, it brought a lot of toxicity into the practice. [Jaz]And the problems get deferred for later, basically. Right? [Sarika]Absolutely. And what happens is that you just need one bad pee, to kind of disrupt everything. So I created one rule. I created one rule. I still have that rule. And that’s no more drama. I don’t want drama. I hate drama. [Jaz]And the wonderful thing about that is, you tell the applicant, whether it be an associate, interview, nurse, hygienist, whatever, That rule is like, this is the rule. And then they accept the term that rule before they join. Right? [Sarika]Absolutely. I’m very honest with them. I tell them exactly what I like, what I don’t like, how the practices run, I’m really pro talking about values. I’m really pro looking at people’s strengths and looking at growth and ensuring that people can take feedback because if a member of the team, doesn’t matter who it is. If they can’t take feedback. Then we can’t have growth. So, all these things are really, really important to discuss right at the beginning at interview stage. So yeah, you live and learn. And I think when it came to recruitment, I had to just create certain boundaries. We had to create certain rules and then we had to agree on how we were going to recruit. And we just decided to recruit differently. We also decided at that point, there was this one point I remember where, oh my goodness. I came back home and I said to my husband, I said, I hate this. I hate where we’re at right now. How did we get to this? And I said, we’ve got to change something. I kind of had to reflect and I’m going to share this with you actually, because I think a lot of practice principals will find this quite useful. I kind of had to reflect back and I had to think that what kind of led to my initial kind of success. And something that I was doing, something that I had to take on was I was doing a lot of self development and I took something all called self leadership. It was something that I mastered the principles of self leadership. I was using it on myself and I thought, well, hang on a minute. I’m practicing the principles of self leadership on myself and I can see what it’s doing. And there’s so much, there’s such a positive impact. But what I now want to do is I want to start using self leadership on my team. So I spoke to my husband, I spoke to my manager and I said that, right, we’ve got to make some changes here now. So we came back, we had a meeting and we relooked at our values. We were kind of like living off our old values in the practice. We relooked at our values because our team had evolved. It had changed. We had changed. So we relooked at our values. [Jaz]This is like a team building exercise kind of thing? [Sarika]Yeah, well, at that time we did it ourselves a year or two down the line. We did it as a team because at that team, at that time the team was still disjointed. We had to, we were looking at kind of building a new team. So it was really the values that my husband, myself and my manager, we kind of sit down, sat down together and we kind of rebuilt those. And then what we did was the members of staff that were toxic. We let them go. It takes a lot to, it’s not easy letting someone go. A lot of principles, it’s actually something really difficult to do, I think, as a human being. But you have to- [Jaz]I mean, a principal is to complain about sleepless nights from the things that drag on from this kind of a stress because there’s so many ramifications associated with that. But it’s one of those things that when you do it, no matter the hardship that you face, it’s like a huge relief. And I remember one of my principals in the past, after he had to get rid of a toxic team member, he just felt like it was like as if they could breathe again. It was like just such a massive relief is the way he described it. [Sarika]Yeah, because like I said, there’s a ripple effect. It’s not about how you feel. I think as a principal, you’re ingrained in your team as well. You’re part of the team. So you’re feeling what your other team members are feeling as well. And if you’re someone that has good connections, good relationships, then they’re going to be open with you and you can see the effect that’s having on them, the impact that’s having on them. So we had to let go of a few members of the team. We also, anyone that wasn’t performing to the level and the standard that they should have been. We also let go of them. And we also made an agreement that from now on, we’re only going to recruit if we think that person’s right for us. [Jaz]I’m glad you mentioned that because one of the questions I’ve been in my head, I want to just pounce the right moment. And this is the perfect moment with the story that you shared is when you are hiring an associate or a team member in general, what’s more important to you? Is it the quality of their CV, i. e. the degrees, the cases they’ve done? Or is it their personality and their charisma and the magic about them when you interview them? Which one of those two are more important in terms of what you found works as a recipe for success? [Sarika]The answer to that is look, I’m going to tell you the world we live in now, so fast paced is ever changing. Patients expectations and needs have changed. Okay, so back in the day clinical skills was always prioritized. You had to be good clinically. Okay, to have a good job. I think now, what makes an excellent or a good dentist, maybe 30 to 40 percent is clinical skills. The rest is all non clinical. The rest is internal leadership. And then you have a little bit of a 10, 20%, which is external leadership. Okay. And within that internal- [Jaz]Can you talk about that? What is that? People are listening about this, encapsulated by this theme of leadership, which is so good and really relevant that I want to talk to you about this. But what do you mean by internal and external leadership? [Sarika]Okay, so there are various forms of leadership, and most people know of leadership as just leadership. But when we talk about leadership, we’re talking about leading other people to achieve external objectives. But something people overlook is something called self leadership. And self leadership is where you learn to intentionally influence your thoughts and your emotions. So that’s your choices and your actions to go out there and achieve your goals. Okay. And so there’s this famous quote that says you can’t go and lead others if you don’t know how to lead yourself. So self leadership isn’t well known in dentistry or in healthcare, but it’s actually out there. Athletes use self leadership. We have top CEOs that use self leadership. We have multinational companies that train their teams on using self leadership. And if you look at some of the most successful people out there and you hear them speak and you read their autobiographies, they’re all practicing self leadership because you have to be able to control yourself from within. It’s about the inner game and it’s about mastering that inner game before you go out there and play the outer game. So I think that- [Jaz]Is it synonymous with emotional intelligence or is that different you think? [Sarika]Absolutely. Do you know, the last time we spoke, we were talking about, like physical health and wellbeing and nutrition and mental health, but people talk about physical health and mental health. What people don’t talk about is emotional health and emotional well being. And what is important here is I think as dentists we’ve got to realize that we’re working with human beings and all human beings are so emotive, more now than they ever used to be, because they’re so in tune. Well, they’re more in tune now, I think with their mental health, physical health side of things. So we really have to be able to, first of all, master and manage our own emotions to then know how we’re going to manage the emotions of our patients, our team members, and be able to then effectively treatment plan from there. So to go back to your question. I think both are important. I think nowadays, clinical skills for me are just a given. I think if anyone’s going to interview in my practice, they have to have an amazing portfolio. The clinical skills are given, but what I’m looking for is, have they started to master some of their inner leadership skills that includes understanding their strengths, that includes their values, that includes confidence and communication skills. How authentic are they? Are they just showing up and giving me a front and pretending to be someone they’re not because I’ve worked in this industry for as a dentist for 18 years, I can judge people quite well. And you can see right through that, and that happens a lot, and that’s a sign of a lack of inner confidence to me. So, these are all the things that I’m looking for. And genuinely, I want someone who’s going to be open communicator, who’s going to be able to take feedback, who can listen to what’s really going on, and be a team player. All these things are really important attributes, I think, when I’m looking for an associate. [Jaz]Things that I read online, Sarika, on these forums, when they’re saying about principals will kind of get together and they almost attack the associates and associates do the same thing where they mention or someone moans about some pay issue or something at work not being available. And then should this be made available to me as per should my holidays be denied because I’m self employed, therefore I can do what I want. And so they have this kind of a friction that you see online. My question to you is where do you think the problem lies? Why do you think there is so much principals versus associates? And what have you been doing because from an outsider watching in to you and a few times you mentioned to me that sometimes a podcast comes out that really hits home and you mentioned that you have a little chat and you talk about the podcast. And so I really like when you said that and from seeing your website I know the great clinicians that you’ve heard that would that work with you. How do you, because I know you spend time thinking about this. How do you foster a positive relationship? And why are things probably not going the right way from what we’re reading online? [Sarika]Okay, so let’s zoom out of that a little bit, okay? Now, prior to being a principal, I was an associate for 10 years. Kind of having been experienced both roles, I’ve learned that, like, long term success for any relationship, whether it’s personal or work related, it’s primarily built on mutual respect. And when this respect is gradually lost, that relationship is most likely going to break down within three years. There’s research behind this. I’ve read a lot around this. So there’s three phases to this. The first phase in the job or the first year even is like the honeymoon phase. Okay, both principal and associate they’re trying to like each other and they’re trying to impress each other. The second phase of the second year is where potential issues will arise. They’re both being a little bit more open with each other possibly both parties are trying to look for solutions. If there is a clash or a disagreement then that relationship moves into the third phase, where then you both recognize that you’re going against each other’s values. So let’s explain what values are because not everyone understands that. So your values are a guide or a set of principles on how you make choices and decisions. And when this is misaligned between two people or even two parties, then you’re going to have disagreements. You kind of, we’ve used that word like toxic, we’ve used kind of where we’ve had relationships that don’t really work. But I think that when a toxic environment or a relationship starts to break down, there are negative emotions there, at play, that are repetitively being triggered. So when it gets to that point, when that respect is broken, you’re going against each other’s values and it’s happening more on an emotive level. And that’s repetitively happening, which then triggers and breaks down that relationship completely. So how do we improve these relationships? And why is that important? I think that the first thing is to establish which phase is this relationship at. So if it’s stage three, okay, it’s quite clear that potentially there’s no going back and you may have to kind of amicably agree to go on your own way, in your own direction. All right, if you’re at stage two, then either party or both parties need to acknowledge that something in this relationship is misaligned. And there is a chance for resolve. And the only way to kind of resolve this is through effective communication. And by that, I don’t mean a text message or an email. I mean, a real face to face conversation. I mean, a real face to face conversation. And this is a real issue these days. People don’t talk anymore. Like I said, this kind of fast paced world that we live in. We’re becoming more and more accustomed to communicating via messaging and emails. And it’s very difficult to create a rich, positive relationship and trust in this way. So I don’t know if it’s just something that we’ve become used to in terms of technology, whether it’s time that we don’t have enough time or we’re creating enough time or prioritizing it, or whether it’s fear that we’re just scared of having a conversation. Especially when things haven’t been running smoothly or there’s a problem, right? [Jaz]What this reminds me of, Sarika, is some of the issues that young dentists come to me with and they share, not because I’m necessarily going to give them a solution, but because I like to listen and I like to understand. And some of the common themes are the grudge that’s in stage 2 progressing to stage 3 is often with the associate who shows up to work every day and the principal who is many miles away and only ever has communicated by email and it’s very official and it’s like a robot. There’s no there’s a lack of that in person magic. And so that I think has not worked well from what I’ve seen people complain of. Maybe it’s a corporate mentality kind of thing taking over there as well. [Sarika]Yeah. This is it, right? And again, it’s going back to values. Maybe for that associate having support, it’s value. It’s one of their values or it’s valuable to them. And if that principal isn’t there, isn’t on site, isn’t available to them, then, it’s going against their values. And so it’s triggering them. So I think this is why it’s so important at interview stage that you really start to having conversations about this. You’re basically just bringing everything to the table. You’re talking about what’s important to each other. I’m going to mention one other thing as well is I always tell associates that you have to think of yourself as your own business. You’re not just an associate working in a practice. You are your own business. And what’s happening is that when you are going to work in another practice, you are then aligning with that other practice or you’re going in partnership with another business. So I’d like for them to think of it on, take a different perspective on it. So if you think of yourself as your business, you have to think, well, as a business, what’s important to me, right? You have to understand what each other’s businesses are about. And at interview stage, you need to have an open and honest discussion between yourselves about it. You need to bring everything to the table. What’s important to you on a day to day basis? What are your values? What kind of culture environment do you want to work in? How do you build relationships? Right? That’s a two way principle. You have to ask your principal, the principal of the practice that question as well. How do you maintain the relationships in your practice? And I’d be asking the associate, how do you build relationships? How do you maintain your relationships with your patients, with your team members? And- [Jaz]The reason why these are great questions, everyone is because if you are nodding and you’re listening, what’s how I can say, yes, absolutely. This is good. But if you ask that question into you and the principal looks at you blankly, like this is something that they weren’t expecting, that they probably haven’t explored their own values. They’re not really touchy feely about these things. And not that you have to touchy feely, but like, this is a very important exercise and for someone whose mind works his way about being value centered, right? All that seven habits of highly effective people being number one value being value centered. I’m all about that. And so if you’re an associate and you ask this and you get a blank look then maybe that’s not the right practice for you. That’s open to talking about these being values led and conversely, if you’re interviewing an associate and you’re the principal, and then you ask about this and then you get a puzzle look or you get an awkwardness, then maybe that is a sign that perhaps maybe this person isn’t at the level that you want in terms of the emotional fulfillment from that relationship. [Sarika]Exactly. Again, if support and mentorship is important to you, which it is to so many associates, then you kind of have to ask, well- [Jaz]Number one thing I think, especially younger dentists, and that’s the number one thing, will someone be around to help me? Will I have someone that I can just show a case to and get some nonjudgmental advice and feedback? [Sarika]Yeah. And I hear this so many times from young dentists that they just say that, like my principal isn’t around or I want to be in a practice where I can learn more from other more experienced dentists or even my principal. So that’s really lacking. That’s the other thing is I might be working two days a week in my practice, but I have regular one on ones with my whole team. I have regular meetings with my team. When I’m in each everyone’s surgery. How’s things going? Have you seen any interesting cases? I am sharing radiographs with them. I’m sharing cases with them. I’m showing my vulnerabilities to make them feel like actually it’s safe and it’s okay for you to ask questions. There’s nothing like a silly question. We’re all here to learn. We’re all here to grow together. It’s not like a singular thing. Your practice grows if everyone within it is growing simultaneously. And I’m a true, true, true believer of that. So it’s also, I think, talking about financial situation, right? What is grossing like, what is turnover like on the other hand, right? And are you aligned in that? Because if your practice wants to turn over this much or they have an expectation from you, but you’re only grossing this much and that’s it, and you don’t understand it or have someone to ask questions, or you don’t know who can help you in the practice to kind of grow, then that’s going to be a problem down the line. And then I think also future goals and growth. Are you someone that is just happy to tick along and do your thing and you’re happy just to sit in your room and get on with stuff or you someone that’s like hungry and you want to learn and like you want to see procedures and you want a bit of mentoring and you want to grow financially, then again, you’ve got to be aligned with that as well because down the line, and I think there has to be open, honest discussions about this, by the way, I don’t think it should be superficial. I think both parties have to be really honest. And if there’s any kind of sense that there is a dishonesty, or there is a lack of information, either dig in deeper, don’t have the fear, just keep asking questions, or, you know, then you just have to look for something that works and is more aligned with who you are as a dentist and your values and what’s important to you. [Jaz]I think the key message here for me from this short discussion on building that right environment is exemplified by something that you do, which maybe it’s not happening enough. It’s just going into all the surgeries, talking about how are you doing today? How’s any interesting cases? I love that you do that. And I think that’s the number one thing that I’ve taken away is that, one thing can just, you can implement this. If you want to have a better relationship with your associates. How many touch points have you created in a day, in a week, in a month? And how is that happening? And that’s really to find out what’s important to your associates and trying to match that. We’re going to pivot a little bit Sarika to ask you, but i’ll give you another opportunity to add anything to that. But the next thing I’ll be asking you about is women in dentistry in terms of actually leaders, principals. Why are we seeing such few women principals? But is there anything you want to just add to the principals versus associates before we move to that? [Sarika]Yeah. Do you know, Jaz, I was just going to say that I think going back to that point that you are your own business and understanding the other business, right? Because there are very few practices out there where the principal is going to be on site is going to be there working. So I think we are in a culture and an environment where there are a lot more corporates that doesn’t exist. But also think outside of the box. You don’t necessarily have to get support from the principal itself. You could have a manager that could be touching base with you. You could have a senior associate that’s been there for a really long time. If you’re a young dentist, it’s about connections. It’s about creating relationships. It’s about growing your own business. So think outside of the box. Don’t just shut the door. If you think that, Oh, X and all these things are my criteria, they haven’t been met, or I’ve had a cross on one of them, right, I’m going to move on to the next thing, because it is difficult to go out there and find a job. It is difficult to kind of tick all the boxes, there are going to be certain sacrifices, there will be some limitations, but it’s about thinking of- [Jaz]Compromises that you have to accept, and then whether that compromise sits below the threshold that we all have, and if there is enough going that sits in line with your values and it’s not, there’s no red card offenses going against your values. And then to actually associates, you’ve got to work on it as well. Have those difficult conversations to, even though it makes you feel sick and anxiety to have those discussions, it’s important to have those because you’re carving a better path as an associate in the practice that you work at. You’re actually looking to work at that relationship and looking to make it work for you and your patients at that clinic. [Sarika]Yeah. So in summary, what’s important to you? Remember, relationships are about mutual respect, aligned values and trust, and of course, open, authentic, honest communication and support. [Jaz]Fantastic. Sarika, why are there not enough Sarikas out there in the world? Why don’t we have more leaders or principals? Obviously, yeah, I know. I know plenty of women in dentistry who are principals, but there’s got to be, I know what the stats are, but when I’m on looking at these Facebook groups, principals, the vast majority are men, even though nowadays. Look at the dental school intake is 60% women, 40% men is what you’re getting in the in the dental schools. And it’s been like that for at least ten years now is it because well women are childbearing potentially and therefore that almost is a big stop in their career and they have to then sacrifice so much of their career and ambition for that or is there equal opportunities that are not existing. Can you share any stories that may suggest that could be happening? I’m sure you’ve done a good analysis to what’s going on. What do you think’s at play here? [Sarika]Yeah. So I think first, let’s talk about why are there less women principals out there, practice owners out there. And then I think what we can kind of link onto is like, what are the barriers that the women face and maybe some of the things that I’ve heard. So look, let’s go back in time. Let’s go back in history. For generations, the role of women has been to serve and for men it’s been to provide. So, what’s happened here is that we’ve been conditioned both men and women to kind of believe and behave very differently. So for men for a really long time, they’ve had access to resources and connections, which automatically gives them opportunities, okay, which is what you need to start a business or even operate a business like a dental practice. And for women, the historical kind of conditioning, it’s so deep that naturally we take more responsibility at home to manage the house and the kids. So in terms of like resource and opportunities, an example of this is that, I didn’t know this, but the right for women to open a bank account was only available in the 1970s. That’s not a long time ago. Did you know that? I mean, not a lot of people know that, but that’s not a long time ago. And so many women, especially like my generation, slightly younger than me, have grown up not being taught how to manage money. Which really affects their money mindset and understanding money, managing it, having a positive money mindset is key to running a dental practice. Okay? So now women have access to kind of resources and opportunities and we’re slowly seeing more and more female practice owners, but it’s going to take time. It’s going to take time for that to grow. All right? I also think that dentistry has been a male dominated profession for a really long time. And even when I first started working around 18 years ago, you rarely saw a female practice owner. Those 120 jobs that I applied for, only three of them were female practice owners. Okay. And there was so male like in character. And I understand now that they had to be because they were in a male dominated profession. So if they wanted to maintain that respect, have that support. They had to behave in a certain way. So I believe that the environment wasn’t supportive for women starting practices. But again, that’s slowly starting to change. I think also in my experience, until more recently, I think that women, if I may say, haven’t been very supportive of each other. Okay, and I don’t know if that’s because of the lack of opportunities that we have. Now, suddenly the gates have opened and this is almost like this competitiveness that is there. I don’t know if it’s fear. I don’t know if it’s about looking vulnerable or this fear of judgment. But, there’s also that the fact that there are very few female to female practice owner support groups and networks which are out there. So even if you did want to open a dental practice, where do you start? Who do you speak to? Where are you going to get honest advice for? Who’s going to give you your time? Who’s going to give you their precious time, right? And I have to say that the majority of my mentors and coaches have been male because even when I went out there to approach women to approach, some of these women are still around and I think they’re awesome. They’re powerhouses. But when I went to them to ask for help, I got nothing. I got nothing. And it’s not like I just asked once I asked a few times. I asked several women and I got nothing. So the majority of my mentors and coaches and have now been male. So I think that there’s that aspect to it as well. [Jaz]Is there an element, Sarika, you think, potentially, and this is just me thinking about relationships in general. And what I find is with everything that I do in terms of clinical dentistry, running Protrusive, the education, everything, there’s a lot involved. So the reason I don’t own a practice is because if I did that it would be the death of everything, all of this stuff. It would be the death of this, right? So yeah. Having a practice is a huge, huge thing to do. I could have easily have started a practice and not have all this. And so this is kind of like my baby. You know, like you said, practice is like your baby. It’s like a relationship. So this is what I have. And my wife has been incredibly helpful. Now, during the MSC, I took a lot of the parenting. I supported her to get through the MSC, which was great, but I had to take a step back from things to allow her to do that. Do you feel as though that perhaps the issue may be that because of this historic references that you made in terms of how relationships were in the past and the role of women in the past, that perhaps to own a practice that at that time in your season of life where a female dentist may be owning a practice that they may need their partner to maybe be a bit more supportive to do that. Do you think there’s an element of that? [Sarika]Yeah. Let’s talk about that. So, I think something you touched on before, and I’m going to connect to this a little bit as well, is that, look, when it comes to women in their careers, there’s always going to be a clash between them and their biology. Okay. So I know some women that feel that there is a finite time in which they can open a practice. Okay. And by the time they’ve gained enough experience and cash, some feel that they have to kind of choose between a relationship and kids or practice because they don’t have the time, the mental and emotional capacity for both. And it could be a reason why more and more women are statistically choosing to have partnerships and children later. And some of them not even at all. I know so many women that are just like, no, I love what I do. I love me. I don’t want to have children. And that choice is open now, right? It was never open before, but it’s becoming more and more open. And I do think that men have to be more supportive of women. If women want both, and I think men are, I mean, I’m just really blessed that I have a really supportive husband who just basically let’s just lets me live through all my crazy ideas, like nothing gives, I’m always like doing something on top of something on top of something, but you’re right. Like, inevitably, if women choose to have children, there may be a career break in that time. They may de skill, potentially they could be a loss of confidence. Women also naturally go through a change in identity. Nobody talks about that after having a baby. They may then take on a job that isn’t necessarily something they enjoy, they’re passionate about, it’s just out of convenience. Because of of childcare. And if you’re a female practice owner, and then you’ve had a child, it’s something additional on top of all your other responsibilities. You’re wearing all these different hats, and it’s not easy. And this is a topic that I love to kind of talk about, guide, and teach and support women on. But I think the world is changing Jaz. I think women are choosing partnerships now where if they are serious about their career, they’re serious about elevating their career, then they are choosing partners that are going to be supportive of them and when it comes to then having children, we create boundaries, we manage our time, we split the responsibilities, we create balance with work and with life which is really, really important. And you need that to have harmony, but also if you never want to stop growing, you need that. You need that balance. [Jaz]And I think what also, what we need is stories like yourself, whereby, you’re a principal, you’re a mom, you wear these different hats. And I think it just needs to be shown more that, Hey, actually, Sarah can do it. Sheila Li can do it. This person can do it. So many great women. Cat Edney in the therapy space, such great women, great leaders, great educators. I see. And I’m like, that’s amazing. But I think people need to be talking about this. And so having that at the forefront and see that actually it can be done. It just needs a major rewiring of how the family life will be run and lots of difficult conversations once again, to be had. But if someone wants it bad enough, it just starts that conversation and knowing that it can be done. It just has to be organized and rewired part that needs to be prearranged, I guess. [Sarika]Yeah. And let’s just touch a little bit on like kind of other barriers that women might face, because I think it’s important to kind of put that out there. And I think it’s really important to kind of acknowledge that gender bias still, unfortunately, exists out there, okay, when it comes to opportunity and pay. Just recently, I had a delegate on my course in May, and she was telling us a story about how she’s been in this practice for a really long time. She’s actually grossing really well. She’s quite really productive, never any issues, and suddenly a younger male dentist comes in and she finds out a year or two later that he’s on a higher UDA value, and then she requests from a manager. At least I don’t even want more. I want to be matched. She’s been there for like six or seven years. I just want to be matched. And even then she’s not given that. And again, is the manager giving information that the principal is giving her principals, never having a direct conversation with her. But gender bias still exists, unfortunately. Okay. And just a message to the women that, you don’t have to be there. You have a choice. If this is what you’re experiencing, then you have a choice. It’s not easy to find another job. I get that. But you still have a choice to be able to move out of that environment. I also think that what I’ve heard is that there’s sometimes a lack of communication from managers and principals because they assume women are going to react emotionally. They’re not going to say something. If something’s gone wrong, they don’t tell them. They don’t give them feedback because they think that, oh, she’s going to react emotionally. So I think, again from the management side of things is that, you’ve got to be open as well, because otherwise that’s going to keep getting worse and it’s just going to snowball into something else. I think other barriers women face is, is really internal, not the external ones, is kind of a lack of self advocacy. Like I said, fear of speaking up, right? And sometimes they feel like they’re not being heard, but you also have to be able to speak up for yourself, right? Self doubt, lack of confidence. [Jaz]I just want to add a bit on that. Like when you are in this position where you’re constantly battling with inner thoughts and you’re not speaking out, then it’s a bit like a bottle that keeps getting full, keeps getting full. And eventually that bottle explodes and then there could be an outpouring. And I always encourage team members and whatnot. Like if there’s something grumbling, always good to just discuss it early on and try to shape your life and career. Cause if you start bottling things up five years, 10 years, then suddenly huge, so many opportunities have been missed. So it’s about giving them the voice and the courage and confidence to speak and actually have voiced their ideas about how they can make a better life for themselves. [Sarika]Yeah. But look, there’s, there’s two things to this, right? Is that I think individuals have to take responsibility for themselves and have self accountability. Not everyone can do that for you. It’s your life. You’re in control of your choices, your thoughts, your emotions. But at the same time, practices can create a kind of a safe environment for people to be open and to speak up. And I think that’s really important as well. Because you have to understand what other people are going through. I think for a practice to grow, to have harmony, balance, have a good culture and a good working environment, it’s got to be a two way stream. And what I found a lot as well is even sometimes when I have created that environment, I’m not getting that other person speak up, they won’t talk. It’s just something that’s deeply ingrained internally. So, you have to keep giving people a chance. Don’t give up on people. And at the same time, I think that associates clinicians have to remember that it’s still your responsibility. You have a choice to communicate with your team as well. Yeah, I think there’s this lack of kind of inner confidence, these limiting beliefs. I think all this self doubt it’s internal kind of self internal barriers within women. So yeah, I just think that they’re kind of, they’re there as well. And like after childcare, I think also lack of flexibility. I think a lot of principals will mention that. So it’s just something that I think women now have to have a plan when they are pregnant. I’ve had two associates that were pregnant that have come out of pregnancy. And what we did was we sat down, we had a chat, we had a meeting. What is your plan? What do you want? How long do you want to be off for? Because then if I know what they want. I can make provisions from my side. I can make a business plan from my side. I don’t have to make a loss. I can manage cover, I can organize all that. And then a month before they’re coming back from maternity leave, there’s another phone call, another meeting to say, are you still comfortable coming back at this time? How are we going to plan everything? What are you feeling? What do you want? Blah, blah, blah. And again, we can just plan everything. So the business doesn’t lose out. We’re not making assumptions and it’s just communication. It’s just talking and having that relationship. [Jaz]So Sarika, we’re getting to the crunch part of the podcast. I’m just going to get some quick wins and some quick tips from you. What tips do you have for all dentists who want to start a principal, but especially who want to be a principal, start a practice, but especially for women? Because some of the themes that are covered are so relevant and they’re not talked about enough. So what are your top tips for women who may be thinking about having their own baby, having their practice that, as I mean by that, basically, right? What can you pass on for your experience? [Sarika]So brilliant. Do you know what? I’m going to talk about top tips for everyone. But I think that women can especially take these on. So I think the first thing is that if you have an ambition, you have a dream to open a practice. The first tip is don’t give up on that dream. Start creating goals and then take action. If you can have goals in your mind, but if you don’t action them, you’re not going to move forward. So it’s about thorough planning. That’s going to be the first stage. Do your research, ask questions, speak to as many practice owners as possible because all practices are different. Okay. Learn and understand what it means to run a practice. What are the costs? What are the systems and processes, CQC, et cetera. Then you need to make a business plan. Okay. And at this stage, be realistic. If you think that the goal is too big or too difficult for you, don’t give up, but instead kind of think outside of the box, like, think, well, maybe I can have a smaller, more manageable practice. Maybe I can go into partnership. So there are so many options and opportunities out there. I also think that know your strengths and weaknesses. If you are weak in numbers, for example, push yourself to understand finance better, speak to your accountant, see what resources they have for you to educate you. Don’t be afraid to outsource financial work, even if it costs money initially, you’ll be surprised how quickly when you start your business, how quickly you’ll be able to pick that up. I also think that if the business plan is in your head, use your current working environment to your advantage. And to learn and practice those skills. So for example, start taking ownership. What does it take to run a practice? How do you manage people? IT skills, stock management, equipment breakdown, take an interest, like learn how things work and function. And if you had problems, how do you overcome it? I also think that you have to have a growth mindset and you have to have resilience because you can’t need yourself if you don’t need other people. And I think that if you’re going to run a practice, I’m telling you now, you’re going to have to be prepared to make difficult decisions and you’ve got to be pretty thick skinned. The last thing is learn to control your thoughts and your emotions because there are going to be stages where there’s going to be a lot of stress and overwhelm. So you have to be really good at managing this. And of course, your time, learning to manage your time, learning to delegate and creating boundaries, I think is really important as well. And that would be my final tip. [Jaz]That theme of understanding yourself and being your best self and having that growth mindset is a recurring theme. And I love it. It’s always a welcome theme in this podcast. And I know some of the wonderful things you do, you’ve touched on some of the courses that you do. Tell us about this movement of Flourish. What is that about? And what are you hoping to achieve with Flourish? [Sarika]Okay. So, we kind of like talked about that the world we live in now is so different. Expectations from patients are really different. And we spoke about what makes a good clinician, right? 30 to 40% clinical. The rest is 60 to 70% now. And not everyone will agree with me, but that’s the kind of my thoughts around it is to kind of do with like inner and outer leadership. So, we can have the best clinical skills in the world. But if we are lacking leadership skills on the inside and the outside, we can’t build rich relationships. We can’t treat our patients efficiently, effectively, and with optimal care. I saw that dentistry as a profession needed a little bit more gender balance, especially as more and more women, like you mentioned, are graduating as dentists. So two years ago. I made it my mission to create something to support women. But before I kind of embarked on that mission, I first had to really reflect on all the barriers and challenges that I had faced in my career and really understand how did I create my success and my happiness in my life and as a dentist and as a practice owner. And it came down to one thing, something that I was practicing for years that I mentioned and started to master was self leadership. It was about mastering my inner game. What all these athletes do, what all do these CEOs do, what all these successful people do. Now a lot of people, especially in dentistry, they don’t know what self leadership is. And it’s not really a new concept, Jaz. Like, self leadership has been used by so many people for so long. So, self leadership, again, is when you intentionally influence your thoughts, your emotions so your choices and your actions to powerfully create and achieve your goals and your objectives. It’s about mastering that inner game and going out there and smashing that outer game. And what that will mean is being an excellent all rounder dentist. An excellent all rounder clinician and self leadership is based on four principles. The first is self awareness. This is where you master consciously taking control of your thoughts and your emotions, so choices and actions. There’s a deeper understanding of those belief systems and that mindset, the mindset that we have, right? Growth, fixed, perfectionist, high achiever mindset. And then the second principle, is self discovery. This is where we have an understanding of what our strengths and our weaknesses are. We’re able to leverage on them and we’re able to make decisions powerfully and communicate confidently. Okay. This is so, so, so important as dentists that we’re able to do this and is a huge skill. The third principle is self management. This means taking accountability and responsibility. And once again, we are our own business. We have to be accountable for ourselves. We’ve got to be responsible for our own actions. [Jaz]Even if you’re an associate, because you mentioned that, I just want to highlight that. Even if you’re an associate, don’t think you’re not a business. You are totally a business. [Sarika]Yeah, you are totally your business. And the fourth principle is self growth. So making goals, actioning them, right? Because you can make goals and sit on them. A lot of people procrastinate, they’ll make a goal, they won’t move from that position, but it’s about actioning them. And then that will in turn influence and strengthen your mindset and your confidence, and it will hopefully inspire other people around you to also be self leaders. So what’s happened is I’ve taken those principles of self leadership, I practice it on myself, but I think I mentioned earlier in the podcast is when we were talking about how did I build my team, we never got to that. But what happened was is that I started to recruit the right people, but I also started to coach my team on self leadership. Okay. And that inevitably meant that they were taking responsibility for themselves. They were making autonomous decisions. We were building trust. We were building richer relationships, building a culture. [Jaz]But Sarika, they were building better lives themselves as well. Cause all that stuff, they take it back home with them to their families. And it improves you in every facet of your life. [Sarika]Exactly. And I think that’s so important because dentistry is just our profession. It’s not who we are. And we say that we want to be professional. But at the same time, we want to bring a bit of our authentic self into our work. I think authenticity goes a really long way. But at the same time, we’ve got to have that balance, right? If we want to be efficient, effective at work, we’ve got to have that balance at home as well. We’ve got to have that harmony and balance and peace at home as well. So this is what self leadership allows you to create, but it’s not only for yourself. It’s going out there and inspiring others to do the same. And that’s why multinational companies use them because they want every single member of their team to be efficient self leaders, because it’s now proven that that’s where you get optimal growth. So basically from this, I created a brand called Flourish. Which is basically to teach everyone in dentistry about self leadership. And I speak at events. So, I speak in front of men and women, dental corporates and teams. But look, to stand for my mission, I also created a two day course called Flourish as a Female. Which I’m so proud to say is the first self development, self leadership course in the UK, run by a woman, for other women. And it gives them the safe space to be vulnerable, to learn about self leadership skills and truly thrive and really elevate themselves and their careers. So this course really, I believe kind of benefits any woman in dentistry, whether it’s clinical or corporate to kind of elevate their careers. So this can be associates, hygienists, therapists, and even principals to kind of really go out there and truly thrive and flourish. I think it’s going to be great for any women that feels demotivated stuck, lost, lack of clarity, has self doubt and fear. Maybe they’ve come back from maternity leave and they really kind of, they’ve lost their mojo and they kind of need that reboot again. And it’s definitely great for female practice owners and even their teams, okay, to kind of recreate it. In a sense, what I have. I’m also a certified coach. So not only like, do they get that? [Jaz]That definitely shines through the way you speak. I think you’re a great role model. We always bump into each other on courses throughout the year. This year, the last 10 years, I’d like to see that every single course. So, it’s been great connecting with you. I can vouch that, sorry. A really warm person, a very great role model. And I think I’m so glad that you started this initiative because I think you need to spread these good vibes and help coach people to live a better lives for themselves in general, but also professionally, which is what connects us. But definitely far beyond that is what the ramifications have. Is this like an in person thing, right? So like location wise, I’ll put the website in the show links. And is there anything else that you want to just say in terms of the website? I think you had a promo code for Protruserati as well. [Sarika]Yeah. So there’s a promo code that’s Protrusive. There’s a huge discount on the face to face clinical course. And yeah, like, I really want to go out there. It’s a passion project, but I want women to really start taking responsibility for themselves, prioritizing themselves and not just focusing on their clinical dentistry, recognizing there’s so much more to that and yeah, really kind of elevating themselves in their game. [Jaz]Well, I think that would be a fantastic. I’d love to promote that. I’m going to put that in the show notes. So please do send me the links. I could just say the website out loud and I’ll put that in the show notes as well. [Sarika]Yeah, it’s www. flourishasafemale. com. [Jaz]Okay, fantastic. So that’s easy to remember as well. Sarika, thanks for sharing so much. So much, so openly telling us about your stories, telling us about how to cultivate a team, teaching us the importance of self leadership. I think it’s absolutely brilliant what you’re doing. More power to you. Really need this. I think you’re going to benefit a lot of dentists, women as well, but just dentists in general. So keep fighting the good fight. And thanks for giving up your time today. [Sarika]Oh, it’s my absolute pleasure. Thank you so much for having me. I really, really enjoyed myself today. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. If you’re watching this on Protrusive Guidance, scroll down, answer the few questions on the quiz, give some reflections. What did you learn from this episode? What will you change about yourself or your practice to make sure these lessons are not wasted? How are you going to implement it? That will actually end up on your certificate. Your CE or CPD certificate will contain that. And I think that’s a great thing to have. Download Protrusive Guidance if you haven’t already. For those who are watching on YouTube, please give us a thumbs up to let us know you got this far. I will put all the show notes, all the links to what Sarika recommended for her course, Flourish. I’ll put it all in the show notes. I have no financial interest, but I am fully behind Sarika’s cause. I think it’s great what she’s doing with empowering women in dentistry. Hope you resonated with the themes that we discussed today and that you’ll think a little bit more about self leadership. Thank you and I’ll catch you same time, same place next week. Bye for now.

Nov 6, 2024 • 34min

Endodontic Irrigation – How to Get Better Success – PDP203

Is Sodium Hypochlorite still the best irrigant for endodontics? Or do we have something novel and superior? How can we improve the efficacy of our endodontic irrigation? What % of NaOCl should we be using? https://youtu.be/z5h2FzHpG68 Watch PDP203 on Youtube Dr. Brett Gilbert rejoins Jaz Gulati to tackle all things endodontic irrigation after a brilliant episode on pre-emptive endodontics. Advanced activation and delivery systems could change the game—are we on the brink of a major shift in endodontics? Protrusive Dental Pearl: Before performing a molar extraction, challenge yourself to first complete an endodontic access on the tooth. This will enhance your understanding of the canal anatomy and improve your precision in sectioning the tooth. By visualizing the canals and the pulpal floor, you’ll refine your angulation for more accurate sectioning. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 02:09 Protrusive Dental Pearl 04:23 Is Sodium Hypochlorite Still The Gold Standard? 06:54 The Role of Surfactants in Irrigation 07:58 Concentration of Sodium Hypochlorite 09:47 Chlorhexidine: Is There Still a Place? 11:32 Advanced Disinfection Technologies 21:31 Evidence-Based Techniques in Endodontics 25:22 GP Pumping This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment) Dentists will be able to: 1. Gain insight into the role of sodium hypochlorite in endodontic disinfection and assess its effectiveness compared to new innovations.2. Discover the cutting-edge irrigation methods, including surfactants, ultrasonic activation, and laser-assisted irrigation, and their impact on endodontic outcomes.3. Explore emerging technologies and innovations that could revolutionize endodontic irrigation. If you liked this episode, be sure to watch the 1st Part – ‘PDP202 – Elective Endodontics? It’s all about Communication’ Click below for full episode transcript: Teaser: When you use a lower percentage, you really aren't reducing or eliminating the risk of sodium hypochlorite accident. If you get 3% sodium hypochlorite out the end of the root, it's going to cause a sodium hypochlorite accident, as will 6%. If you're trying to eliminate risk using a lower concentration, I don't think it's as effective as you think, but you are taking away some of the strength that you're looking for to kill the bacteria and dissolve the tissue. So my advice would be go full. Teaser:We recognize that training our general dental colleagues on endo is paramount because we don’t want the option of implant to come in place of saving the natural tooth simply because of fear or the fact that they just don’t feel well enough trained to do the endo. So I believe as a dental community, the more we feel comfortable and proficient in endo, the more teeth we save and the better our patients are. Jaz’s Introduction:Is sodium hypochlorite still the best thing in irrigation? If it is, what percentage should we be using? This one might actually surprise you. Is there ever a time when to use chlorhexidine. Whatever irrigant we’re using, how can we improve its effectiveness? Hello, I’m Jaz Gulati and welcome to the part two with Dr. Brett Gilbert. How awesome was he? Please do check it out if you haven’t already. We talked about elective endodontics or preemptive endodontics. I love the clarity and the passion in which he speaks with. And he definitely continues it on into this episode. He’s so knowledgeable, he’s so passionate about endodontics in general, but especially the innovation in irrigation. Because after all, endodontic success is all about killing those bugs. And Brett has so much experience in trying all the different things out there. And towards the second half of this episode, he really talks about what are the innovations. What’s around the corner? What’s the next best thing in irrigation? But then I also squeeze out of him the all important real world question, which is no matter what clinic you are in the world, how can you improve your irrigation? So we also talk about GP pumping right towards the end. This episode is eligible for CPD or CE credits. This one’s 0. 5 CE credits under the topic of 070 endodontics as Protrusive Education is a PACE approved provider. Make sure you’ve got the Protrusive Guidance app, so you can just answer the questions after this episode. Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl, and can you believe we already have 291 episodes? That’s across all the group functions and the interference casts. And combining all the stuff we do in the podcast, we’re almost at 300. We’ve also reached a really cool feat recently, whereby we now we’re ranked in the top 1% of podcasts worldwide in any genre. So I really want to thank you, the listener, the watcher for supporting Team Protrusive. Your support, your subscriptions, your wonderful engagement has meant so much to us and allowed us to create this content and bring on guests just like Brett and all the 200 plus guests we’ve had on. I want to thank all the guests who come on the show as well. But before we join the main interview, let me give you today’s Protrusive Dental Pearl. How can you improve your endodontic access? Well, let me tell you the secret of improving anything in your dentistry. Any technique you want to improve in dentistry, you just have to do more of it. Now, what I don’t mean is every patient start accessing their first molar, trying to find MB2 just for the fun of it. That would be wrong, but here’s a really cool idea. As you know, every time I extract a molar, 95% of the time I will be sectioning that molar. So for a lower molar, section around the middle to separate it into its mesial and distal root, and for an upper molar, more often than not, it’s separating it into its three roots. So I’m very pro sectioning, it’s kind to the bone, it makes your extractions easier. Makes extractions more predictable. I already have podcast episodes on this, and I also have sectioning school, my mini masterclass on Protrusive Guidance, if you want to learn more about sectioning. But here’s how we can kill two birds with one stone. How can you improve your sectioning? Because when you start sectioning, the most difficult thing is getting that angulation of the bur correct, so that you cleanly cut through the fication or the root exactly where you want it. So how about this? The next time you’re going to do a molar extraction, How about you challenge yourself to first do an endodontic access? The tooth’s coming out anyway, right? So how about with your bur, you go in for the kill. You get to the canals. What this will do is teach you about endodontic anatomy. It’ll teach you about where the canals live. And the more you do this, the more you’ll end up improving when you actually have to do a real access. It’ll actually make you quicker as well. Because you have nothing to lose in that scenario because the tooth’s coming out anyway, you’re not going to be afraid to perforate. Because the point is, for sectioning, once you can see the canals, you know exactly where to section. When you see the pulpal floor, it makes the angulation of your section so much better. So, now with the sectioning, you’ve improved your extractions, and now by the fact that you accessed it first, you’ve improved your sectioning, but you’ve also gained more experience in doing an endodontic access. So I hope you enjoy that pearl. Hopefully it’s applicable to you. Any limiting beliefs you have, oh I can’t do this in my clinic for x, y, and z, just do it. Even if it just means you book an extra five minutes and that five minutes is what you spend on the access. Oh, and please use some good burs. It makes a huge difference to being efficient. Anyway, let’s join Dr. Brett Gilbert on how we can improve our endodontic irrigation. Main Episode:Irrigation! Okay, so I know you’re really hot on this. So the proper disinfecting protocols, let’s talk about where we are in 2024. Cause I was taught that sodium hypochlorite is the gold standard. So the first question is, is there anything better yet? Are we still relying on 3%, 5.25% wherever it is sodium hypochlorite? [Brett]We are, but what we’ve learned is a few things that are important to know, which is that the commercial store bought household bleach is not the way to go. And the reason is, is that what we’re dependent on for the antimicrobial bacteriology is to actually have free chlorine ion and the amount of free chlorine ion in bleach, it’s very unstable. It’s very fragile. We think of bleach as this noxious, hardcore substance, but it’s actually very fragile. It’s sensitive to air to light. It can become contaminated. And even though it’s still, unfortunately, we’ll put a bleach stain on our beautiful new fig scrubs like you’re wearing there Jaz. It doesn’t mean that the free chlorine ion concentration is high. So we want you to be using a proprietary blend sold by a dental company where there are controls, there’s an expiration date. And most importantly, what we found through our studies is that adding a surfactant to sodium hypochlorite really changes its effectiveness because surfactant lowers the surface tension of the solution, allowing it to flow into these crevices. We have to think, we think of the root canal as a vertical line, but it’s so much more. And so we want to get penetration as much as possible. So for really not much more of an investment, we’d like to see you using some type of branded proprietary solution. And many, many dental companies sell these. So that would be the biggest change. Yes, sodium hypochlorite, but in the form where we can really control more of understanding that when we put it in the tooth, which is the most important part of the procedure, the chemical disinfection is the most important part. And you would hate to be trying to do that with the solution that actually wasn’t very strong or active, even though you in your perceptible senses would have no way of knowing. So that would be the biggest thing is proprietary with surfactant. [Jaz]I was always taught with using these grocery store bleaches, which they used to back in the day. I mean, people still probably do now, but that was very popular back then. I know there’s a grocery chain here called Sainsbury’s, and apparently their bleach was what the endodontists used to go for, get a trolley full of 30 of them and go out. But one of my endodontist mentors taught me that, yes, apparently there’s lots of crystals and lots of other nasties in there that you don’t really need for your root canal. The whole thing about surfactants, is that already in the bottle or is this something that additionally you add. [Brett]Yeah, no, it’s part of it. It’s already pre mixed. And in fact, there’s even a solution from a company called Brass or that’s a one stop shop. So, you’re looking at organic debris removal and inorganic debris removal. So you might be chloride is organic, right? It’s tissue. It’s bacteria. It’s biofilm. Then you need like an EDTA type material, which is going to be the inorganic, the dentine proteins, any harder substances that are removed from the walls. And so it’s always been this funny mix of the two. And now there’s actually a solution that’s all in one. And so it’s becoming easier to be able to do this. I would say that one of the most important, there’s a ton of devices. I’d love to discuss if we’re going to get into it today, there’s been incredible explosion of technology in endodontic irrigation, but I think this is the most basic investment that each dentist needs to make is finding the right sort of proprietary stabilized solution that you can trust when you put it into the tooth. [Jaz]When I was a dental student, we used to use something like, 0.5% or 1% because that was like a safer amount as a dental student when you were learning. And then I learned that, okay, use something like 3% or 5%. And then if you use it heated, it actually makes it more effective and that kind of stuff. What advice are you giving to general dentists out there? What percentage should they, now they’re, they’re converted. They’re like, oh yeah, Brett said you have to use a propriety, put down that Sainsbury’s bottle, go on the website or to an official endo supplier, buy the propriety stuff. But what percentage should they be putting in their basket? [Brett]Well, I know it’s going to be upsetting for, cause I know in Europe it’s taught differently, it’s very low percentages, but the way that I look at it personally is when you use a lower percentage, you really aren’t reducing or eliminating the risk of sodium hypochlorite accident. If you get 3% sodium hypochlorite out the end of the route, it’s going to cause a sodium hypochlorite accident as will 6%. And so what you do though, because we know that, again, as I mentioned, sodium hypochlorite is very unstable and it’s deactivated very, very quickly. So the higher concentration actually isn’t going to be that for very long. So we recommend in my school of thought and where I learned and I think pretty much across the U. S. that the full strength is the best bet. And so most of these you’ll be able to find will be more of a 6% solution with surfactant. The material I mentioned, Triton, which is the all in one is actually two canisters within the same bottle. And it’s actually 8% on one side. But once mixed, it’s actually 4% when it goes into the tooth. So there’s a lot to it, but my advice is, is if you’re trying to eliminate risk using a lower concentration, I don’t think it’s as effective as you think, but you are taking away some of the strength that you’re looking for to kill the bacteria and dissolve the tissue. So, my advice would be go full. [Jaz]Go hard or go home. But what about the use of chlorhexidine 2%? Like I’ve been in clinics before in the way in the past where they weren’t that well run. And then you look at the nurse and say, can I get some irrigation please? And then they give you Corsodyl 0.2%. And I’m thinking this is doing nothing. There’s no dissolving of the organic matter, et cetera. So where are we at now in terms of chlorhexidine? Is it something that we just need to just bin or is there still a place? [Brett]Well, it has a place as an additive. So for instance, if you’ve heard of Q mix or there’s a number of different product called smear off, it’s sort of the EDTA solutions for the inorganic debris removal. You’ll often see chlorhexidine included in there as an additive. There was a time in my early days where 2% chlorhexidine was in vogue in retreatment. But ultimately the research never really stood behind it as much as we thought, and so I don’t really ever use it anymore. And to your point, it would be ideal as an endodontic irrigant if it dissolved tissue, which it doesn’t. And that’s why sodium hypochlorite remains the king because ultimately there’s nothing else that will dissolve tissue. And that is the most critical part of using endodontic irrigation. We have to get those bits and pieces out of there and you can’t just deliver it all out in mass. We really need the dissolution of it through solution. [Jaz]And when chlorhexidine is mixed with hypochlorite, is it true it makes a carcinogenic product that you should totally avoid that kind of stuff, right? [Brett]It does if you’re using just essentially the store bought bleach and just a regular chlorhexidine. If you’re using these proprietary blends, you can actually interact them without reaction. So that’s another advantage. [Jaz]I did not know that. Okay, fine. That’s very interesting. I definitely didn’t know that. Not that we’re recommending using CHX anyway, unless it’s an additive, as Brett said, but good to know. So now tell us about these new technologies. What is Dr. Brett Gilbert using in his clinic to maximize that disinfection and tell us about the evidence base. Is it established yet? Or is it up and coming? I would love to know what’s new and great in the world of disinfection. [Brett]Yes, let’s start on the most basic level, which is that at this point, probably the gold standard in terms of evidence is passive ultrasonic irrigation. So you put the irrigation solution in the tooth and you use some type of ultrasonic tip to activate it. And by doing so, you’re hoping that you’re producing some cavitation. Cavitation is the implosion of a liquid molecule, and once it implodes, it has sort of this bombardment force against the wall. So you’re basically able to essentially hit the walls of the canal with the solution to get better penetration. So you would use that in an in and out motion. Now, ultrasonic and sonic are different. Now, sonic activation is very common. The endo activator, my good friend, Cliff Ruddle developed this. It’s been an incredible seller and to your eyeball, you see it swirling and moving. And that is good. It’s better than nothing, but the studies would show ultrasonic activation to be better penetrating into lateral canals, apical anatomy. So that’s sort of our basis point. If you can at least do ultrasonic activation with these proprietary solutions that I’m mentioning, you’re basically at the gold standard, but there’s been so much development in terms of the use of laser assisted endodontic irrigation. Multisonic irrigation. So I’ve been very lucky in my career to have been able to test pretty much everything, you know? So if you look at what’s really kind of changed the paradigm of irrigation, it kind of created a new category. Very disruptively was the gentle wave, which many of you may have heard of. This is from a company called Sonendo out of California. This is a closed system. So basically you build a little platform and then the handpiece fits right into that standard platform. And then basically you hit the gas and it’s an eight minute cycle. It’s cycle sodium hypochlorite, it cycles distilled water. And by closing the system, it creates a situation where you’re able to essentially de-gas the solution. So if you think about if you had a glass of water and you wanted to propagate energy through it, any little bubble in the water, we know this from physics would dissipate some of that energy. And so what this console does is it actually pulls all the gas out. So if you can imagine the inside of the tooth being filled with solution. But no bubbles at all. And now it has this energy, this broadband multisonic energy. And so it’s very disruptive to the walls. It creates a negative pressure so that it allows you to really get the solution down to the end of the route. And so it’s an eight minute cycle and there’s been some tremendous visual effects of that. Now, from a research standpoint- [Jaz]I mean, while are you talking, cause I’ve never heard this before. I’m Google imaging this. I’m looking at it. It’s looking like a big bulky machine, right? [Brett]Oh, it is. Yeah. [Jaz]It’s pretty sizable. [Brett]Yeah. It’s significantly. And it’s a costly machine. I mean, it’s getting towards six figures and even per procedure, they call it the procedure instruments are one use and they’re expensive. And so this did really change the game, but there are limitations to where it can be used. If there’s any communication to the sinus, you have to be very careful. If there’s any type of decay or leakage under a margin. This will tear right through it. You really have to be very specific about where it’s used. But ultimately, as I mentioned, visually, you see some incredible cases with just sealer, just through three canals at the apical end and out lateral puffs, et cetera. And a much of the research it’s out there is favorable, but we do have some question marks about the unbiasedness of it. Just being totally honest. I have some of my best friends who swear by it, who teach it and they get great results. And so that’s one option that really started this new game, but then lasers have sort of come into play. And so laser activated irrigation. And by this, we mean that the laser energy is both able to sort of activate and stir up the solution, but also the laser energy can be absorbed by the water and dentine, creating an opportunity to really effectively debride and disinfect the dentine. And so, I’ve been lucky. I’ve used the gentle wave. In my practice, I’ve had two different stints with it. I don’t have it right now. I have three different lasers in my practice right now. One which is Erbium YSGG. And with this Jaz, you actually have the solution in the tooth and it’s like a little fiber tip, maybe about a 21 at the tip, right? Think of like a small hand file. And you take it down halfway. And as you activate, you bring the tip out at two millimeters per second. So basically it’s a eight second cycle. And then I go into the next canal and the next canal, refresh my solution, do it again. I can also use this with water. So then I can take the tip closer to working length, again, withdraw, and it has what’s called a radial firing tip. So if you imagine like a cone coming out, almost like an inverted cone bur right? So as you’re in the canal, this radial cone is able to basically paint the walls with the laser energy. So that’s one option. The next option is Erbium YAG. Now, what’s different about this one is again, solution goes into the tooth, but now the tip simply goes into the chamber. It’s about three to four millimeters off the floor, hit the gas, and there’s a tremendous impact that you can see through the microscope. You can see a lot of this on my Instagram channel If anyone’s interested, I have a lot of videos related to this. So those are the two primary lasers that are available right now. We’re seeing really nice results the advantage. There really aren’t limitations to its use. Whether you have a sinus perforation, anything like that, we also find that we are having tremendous success doing endodontic surgery, as well as resorption repair with the lasers. And these are technologies that are very versatile in the office. And so we’re very excited about that. Very recently, I’ve just test drove and actually it’s my last post right now. Another company came up with basically a little tip that goes down into the canal. It’s a 19 at the tip. Okay. And it actually drives saline. So by driving it out at a certain speed out of the 19 tip, it creates a cavitation flow. And so now you have an opportunity to basically power wash inside the root canal. And the reason that this is unique is we’ve never been able to do this before because sodium hypochlorite is too risky. Even EDTA, we don’t want to drive that out of the end of the route, but by utilizing saline, we have an opportunity to have more velocity and more cavitation to sort of essentially power wash inside and I’m really impressed with the potential of it. Again, if you look at the general dentist doing endo and you look at what your heart rate does, right? You look at the stress that comes because of the risks. And so if we did have a day and age where we could irrigate very passively with the sodium hypochlorite, not trying to drive it down. So eliminating the potential accident, be able to finish the job with saline in a powerful force, and then ultimately obituary with a material that would not ever have to be worried about extrusion. Now, I believe we open up endodontics to general dentist in a greater way where there’s not so much worry and risk. And so there’s a lot of exciting things happening. I think as an endodontist, we recognize that, training our general dental colleagues on endo is paramount because we don’t want the option of implant to come in place of saving the natural tooth simply because of fear or the fact that they just don’t feel well enough trained to do the endo. So I believe as a dental community, the more we feel comfortable and proficient in endo, the more teeth we save and the better our patients are. And there’s no question there are not enough endodontists in this world to even come close to eating the whole pie of endo. So it’s critical that we educate. And that’s why I appreciate you having me on because I think your community obviously, or they’re advanced learners are looking to get better. And so exposing them to every discipline, especially the ones that most people would like to just punt, just, I don’t want to deal with this. I had a bad experience. I had fear. So I have an online program called access endo. It’s a community I formed in 2019 where I really mentor dentists in endo. So that includes curriculum, but it also includes live coaching. And the best is like dentists send me their cases and I actually guide them through their cases. And with the electronic medium online, I can actually be like you’re supervising, attending in your clinic. So I’m really putting myself out there to help dentists because I believe there’s a tremendous payoff for the dentist, for the patient and for all of us to see a more proficient level of endo across the board. [Jaz]That level of mentorship you described, it really is the pinnacle. Something that we’re setting up is called a Intaglio, Intaglio dental, whereby we’re going to make mentorship much easier because it’s difficult to find the right mentors. And I think it’s great. You’ve identified yourself as if anyone needs an endodontic mentorship, definitely check out Brett. I’ll put all his links there. That sounds amazing. But one thing that we’re trialing basically is just like you said, having the system whereby they have a loop mounted camera or the scope camera is being fed into zoom and then you’re in their ear saying okay, yeah, that’s good, that’s good, okay, do this, try this now, and I know they use it in medicine, doing crazy surgeries from halfway across the world to get the best brains on board, and I think totally it needs to be tapped into in dentistry and sound. It’s amazing to hear you’re already doing that. The question I have regarding going back to clinical is, we had an episode with Pasquale Venuti. He talked very interestingly about process based and being outcome based. And a lot of times we are like process based. The different steps and the different techniques and the fancy gadgets and stuff, whereas ultimately to have the outcome based evidence, unfortunately, there’s no shortcut. We need to wait 10, 15 years to then look at the data and say, okay, yeah, this improved success rate in this scenario by 20% or 18%. What evidence base do we have? Is it too early? Is it too primitive? Or do we have any established evidence base on these novel techniques? Are they actually making a difference? Because we know that root canal treatment is actually quite predictable. How much of a difference is it actually making? [Brett]So it’s a great point. And the reality is, is we call this advanced disinfection protocols and we don’t have a lot of evidence. That’s the bottom line. I mean, we’ve had to rely on, which is eyeball evidence. You know, what are we doing? We’re seeing more lateral canals filled with sealer, right? So I always say, when you look at sealer extrusion through little apical foramina, we know there’s multiple portals of exit. We know there’s lateral canals. And when you see the sealer, if nothing else, it’s a storyteller. Hey, it’s a storyteller of anatomy. You now at the end of the procedure, like, wow, that’s why there’s this lateral vertical bone loss on this tooth because I had a lateral canal there that I can see now. You also know that in order to get sealer to go into these spaces. They have to have been cleared of debris because we know even on a level of smear layer, it’s going to block sealer from exiting out of a lateral canal and so the story is that yes, I use the laser. I use the gentle wave and now I see the sealer. That’s pretty much what we have. We have had cases that we see heal tremendously fast. But we have had cases that we don’t see heal. And what’s important to realize is that the reason that we’re doing this is because we recognize that minimal preparation is key for dentine conservation. And most importantly, for all the dentists out there that are part of your community, recognizing that the pericervical dentine, the dentine, four millimeters above the CEJ and four to six millimeters below is the key dentine that supports the strength and fracture resistance of the tooth. If your access is too big, it’s going to put more force on that pericervical dentine, we actually find that the preparation and the taper of that preparation doesn’t impact the fracture resistance as much as how big you open the orifice. So being aware that we want to conserve the dentine. And so what these advanced technologies do Jaz is they allow us to keep the prep small, but still get the cleaning down inside there. And that’s what we’re after. Do we have the evidence of outcome? We don’t. I wish we did. We’re spending an awful lot of money over here around the world and in endo on these devices because we so want to improve. We want to get better outcomes. We want to save teeth, but ultimately it takes time. So you have some that put their necks out there first. I’m one of them for whatever reason. I’ve always felt like someone has to try this for the sake of everyone else, even though at times it feels a little risky, but ultimately I think we’re at a point now where we are going to start to see some more studies, but like I said, if you look at the gold standard from evidence or outcome, it’s the passive ultrasonic activation that has the most evidence and that would be a great starting point because it’s not expensive to institute into your practice and your protocol, but ultimately you can have evidence based understanding that it’s definitely better than needle irrigation alone. No question. [Jaz]Well, you’re definitely a pioneer and that’s absolutely clear from speaking to you. An old fashioned technique that I still do is GP pumping. Your thoughts on dentist GP pumping. And therefore, can you also give us some guidelines how best to do it? I remember one dentist, old school dentist who taught me to dip the master GP cone, just the tip of it in some chloroform, just a tiny bit. And then take it to the end and then they’ll kind of make the shape of the apical foramina and then use that to GP pump. I was like a little bit concerned about doing that, but what is a good safe protocol, a good safe way to do GP pumping and just describe for our younger colleagues what that actually is. [Brett]Yeah, so again, so GP pumping is just manual agitation again, just trying to get the solution to flow a little bit more. Obviously, that’s going to have very little impact in comparison to an ultrasonic energy coming through it. The custom cone, dipping into chloroform. Obviously, the last thing we really want to do is introduce chloroform to the apical end where it can escape. And as I mentioned before, It’s not the Gutta-Percha we’re hoping to seal. It’s the sealer. So to me that, although I was taught the same way, I don’t think that that holds a lot of weight. In fact, I think we really want to just have chloroform be out of our operatory in general. Why bring something noxious and carcinogenic to our patient’s mouth? Yeah. So at a very minimum, doing some type of gutter percha agitation of the solution. But as I said, if you’re here, if you’re listening, if you’re interested in endo, you can buy an ultrasonic activation tip that goes on an ultrasonic unit, very inexpensive and ultimately gives you a much better flow and activation of that solution. [Jaz]Can you recommend a brand? [Brett]Yeah, so there’s one Vista Apex out of the us. They have a handheld unit called the Endo Ultra, so that’s just like a single unit. But if you’re using an ultrasonic and if you learn endo from any endodontist, you’re gonna learn that an ultrasonic tip for uncovering canals. Finding your preps is so key. You want to find MB2, you want to be able to kind of be thorough and finding the canals. And so something like there’s a tip called Irrisafe, from a company called Acteon that also is very inexpensive. It can be used 50 times it’s autoclavable and on an ultrasonic, you can see if you go in and out, it creates that cavitation. So those would be two suggestions. Just top of mind. [Jaz]Amazing. Brett, that was absolutely fantastic. I’m so, so happy to have you. I’m so thankful to Tom Levine from the community once again for connecting us. Please tell us how can we learn more from you? So obviously you’ve got on the cusp podcast for those who’d like to have mentorship and identify you as someone. And I have to say, Brett, I really appreciate educators like you. And I think everyone else as well. My community going to love you because we love direct. We love direct answers. Here’s how it is. You’re also very balanced, but you’re also just no fluff. You give us the answers and we absolutely love that. So I know everyone’s going to love you. So how can they learn more from you? [Brett]Yeah. So again, my access endo community, you can find me at accessendo. org. You can message me on Instagram, but we have a great community. You can take a free training and just sort of get a really great training on different aspects. And then at the end, learn a little bit more about joining our community. Really, really want everyone to tune into on the cusp. It would be so honored to have you. This is different than what we’re talking about here. This is really for clinicians about clinicians, but it’s about sharing the journey, the human journey, and the ideas that as more of us share about our journey and how we’ve managed stress and how we’ve dealt with burnout and how we sort of do daily practices to keep ourselves going and healthy because I believe when you are doing work on yourself, you’re investing your time during your day to work on yourself as a human. That human walks into the operatory and is a better doctor and that better doctor provides better treatment. If you’re bringing the weight of the world and stress and sadness and trauma into the operatory with you, you’re not going to be as good of a doctor and neither will be your treatment. So on the cusp is about tuning in, hearing these amazing stories and journeys and having something resonate with you. Something someone says that becomes that instigation to say, you know what? I’m actually more interested in finding fulfillment in life than a full bank account, a fancy car and a big house. Because as youngsters, we choose this profession. We don’t know anything about anything. We don’t even know who we are, but we make an investment of time, money, and energy that is so tremendous that you really can’t turn around and walk back out. So why don’t we learn from others journeys of how they’ve managed this stressful, burdensome profession, where, as you mentioned from the jump, we sometimes take everything so personally, that’s what my podcast is about. It’s about finding fulfillment in life and doing it while still bridging the gap as this clinician who cares, but also has this other side as a human to make sure that when you come home from work, you’re not so dead tired that you can’t talk to your family. You have nothing to offer. You’re just dead. And I’d rather see you come home and be still ready to interact with the kids. Do something that your spouse asked you to, because you might work all day long and take care of a million people, but when you get home, you haven’t done anything for them. And so the goal of this podcast is to get you feeling more fulfilled in your life so that you can be a fuller person. Everywhere you go and ultimately find that healthy balance between the stress of work and the joys of being alive because it’s a short period of time and I’m trying to make the most of it. So that’s what the podcast is about. [Jaz]Absolutely beautiful. I’ll definitely put the show links on YouTube and on the podcast below. So please guys check it out. I think that we all need this. We also have coming up in December on our podcast, dentist life, work life balance. So I’ll be sure to bring you on again to just go. Cause there’s so much we talk about and I’d love to explore this further. Brett, thank you so much for giving up a time to really enhance us in our endo, our irrigation protocols, our judgment on preemptive endo and giving us that lift that we all need. You are absolutely brilliant at doing that. Thank you. [Brett]Thank you. And I want to acknowledge you. The podcast is awesome. You’re doing a great service. You bring great energy to the show and that’s what you need, right? You want energy so that the information is absorbed. It’s something that actually excites you and gets you feeling excited. So I feel pumped after being here with you, Jaz. So I’m ready to get back in the clinic tomorrow and get after it. [Jaz]Amazing. Thank you so much. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. The future of endodontics is very exciting. And don’t you just love the human side of Brett? And the mission that he’s on. So to support that, I’m going to put all the show links to Accessendo and his community on there. He’s obviously a fantastic mentor to have, and I’m very grateful for him sharing his time with us over this two part episode. Now, if this is the first one you’re listening to, please do go back an episode. You missed a really good one on elective endodontics. And of course, if you’re on our community, Protrusive Guidance, answer the questions, get your CE certificate. And if you’re not part of the Protrusive community yet, if you identify yourself as a nice and geeky dentist, this is a home for you. Head to www. protrusive. app, make an account, and then you can check us out on iOS or Android. It’s all singing, all dancing app we have. I think you’ll be quite impressed. We also host monthly webinars live, sometimes me, sometimes I’ve got a guest on, in addition to what we do on the podcast. If you do want to get CE, there are paid plans available, and they’re the ones that support the podcast. So if you’re gaining great value from the podcast, please do show your support by signing up as a premium member or for the ultimate educational plan if you want access to things like sectioning school. I want to thank the team as always. Thank you Erika for doing fantastic production. Thank you to Mari, our CE Queen. Thank you to Nav and Krissel for making sure everything is quality controlled and scientifically correct. This podcast would not exist without the team. And thank you to the listener, once again, for listening all the way to the end. Hit that subscribe button. I’ll catch you same time, same place next week. Bye for now.

Oct 30, 2024 • 43min

Radiology and Radiography for Students – PS011

What’s the difference between radiolucency and burnout? When’s the best time to use a bitewing vs a periapical radiograph? When should we pick up the bur for interproximal caries? Have you heard about the 4 white lines an OPG radiograph? https://youtu.be/wCV3U8-OAvI Watch PS011 on Youtube This episode is packed full of great tips and techniques that will help you understand how to produce great radiographs as well as being able to properly figure out what they are trying to tell us. Radiographs can be tricky, whether that’s due to them being flipped, upside down or due to cone cut, that’s why this will help shine some light on how to get comfortable with radiographs as well as how to manage our patients after we know what we are dealing with. Need to Read it? Check out the Full Episode Transcript below! Don’t miss the special notes on Radiology and Radiography for Students available exclusively in the Protrusive Guidance app! (Join the free Students Section) This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App! For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. If you love this episode, check out PS003 – Routine Checkup Click below for full episode transcript: Teaser: This episode is the bare basics of radiography and radiology, i.e. the taking of the radiograph and the interpretation. How do you really know if that radiolucency you see is cervical burnout or is it actually caries? What are the four white lines on an OPG radiograph and why are they important? And why you should be really careful with radiographic interpretation? And it's really important to marry the clinical picture, because that's how you come up with a clinical diagnosis. [Jaz]Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This is for young dentists, students, but a lot of qualified dentists have been really enjoying this basic series, this Protrusive Student series. And so what we’re going to do from the next episode is we’re going to make it CE eligible. The next episode is actually on basics of extraction, but before we do that extraction, we need a radiograph. And it’s a topic that you guys asked for on the YouTube comments. So there we have it. And remember, if you are a dental student, make a free Protrusive account. Go to protrusive.app and then email your username or your name on the platform to student@protrusive.co.uk. And you’re going to get access to a secret area, which has a bit more of the premium goodies inside. Every PS episode, we have some student notes to provide you as well, made by Emma Hutchison, our Protrusive student. And the ones today are all about radiography and radiology. Hope you enjoyed the main episode, I’ll catch you in the outro. Main Episode:Emma Hutchison, our Protrusive Student. Welcome back to the student’s edition of the podcast. I know you’ve got exam results coming up and you’re going on your elective soon. How exciting. [Emma]Yes, very exciting. So I’m just finishing up the last bits and bobs of my elective project and then I’m going traveling for two months. So, I should also get my exam results next week sometime when I’ll be away. So, hopefully everything’s good. [Jaz]We’re all rooting for you. We know, you know, fingers crossed you’ll do well and you’ll report back to us. If anyone in Asia is a dental student or a dentist, and you happen to see Emma walking in a mall, an air conditioned mall, take a selfie with her and tag us on Protrusive. Let’s see if this social experiment works. Let’s see how much we’re spending. That’d be cool, right? [Emma]Yeah, it would have to be an air-conditioned place because I’m from Scotland, so I’m not going to do well with the heat over there at all. [Jaz]Excellent. Well, today’s chat and the subsequent protrusive notes which will go on the Protrusive Student Section at of Protrusive Guidance, which is our app, our community, is about radiology and radiography, right? And before we go further, I kind of have like to put a disclaimer and a lot of the Protruserati are used to me using this disclaimer now and again. There are some things that I teach and there are just a small part of dentistry. Most of dentistry, that I do, I share. I don’t teach, I share, because to be honest with you, I’m not in a position to teach that kind of stuff, but I’m there to share my own experiences, and there’s some that my unknown unknowns I’m always just seeking to learn more and more and more. So when it comes to radiology and radiography, I’m sharing, and what I have on you, Emma, is I’ve got like, 13, 14 years of experience over you. And that’s why I have to offer you in terms of the kind of things that used to bother me when I was a student. But I want to just say that take everything with a pinch of salt what I’m saying, because I’m trying my best to guide you and students and young dentists listening, but I’m not the radiology expert here. So it’ll be just to unpack the experience that I have. [Emma]Yeah, not a problem. Not a problem. I think in dentistry, there’s always so many opinions and everyone has so many different experiences. So everyone will have an opinion, everyone will think differently, this, that and the next thing. So yeah, we’re all just learning. So. [Jaz]Well said. Well said. So come at me, Emma. What have you got? [Emma]So first question, I’m going to say. For yourself, Jaz, we’re always taught to be really methodical. Let’s say you’ve got a pair of bite wings there. What are your essential steps in reading and interpreting dental radiographs? Like, what should students look for? What does your method look like? Because it can be really overwhelming, especially in an exam. I was faced with full mouth peri-apicals, and it was just questions, boom, boom, boom, boom, boom. And you just had to be really methodical. But what does that look like for you? [Jaz]Great question. I think I’m a big believer in checklists when it comes to radiographs. So first thing to do is make sure it’s rotated and flipped correctly. The right way, like usually I don’t have to flip it, but make sure it is correct and it’s orientated correctly. The next thing to check for is that is it good enough quality doesn’t need repeating and you’d hope that 95 percent plus a time it’s acceptable quality. So you have to grade your radiograph. So it used to be like grade one, two, three. Now it’s like A or N. So it’s either acceptable or not acceptable. And you have to obviously justify in your notes the reason for taking a radiograph. So Emma, what would be the typical reason to justify a bite wing from what you’ve learned? [Emma]Caries and bone levels, perhaps? [Jaz]Yeah. And specifically, it’s interproximal caries, right? [Emma]Interproximal caries, yeah. [Jaz]What I say to my patients is that, I need to take these x rays because there are bits of teeth that I can’t see. I can’t see between the teeth. This is where x rays help me. And so it’s very important when writing the justification. It’s interproximal caries. And so really interesting point. Early on in practice, you just get into a rhythm of doing things and you need to start questioning why we do certain things. Why do we take this bite registration? Why do we do a certain stage in dentures? And so, I remember being a newly qualified dentist and just, oh okay this patient hasn’t had bite wings in like three years, let’s take some bite wings. And you take a bite wing and you see that actually this patient has like every other tooth missing and no history of periodontal disease. So if I can see the interproximal surfaces, why did I just take this bite wing? You see what I mean? So you really have to think critically and I’ll share a, I guess an honest mistake I made recently. Okay, I’ll share an honest mistake. I know this is deviating a little bit, but I think it’s really nice to learn from the failures and mistakes of others. Had this really nice gentleman who has had an issue whereby the wisdom tooth was causing decay in the second molar. So low wisdom tooth impacted, that wisdom tooth was removed. Okay, and the decay seemed minimal and it was really deep down. It was like covered by the gum. So I thought, okay, maybe we can just safely monitor this. When we came around to the interval of taking bite wings. Okay, I did not capture the distal of that second molar. [Emma]Right. Okay. [Jaz]Didn’t capture it. And so lo and behold, he came in an emergency and he had pain from that tooth and there was a much, much bigger caries than what we initially had some years ago. And so it’s really important that, yes, we want to see the interproximals, but we have to tailor it to the individual. If we know that actually someone’s not got any restorations or no historical caries, or you’re not watching the premolars, then maybe in that patient, the distal of the second molar for those patients is more important. And sometimes you can’t capture everything. So it’s important to tailor it to that individual. Going back to what you asked, though, in terms of the checklist and actually being systematic about it, totally the right word is systematic here. So what I would do is once I’ve made sure everything’s correct and orientated and acceptable quality, I will always just start with the bone levels. I’m having a look at bone levels and I’m reporting on that. So I’m doing as a percentage bone loss, although. Arguably, you need a PA to see a percentage because you can’t see the whole root. But you can kind of guesstimate. We know average how long teeth are. So it’s not like a mild bone loss, moderate or severe bone loss. And then I’m looking at the interproximal surfaces where they touch very, very carefully. It might be changing the contrast. And what we do in practice, actually, is we have this code that we use on the charting. So you guys are probably, are you guys computerized? Are you guys like paper notes? [Emma]We’re still paper notes, yeah. [Jaz]Okay. So what we do is on the computer, like do from previous bite wings stuff. If we know it’s like a little radiolucency, we’re going to mark on the chart, on the digital chart, a WB. WB stands for watch bite wing. That means we’re watching this area on bite wings. So as well as clinically, we’re checking on bite wings. So I will have a look at my chart on one screen. I say, hmm, there was a watch bite wing place in 2017 on the distal of the upper left second molar. Let me have a look now. And often it’s nice to compare old radiographs. to see any changes and that’s really important stuff. So maybe I’ll have the left bite wing from a few years ago and left bite wing now and I’ll just compare the bone levels and I’ll compare any watch bite wings, any changes. I’m then looking at the restorations and any sort of radiolucencies or any ledges or all the issues with restoration. So starting with the bone, then the heart structures and I would report on those. [Emma]Okay. Yeah. So just your checklist, like you were saying, I know for me when I’m in clinic and I’m doing a radiographic report, I have everything written down, like, teeth present, restorations present, boom, boom, boom, and just keep yourself right in that respect. I think that’s a very important thing to do. [Jaz]In the real world, like, to write teeth present, I just feel it’s very laborious, right? [Emma]Yeah, yeah. [Jaz]So we’ve got the chart already, right? I’m looking more for, like we did the routine checkup episode we did, and we added the video. I don’t know, did you watch that video, Emma, of the routine checkup I did, yeah? [Emma]Yes, yes, I have done, yeah. [Jaz]Was it useful? [Emma]Yeah, I think it was. I think it’s always useful to see other people’s methods and how they go through things, et cetera. I think it’s definitely- [Jaz]Even some dentists have messaged on there saying, well, you know what Jaz, I’ve been a dentist for so many years and it was just nice to see some validation routine, check up how you do things. So that was good. So in that one, you’ll see that I’m comparing previous radiographs and we know we have the charting already. So I just feel like in a time efficiency, when I’m doing a report, I’m not reporting on all the teeth present. That goes without saying, but I know at your stage, that’s what you’re expected to do because you’re learning the bare foundations. But in the real world, I don’t report on all the teeth present. It’s like, okay, teeth present as expected. Okay, I’m just looking for, okay, good bone levels and no obvious caries. And then I’m looking for the actual things to watch out for, and that’s just the honest truth. [Emma]Yep, no, a hundred percent. I think when you get into the real world, it’s a lot more fast paced. Not that that’s a bad thing. I mean, you have the time to report on your radiograph what you need to report, but at Glasgow we’re still expected at this stage to do full radiographic reports for absolutely everything, which takes such a long time, but it is good to getting you used to looking at radiographs. Being methodical in your approach, and then by the time you get to your VT, hopefully and beyond, you’re a lot quicker at doing your radiograph reports and you see things straight away. Whereas at the moment, I still have, it’s still very overwhelming. So- [Jaz]Take your time. We’ll take several minutes at this stage. But just one thing on that, I think the most common mistake you can do is just like, imagine you’re taking bite wings because you suspect, okay, there’s something perhaps going on around the upper left first molar and you take your bite wings and your eye immediately goes to the upper left first molar and you kind of like skim over the rest. It’s really important to check the follow, trace the bone levels everywhere. And the most common one is like the distal of the second molar. There’s something there and you just didn’t spot it. And then years later, you see a patient comes back with symptoms. Oh yes, there was something there I didn’t see at the time. So it’s really important just to check every single area, like typically where you’d find cervical burnout, right? Like that radiolucency by the neck of the teeth. And just look at those areas and look at the contact areas where caries typically starts just for every single tooth, just tick it off mental checklist. And the most important thing medical legally is have you justified the radiograph in your report? Have you graded it and have you noted that the findings and it’s really important just to comment on the bone levels and any radiolucency, anything of concern that you’re watching for? [Emma]Yeah, absolutely. Like, what is it called? I think it’s satisfaction of search. If you’re looking for one thing and you find that and then you just lose everything else. So it’s so important to have that wee checklist. Either in front of you, I have mine sitting in front of me, written down in a notebook or just mentally as you get a bit more experienced, I’m sure. But just as you were talking there about cervical burnout, what are some more common pitfalls or mistakes to avoid when you’re reading and interpreting dental radiographs? [Jaz]So common pitfalls, but also just rewinding a bit to what we said about satisfaction and looking at something and satisfying your query. OPGs are the big one. Like, OPGs, there’s a lot more noise, right? And then you see so much, but you were concerned about the wisdom teeth. And so you look at the wisdom teeth, but there’s so much data in OPGs. So my top tip for OPGs, this is what I was taught in dental school, is that, what are the high risk areas? Like, think cancer, right? If there’s something cancerous going on, something worrisome going on, the four white lines. Have you heard of the four white lines for OPGs? [Emma]Four white lines. No, I don’t think I have. No, I don’t. [Jaz]No one else knows about this. It’s not just because you’re a student. Because when I speak to other dentists, I was like, I speak to them and said, do you guys report on the four white lines for OPGs? Then they look at me like puzzles. So it must have been a Sheffield thing that we were taught basically. The four white lines we look for are the hard palette. Can you see the hard palette? Right? You see that? Okay. That’s the horizontal line radio. Opaque line going cross, right? So can we see the hard palette? Are there any abnormalities there? The next one is the floor of the sinus. Okay. So you want to see, trace the form. You don’t want to see a break in the lining, the cortical lining of the sinus, because that could be a worrisome, that could be maxillary sinus cancer or whatever, or some sort of issue going on. So really important to check that. So that’s the two white lines. The third one is the posterior wall of the sinus. So the way you see that is, although it’s a posterior wall, you will see it on OPG as a vertical line. So the floor becomes vertical, okay, as you go distal, and that’s the posterior wall of the sinus. So again, I’m just checking that white line. So that’s three white lines checked. And the last one is the zygomatic buttress. Okay, the zygomatic buttress. Are you familiar with the zygomatic buttress? [Emma]Yes. Yep. [Jaz]It’s kind of like where the zygoma bone makes like this radioopaque line as well. And it’s important just to trace that. And I just mentally tick those off. Now, to date, I have never found one that had an issue or a breakage, but this is where I report my OPG for white lines. Check, check, check, check, like a checklist. And then I check the border, the external border of the mandible, the ramus. I’m looking for like any fractures, any radiolucencies, basically. So that’s usually intact as well. Then I comment on the bone levels. Then it’s really important to check systematically upper right last molar. So this could be the wisdom tooth, check tooth by tooth by tooth. You’re looking at the apices, any abnormalities, anything that you think needs more investigation. So sometimes we supplement OPG with a PA to get a bit more data. Although nowadays the OPGs are so good. The qualities are so good that machines that we have that can really negate the need for additional PAs. But the common pitfalls is one of them. Yeah, looking for what you want and then skipping past it. With bite wings and stuff, I think it would be like the actual taking of it would be like a cone cutting. Are you familiar with cone cutting? [Emma]Yeah. Is that your collimation is not quite right or? [Jaz]Correct. So you’ve got the beam and you’ve got the film and the kind of out of alignment. And so the x ray managed to miss the film a bit and therefore you get this like white space on the radiograph. I mean, that may or may not be detrimental. If you get like half the radiograph gone and the reason why you took it was to see all the interproximal areas, then that’s not acceptable. And you have to repeat that basically. In terms of interpretation, the other common issue, other than like in a missing distals of certain areas because your eyes don’t go there is a confusing cervical burnout for caries. Caries typically starts at or just below the contact area. So if you’re seeing another radiolucency a little further down by the bone level, you really have to question, hmm, could this be cervical burnout? And cervical burnout happens because as the radiograph goes through the tooth and at the neck area where there’s little curvatures and how thin it is, it appears a slightly radiolucent there. And so we don’t want to confuse that as caries. Have I ever done this before? Yes, I have. I have confused cervical burnout as caries before. And you go and you think, whoa, okay, fine. That was not caries. Okay. And so it really needs to be hot on it. So little clues you can have is, you look at the mouth in general. If someone’s generally not got many restorations and you’re seeing this area, then you’re probably thinking, hmm, it’s not the typical place that I’d find caries. This could be cervical burnout. The other thing to do is remember, that radiographs are just one data point, we do not treat radiographs. Technically one of my, I think Prof Avijit Banerjee taught me that you cannot diagnose caries from radiographs. You can only diagnose radiolucencies. It’s up to you to add the clinical picture to then be able to diagnose caries. So actually, technically, if I ever write and I do this, I’m being honest, I write sometimes, yes, caries, we see, we do this, right? Caries noted on the radiograph, upper right 5 distal. That’s technically wrong. Radiolucency noted, upper right five distal in the inner third or in the outer third of dentine, for example, you make that comment, but we cannot technically say it’s caries. So we to add now are clinical checks. So clinically I would check on the high magnification, my lighting, feel gently with my probe, not to like probe hard into it, but check like the surface, right. Using the sort of sideways of my probe or maybe even using a ball ended probe. And if in doubt, there’s a really cool technique whereby if you’re really unsure where there’s a cavitation. Because the difference between, I don’t know if you guys are taught this, but the difference between potentially restoring something that’s early, enamel or just interdentine and not restoring that one is whether it’s cavitated. Do you guys follow this as well? [Emma]Yes, more so in, like, paediatric patients, maybe. What do you mean? Do you mean, like, for whether you would restore it or not, like, early caries, or? [Jaz]Yeah, so let’s imagine we have a lower molar, right? And mesially, you see that the enamel’s got full radiolucency, okay? And now, it’s just into dentine. There are so many factors to consider whether you treat this or not, right? Like the patient’s oral hygiene status, their dry mouth status, are they using a fluoride toothpaste, their history of caries, all this stuff is really, really important, their caries risk in general. But actually, at a tooth level, If that enamel is still uncavitated, so still a shell of enamel that’s not broken, that potentially may sway you to, hmm, let me tell the patient that there is some decay there and talk about perhaps being conservative and monitoring it very closely and doing repeat radiographs in the future. But the deal breaker often is if it’s cavitated, i. e. there’s a surface breakage, then that is a deal breaker to perhaps, okay, we need to restore this. And so do you know about any ways that you could check if it’s cavitated or not clinically? [Emma]Clinically? I don’t know, actually. No, like, apart from just looking, like, clinically and seeing if it’s cavitated, or would you call it clinically? [Jaz]You would, but it’s very, very difficult. And you try and fill with your probe, but you often can’t get to that area. And it’s tricky and it’s very difficult to do. So can you think of another way? I was blown away when I first saw this as a student, by the way. [Emma]I don’t know if this would just be for paediatric patients, but could you put a separator in there? [Jaz]Yes. Well, you could put a separator. It’s more amenable in paediatric dentistry, but a really cool way to do it. Now, I don’t know if you’ve heard of Louis Mackenzie. [Emma]No, I don’t think so. No. [Jaz]Fantastic dentist. Unfortunately, he passed away last year. So, you know, rest in peace, Lewis. He did an episode with us called To Drill or Not To Drill. It’s one of the early episodes of the podcast and this guy was a fantastic speaker, really humble man, really one of the sweetest dentists ever. So his presence in dentistry will always be missed. So just paying a tribute to him. I saw one of his lectures, I was a fourth year student, it was the BDA conference, saw one of his lectures and he described this exact scenario. It was like, hmm, how can you tell if a tooth is cavitated or not? And this is what he said, he said, I am so sad that this is what I will do. I’ll place a wooden wedge inside. So now you get some separation. And now, he will squirt some light bodied silicon into that interproximal area. Let it set a bit and then use the tweezers to pull it out. And now that will show you whether if it’s smooth in that area or has the light body silicon actually, for want of a better word, evaginated or extended into that cavitation. And that can be the difference between whether it’s restoring or not. So when I saw that, and I’ve used that a few times and I’ve been unsure basically. So it’s another little trick that you could use. [Emma]That’s very, very interesting. Very interesting. The only other way that I’d heard of was pediatric patients may be using a separator to open that space a wee bit, but even I don’t imagine you would ever do that on your adult patients. [Jaz]You could do and I know some people that can do this, but I think with this little trick it saves the patient some grief and going home and having the inconvenience of having a separator. [Emma]So another question that I had for you Jaz was, what sort of strategies do you use to use your radiographs as a communication aid with your patients, like I’ve seen a lot of clinicians do this very well, but how do yourself use these bite wings to say to your patient and even motivate your patient, this is what we’ve got going on and this is what we need to do to treat it to get them to understand. [Jaz]Yeah, really great. And I don’t know if you’ve heard of this relatively new ish software called Pearl. There’s some other ones as well, basically, I think. But this is like AI to read the radiographs. And basically, their slogan is Radiographs now in color. So what it does, it like, instead of the radiolucency, it’ll like paint it red. And so the patient can see clearly. [Emma]Wow. [Jaz]‘Cause quite often in the scenarios you’re showing the patient like, can you see the radiolucency? And they’re look at you blank. Like, no, I cannot see that. And that’s happened to me. Like, when you are learning, probably you will not see things that I can see ’cause of the difference experience. But are patients are the same, like you show them a radiolucency and like, wait a minute, what are you sure I can’t see it. So sometimes having it colored by AI is just so some of these softwares are great. I don’t use them myself yet, but that’s cool. That’s very exciting, right? So what I would do is I’d have it on my flat screen TV I’d stand next to a radiograph is that can you see this is your tooth over here. See this white area here That’s a big metal filling you have in the tooth. Can you see where the teeth kiss together where the teeth kiss together? That’s called the contact and that’s where decay starts. This is why it’s really important to floss or teepee, etc. Can you see there’s a shadow over here? The shadow is a black area. It’s black because the x ray goes through mush. The mush can’t stop the x ray. So the x ray goes right through the mush and it’s not as hard. It’s softness. It’s soft mush inside your tooth. And so I’ve counted them and you have X number of areas. Now, these ones are gonna be okay. But can you see this one over here? Can you see that it’s much, much bigger? And hopefully they can see it and you highlight it. That’s the one that we need to treat. Because if you don’t treat it, it’ll become here. And can you see this other little black area? That’s the nerve. So every tooth has a nerve. And although you’re not feeling pain yet, most dental conditions are painless. When the pain starts, that is too late. That is a very late stage start. So most dentistry is painless, but when the pain comes, it’s often too late. This is what we’re presenting to you in the x ray. So then I’d maybe describe the bone level as well. I often describe the bone as these are your roots and this is your bone. Thankfully, Mrs. Smith, you got plenty of soil around your roots, okay? Your soil is good, okay? And it helps them to understand it. [Emma]Yeah, no, that’s good. A few wee tips in there, I think. It can be really difficult. [Jaz]Because your experience as a nurse, right? What have you seen that you liked? Anything that you remember that you, oh, I really like this. [Emma]A dentist that I worked with, John McCall, I remember him talking through radiographs with patients. Just making it really simple, again, big TV in the practice, radiographs up there. So these are your teeth, this is the upper, this is the lower, this is the left, this is the right, and the spongy bit round here is your bone. And just sort of setting that base for your patient to know what you’re looking at, first of all. And then, like you said, again, just going in, can you see this, this darker area here? And just going from there. I think it can be really difficult for students to do that in layman’s terms. If you’re with a patient, you just want to dive right in and then, oh, you’re pulp, blah, blah, blah, and they don’t have any idea of what you’re talking about. I find that quite hard to use radiographs as a communication aid at the moment, because at the moment they overwhelm me, but I think definitely that’s something that will come with experience. [Jaz]100 percent. [Emma]Yeah. Just quickly looking at a radiograph and then instantly knowing what to say to your patient and using that in a way that they can understand can be huge for patient motivation as well and just getting them to understand your treatment options. [Jaz]It’s about the understanding and communicating the issue well. The radiographs are very important and the explanation, but that will come. The more you do it, the more second nature it will become and the more layman’s terms you will use, which is so, so important. In the routine checkup video, which is available on the student section again, I’m just reminding everyone. I made a mistake because I never had done this before. I promise you that I would. And so usually I record procedures and it’s just me in silence recording procedure. And then later I might narrate it. For example, in sectioning school series, we have all these extractions that I’ve done and I’ve narrated it. But when I was doing this, like the whole conversation with the patient was being recorded. And so I was a little bit self conscious about that. And so they came to one bit of explaining some treatment. And you might’ve seen my commentary on that saying there was too much jargon here. This is not how to do it. So, very often you’ll feel that way. And it’s really important to, after every patient says, hmm, what went well? What went wrong? What, how can I improve my communication? If you keep doing that for years and years and years, you’ll find that actually, the more you simplify, the more you go back to basics, the more you make it softer and easy to understand, the more effective of a communicator you become. [Emma]Yep. And I think radiographs are obviously hugely essential in dentistry, but they just have so many other benefits in terms of communication with your patients. But that’s a really good skill to have is just putting that into something that the patient will understand, which of course, like I’ve said, just comes with experience. So my last question for you, Jaz, was, and this might be a big question, but let’s just see quite generally. Let’s say a patient has irreversible pulpitis, it’s going to need an extraction or a root canal. You take a peri-apical at what point does the extent of the caries call for an extraction over a root canal? [Jaz]Oh, I love this question so much. A reason is because I’ve just posted a radiograph yesterday on the community on Protrusive Guidance, okay? And I said, okay, what are you guys gonna do? I sort of pitched it. Okay. So this is the scenario and what I used to see as the worst part of dentistry. It’s like everyone’s got different opinions. I now see it as the beauty of dentistry. Okay, so you must see it like this, otherwise you will have a miserable career. So the beauty of dentistry revealed that everyone has, okay, some people use some sort of bioceramic materials. Some people say root canals. Some people say, actually give the pulp a chance. Let’s try and restore it. Unless you can get a seal. Some people suggested a hemisection, all sorts. All right. So it was all in there. And it goes down to that question where, at what point do you decide, it’s a question whether it’s restorable or root canal is an optional, just remind me the question again precisely. [Emma]Between extraction and root canal, like at what point does it just need to go? [Jaz]Okay, so, extraction and root canal, the other way of pitching that is restorable or unrestorable. [Emma]Okay, cool. [Jaz]Should we go with that? Because sometimes a tooth may be restorable, but the patient will not consent to a root canal. It may be restorable, but to restore it, it needs a root canal because the pulp is either necrotic or it’s irreversibly inflamed, and therefore it needs a root canal. But actually what we’re going to gain more from is, okay, what are the radiographic parameters to use when we’re deciding whether if root canal is even an option here, right? Okay. So if we have a PA, okay, and you’re getting to the territory where you’re thinking, hmm, I’m not sure if this tooth is restorable, the first thing to do is take a bite wing. Have you heard of this one? [Emma]No, I don’t think so. [Jaz]PAs often vastly overestimate how much caries there is. And they can make the situation much worse or, or different to what is going on. Sometimes by having a bite wing, because the angulation, you get a much better degree of assurance of the exact level of the caries. So in those cases, you should supplement your PA with a bite wing. So now you have a bite wing and now you can better access the exact extent of that radiolucency. A really good tip that was given to me by a guy called Dr. Barber from Sheffield. This was when I was at DCT was when the radialucency extends below the floor of the pulp chamber. Let’s look at a molar, lower molar. Okay. Imagine young patient, large pulp chamber. We have the top of the pulp chamber and the floor of the pulp chamber. Imagine now the radialucency is getting towards the pulp chamber, but now it’s getting so far low that it’s getting to the floor of the pulp chamber. When it gets towards the floor of the pulp chamber, that is one consideration. it’s not a hard and fast rule, but if it’s getting that deep now that it’s at towards the floor, it’s gone beyond the top. It’s now approaching the floor of the pulp chamber. It’s now on very shaky grounds. So the one I posted is on very, very shaky grounds. So now you’re thinking, okay, how important is this tooth in this patient’s mouth? How strategically important is it? What kind of patient do we have here? Do we have an A plus patient with fantastic oral hygiene? With the otherwise low care he’s experienced? Bit of bad luck here? Maybe a wisdom tooth kind of issue? And how much are we willing to fight for this tooth? And what is a patient’s attitude? And the way we sometimes, if we have those 50/ 50 scenarios, It’s really nice to pitch it to a patient in this way. I like to say this to a patient inspired by some communication tips I picked up from Lincoln Harris. I said to him, imagine, dear patient, that you spent a fair chunk of change on this tooth. Imagine six months later it had to be extracted, because the root canal failed, because you never got a good seal. Would you say, you know what, I’m glad I tried, because there was a chance that this could have lasted 10, 20 years. Or would you feel absolutely devastated? We feel like an idiot for spending money on it. What would your mindset be? And that will answer it sometimes. If they say that, they’ll be absolutely devastated. That’s six months later to have tooth out, then that answers it because it’s not very predictable. Predictability is the key word here because when it gets that level of deepness of the caries, then it’s not as predictable. To get that seal is not as predictable. So that’s number one, right? If they say, oh, you know what? I’m, I’d be glad because I really want to say this truth and willing to give it a shot and willing to accept that in six months time, I’m not going to cry about it. I’m going to be a big boy kind of thing. Okay. So if they say that, then, okay, if you think that your clinical skills are good enough and the patient’s up for it, then that may still sway you. Now, if it’s going well below the floor of the pulp chamber, then okay. That’s bad news. Because then you’re really, by the time you restore that A, to get the seal, to get the matrices that far down low is very, very difficult to actually do a good precise job is very, very difficult. Also biomechanically, that tooth is very weakened. The next thing to consider is would you perhaps need something like a crown lengthening? Do you know what a crown lengthening is, Emma? [Emma]Yeah, I’ve nursed in a few crown lengthening surgeries. Do you use like an electrocautery or something? [Jaz]It can do, to remove the gum. [Emma]Yeah. That’s I’ve only ever seen it on a few anterior teeth. [Jaz]It’s more common on anterior teeth and so, posteriorly, so there’s aesthetic crown lengthening whereby we’re changing the gum levels to get a nicer smile, and then there’s functional crown lengthening, we’re making the tooth a bit bigger by removing some bones, so imagine you’ve got distal caries and a molar really deep, like almost kissing the bone, so if we can make the bone go more apical, drill away some bone there, and allow us to restore this tooth in a much easier fashion, i. e. allow our matrix, allow our wedge to actually get down there and make a seal, allow our crown to actually sit, our future indirect restoration. Sit on healthy tooth structure and not near the bone, basically, that’s a good thing to do. So, we have to then think about finance as well. So whilst it could be restorable and it’s debatable, we have to think, hmm, at what expense? Once you factor in crown lengthening privately, once you factor in a root canal, once you factor in a crown, you might be in implant territory. And so, cost benefit analysis, and how predictable and how easy or otherwise it is to get a seal. These all will play in in the real world when you’re decision making. So in terms of purely a radiographic level, I very much look at this where it is in relation to a pulp chamber. I look at the patient as a whole. You take a step back, look at the patient. Is this patient deserving? And it’s not a nice way to think about it. But really, if they’ve got a gob rot, this one tooth is the last of your worries, right? In that mouth, the most predictable thing for sure would be an extraction. But if it’s a well cared for mouth, then sometimes we do do a little bit of heroic dentistry as long as the patient understands that what we’re doing here is really higher risk, higher reward. We get to keep the tooth, which is great, but it’s higher risk, higher reward. [Emma]Yep, that makes sense actually. And I’ve never really thought about it in that sort of way where you do need to take a step back and look at the patient. The patient, there’s so much room for the patient to make decisions in their treatment planning and I think coming back to communication, like for me if I was a patient that could be quite hard to grasp without being shown, okay this is where this dark bit is and I don’t think that’s going to be able to be saved xyz. I think that’s a good way to look at it, your landmarks and being able to show that on a radiograph can be good for the patient as well. But no, that’s interesting. [Jaz]So top tip there, remember to supplement with a bite wing. Really important as well. And so, yeah, to look at the bigger picture. I remember being a DCT at Guy’s Hospital, oral surgery department, and all day long we’d be doing extractions and extirpations, right? I remember these two American students came to Shadow, for like the elective kind of thing, right? And so I think they’re American Australian. I forget now. Anyway, I saw this one lady, And she had caries and a molar that was causing pain and the diagnosis, the official diagnosis was irreversible pulpitis. The tooth was restorable. Like, it was a home run. It was like way above the bone. It was a home run. It was decay into the nerve, but it was a home run root canal. But after having a discussion with the patient, we decided that the extraction would be the best for her. And she left and she went to get an extraction and these students were gobsmacked. They’re like, wait a minute. What? This tooth was savable. Why didn’t you do the excavation and send this patient back for root canal? And it was an important lesson I was able to pass on to them because it’s a lesson I’d learned some years ago was actually, yes, it’s restorable, but just because you can doesn’t mean you should, because that patient, okay, you have to look at the tooth factors. If that tooth, right, doesn’t have an opposing tooth, then what value does that have compared to, okay, it doesn’t have a tooth now or an implant in the future. If the patient is really not in a financial position to consider and they express that, like, look, I’m actually not looking to spend any money on this tooth. I would actually like to have my patient preference is to have this tooth out. You’ve got to take that preference. Now, if it’s healthy pulp and it’s reversible pulpitis, I would dress that tooth. Right? I would not extract it. I’d be like, no, I don’t think there’s a reasonable option for what you present with. But when the alternative is a root canal and the patient doesn’t want that, then you have to think about the patient as a whole. So it’s not just about the depth of radiolucency and whatnot. It’s about looking at the patient, their own preferences, their history of dental work, what’s opposing it and all these factors. [Emma]Yep. And I think that can be quite frustrating when you’re going through, not frustrating, but you’re going through dental school, learning how to save all these teeth, and then when it comes to the real world, sometimes that’s just not feasible. And like you said, you have to go with the option that A, the person can afford, or that the treatment that they are willing to tolerate. [Jaz]Tolerate, afford, and maintain as well. Like you might be able to afford it, they got gob rot everywhere. They got super, super dry mouth, and it’s going to be difficult for them to maintain. But equally, Emma, you might have a scenario where in anyone else’s mouth, you’d extract. But because that patient is on bisphosphonates, IV bisphosphonates, they are higher risk of things going wrong and the bone not healing. And therefore, in that patient, you’re going to really do a bit more heroic dentistry and try and do what you can to save that tooth. So this is where the patient’s medical history and all those factors come into play as well. One last thing, which you haven’t mentioned, which I think is really worth mentioning in the realms of if predicting if something is restorable or not on a radiograph is remember that the radiolucency you see on the radiograph, the clinical caries will be 33% more. I remember this being taught this. It’ll be worse clinically than it is on the radiograph. Always remember that. [Emma]Okay. Yeah, that’s a good one to remember. And also a good exam question. A good exam question. [Jaz]Yes. And I was, it reminds me of another lesson I was taught as a third year dental student. I had this really carious premolar I was treating and it was making me stressed. Like as a student, like just, seeing so much caries was a stressful experience for me. I was stressing. I was sweating. I was like, Oh my God, when do I stop? There’s still more caries. I’ve got to go. There’s still more caries. I’ve got to go. And it took me like two hours to put this GIC, right? And the patient leaves and the tutor looks at me and he wrote a comment. His name is Abdul Rahman Elmougy. He’s now a restorative consultant. So Abds, if you’re watching, listen to this shout out to you, my friend. He wrote in the book, he’s like, don’t be shy with a tooth of poor prognosis. Let me say that again. Don’t be shy with a tooth prognosis, okay? We didn’t owe that tooth anything, okay? The tooth had served its time, okay? We were doing this tooth a favor. We were trying our best, okay? This tooth was on shaky grounds. So the way I approach this situation now is A, you tell the patient this is an investigation. We’re not doing a filling. We’re actually just seeing if this tooth can be saved or not. I will tell you what the outcome is once I remove all the decay and I address it, okay? So you’re going to walk away with this information whether we can even save this tooth or not. Your tooth. This is like doing CPR for the tooth. Right. So that’s what I pitch it. But when you’re removing caries on a tooth, which is already really poor prognosis, don’t be shy. Don’t be like little tickles. Okay. Get the big bur out. Okay. Be responsible, be precise, but don’t like be very gentle. Start tickling. You need to get this mush out. Go for it. Okay. Yeah. See what’s left. And so that really served me well, actually don’t start stressing because there’s huge caries. That’s it’s the patient’s fault. You didn’t put the caries there. And sometimes hit the patient who sometimes you get certain types of personalities and they get very like, well, but do this and do that. And just remember, hey, well hang on a minute. I didn’t put the decay there. I’m helping you, but I didn’t put the decay there. So it might take some years, Emma, to be able to be confident enough to say that to a patient, but it’s one to have up your sleeve. [Emma]Yeah. I’ve heard people saying before it might have been yourself actually like you didn’t put the caries there, and if there’s moosh there, then it needs to go. I think a lot of patients sort of demonize dentists. Like, I didn’t do that to your tooth. That’s hard to sort of, I wouldn’t ever say, oh, it’s your fault, blah, blah, blah. [Jaz]But it’s a hard one. I hear, Emma, is patients saying that, Oh, my dentist drilled too much. And so that really for me is a failure in the communication department. So it just means that, oh, we’re going to do a filling today. There’s some decay. Let’s crack on. Really? That kind of conversation should be like, there’s some decay here. I don’t know how deep it is. I think it’s actually, look at the radiograph here. So look at this x ray. This is the dark area. That’s the mush. But actually in the real world, this mush is going to be much deeper. So I’m telling you now, although you’re not in pain now, there’s a real chance. Your nerve might be in pain because your decay is really uncontrollable. And although you’re not in any pain now, this could become a painful scenario. If you’d wish not to have this treatment done, that’s fine. But you’re looking at having this tooth out. But if you still wish to try and save this tooth, remember the kind of symptoms to look out for are X, Y, and Z. And now your patient is really much more informed than their understanding that actually is their problem, not yours. [Emma]Yeah. No, definitely. I think and another one is I wasn’t in pain before I went to the dentist and- [Jaz]Classic. [Emma]I don’t need treatment done because it’s not sore. But again, that communication like, well, if you don’t get something done, then it will be sore down the line but she pick up along the way. [Jaz]A hundred percent. And as per the GC criteria in the UK, we have to tell the patient the risk of the treatment, but always the risk of not doing treatment. So, Miss Smith, I know you’re concerned the decay is deep, and actually after this procedure, you might be in a lot of pain, you might have a sleepless night because it’s very, very close to your nerve, and this is the reality of the really deep decay that you have in your tooth, Miss Smith, right? So your tooth is in a really troubled state, so we need to do CPR for the tooth here, but if you want an alternative, the option of not doing anything, although you’re not in pain now, this is going to be potentially a very painful issue in the future and whilst we might be able to save it now, we probably won’t be able to save it in the future. So the risk of doing nothing is not recommended and I’m not recommending this treatment, although you may choose to do nothing because you are well within your right. [Emma]Yes. Yep. The option of doing nothing is always there, but it’s not often recommended. [Jaz]Correct. And patients have to consent to doing treatment or not doing treatment. And so we put it on the table, but it’s the way we communicate and the gravitas that we explain things, which is really important. [Emma]Yep. Yep. Absolutely. [Jaz]Amazing. Emma. So we’ve covered now some degree of real world radiography. We talked a little bit about OPGs, periapicals, and grading and assessing. Looking at things in a systematic way and actually drawing out the real world, the communication gems, which I think this episode really evolved into in the second half. Please tell us about the notes, the Protrusive Student notes that you’re adding on every time you do an episode. Tell us about what you’re going to cover in this round. [Emma]So this month’s notes about radiography, of course, I’m going to go through what we’re taught at Glasgow about your radiographic reports and your checklist. And what I personally have in my wee book that I carry about with me, a bit of localization and parallax technique, common mistakes that we make when we’re interpreting radiographs and it’s just, yeah, basic interpretation, things like that. [Jaz]Excellent. Very excited to put that on. So Emma, thanks so much for all the hard work you do for Protrusive and I hope you have a fantastic elective. We will meet again. Obviously, people will not know the difference because we’re recording ahead of time, but we can’t wait to hear in the next episode your stories about your elective and from the Protrusive Community, we’re thankful for all that you’ve done so far, but we look forward to rejoining and continuing your good work. [Emma]Perfect. Thank you so much. Jaz’s Outro:Well, there we have it, guys. Thank you so much for making it all the way to the end. Please let us know what should we cover next in this basic series, in this Protrusive Student Series. Like I said, the next one’s on extractions, and it will be CE eligible because I find that so many dentists are also tuning in, and it’s nice to reconnect for validation when it comes to the basics. If you know a colleague who will benefit from these episodes, please send them a link to our podcast, and at least join the community of the nicest and geekiest dentists in the world. That’s Protrusive Guidance. You can get it on iOS and Android, and our thriving community is absolutely awesome. Nice people. Not like what you see on Facebook. Facebook is junk, in my opinion. So if you are a keen listener of Protrusive and you want to connect with other Protruserati, that’s the place to be. Thank you so much for listening all the way to the end. Once again, I’ll catch you same time, same place next week. Bye for now.

Oct 26, 2024 • 34min

Elective Endodontics? It’s all about Communication – PDP202

Does ‘elective’ or ‘pre-emptive’ endodontics have a role in Restorative Dentistry? It almost feels dirty to me as I try my best to PRESERVE pulp vitality! But sometimes this bites you, and you wish you had carried out root canal treatment before cementing that crown. At what point can pre-emptive root canal be justified in a world where MTA and biodentine exist? https://youtu.be/9Gc_yik9fDU Watch PDP202 on Youtube In this episode, Jaz sits down with renowned endodontist Dr. Brett Gilbert to delve into the intriguing world of elective or pre-emptive endodontics. Together, they explore challenging cases where teeth with uncertain pulpal health may require root canal treatment, whether due to caries or crown prep. Dr. Gilbert sheds light on patient communication strategies, the role of bioactive materials like biodentine and bioceramic sealers, and how to make crucial decisions about preserving pulp vitality. Protrusive Dental Pearl: Dr. Pav Khaira suggests using Alvogyl, commonly used for dry sockets, to treat pericoronitis! After cleaning and disinfecting the area, place a small amount under the operculum for immediate relief and to soothe inflammation. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 3:01 Protrusive Dental Pearl 03:55 Dr. Brett Gilbert’s Journey and Philosophy 07:17 Elective or Pre-emptive Endodontics 11:06 Radiographic Measurement 11:40 Real-Life Encounters 15:29 Discussing Treatment Options and Patient Communication 20:28 Can Biodentine Prevent Root Canal? 22:45 Materials and Techniques in Endodontics 26:16 Death of Gutta-percha? This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment) Dentists will be able to: 1. Learn what elective or preemptive endodontics entails and recognize scenarios where root canal treatment may be required due to caries or crown preparation, and how to approach them.2. Discover effective strategies for explaining treatment options to patients, improving trust and decision-making.3. Gain insights into the use of bioactive materials like biodentine and bioceramic sealers, and their benefits in preserving pulp vitality. If you liked this episode, you’ll love Post Operative Pain after Endodontics – Prevention and Management – GF017 Click below for full episode transcript: Teaser: I do believe in these instances, you are justified to recommend the treatment. You're not demanding it. You're not saying it's dogma, but you're having a conversation so the patient understands. Because what happens if you don't is you do your work, you're doing it in best faith. Patient winds up in pain, and they become very angry. Teaser:They become agitated, and they want to blame the dentist. And without a conversation, without a dialogue, they’re clueless, and all of a sudden, they just think you did something wrong. You are a human, and you are the doctor. Speak to yourself. Let the words flow out so that you can explain all the different possibilities in a way that the patient feels heard, understood, but also nurtured, and at the same time you realize this is biology. We are not in control. Jaz’s Introduction:In a world where we want to do everything to preserve pulp vitality, is it ever appropriate to carry out elective endodontics? Another terminology that our guest today, Dr. Brett Gilbert shared with me is preemptive endodontics. For example, you have a tooth with dubious pulpal prognosis. And you know that by prepping it for a crown or by removing the caries, this tooth may need root canal treatment. Is it okay to just go ahead and do the root canal so it doesn’t bite you in the behind in the future? You see, I was always taught to do everything possible to preserve pulp vitality. So I started my career being very much against it. And yes, I burnt my fingers a few times. So we’ll ask our guest today, who’s a specialist endodontist, and you know what, Protruserati, you’re going to absolutely love him. He’s so direct, he’s so quick, he’s so punchy with his answers. And whilst this episode is just half an hour, it’s part of a two part special. So this half an hour we focus on elective or pre emptive endo. We talk about things like biodentine and bioceramic sealers. And this is worth 0.5 CE credits or half an hour’s worth of enhanced CPD. The subject code for this one, because we are a PACE approved provider, is 070 endodontics. And in the part two of this episode, we’re going to discuss irrigation. Is sodium hypochlorite still the best thing around? How can we improve the efficacy of our irrigation? How can we get all those bugs? Because endo is all about getting rid of the bug. So that’d be in part two. So don’t miss that one next week. Dental PearlHello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. And this one comes straight from the protrusive community. As you know, we have our platform, it’s called Protrusive Guidance. It’s been going strong for about seven months now. There’s over 2000 dentists on our community now that have been approved. So there’s hundreds of people who want to join, but we manually approve each one because A, we want there to be only dental professionals in our group. You want this to be a safe space and I want the nicest and geekiest dentists in the world. So if you identify yourself as that, please join us because today’s pearl comes straight from the community. We have a very busy chat section of our community, and someone was asking about the management of pericoronitis. And then came Dr. Pav Khaira, who’s like the implant guru, but he dropped such a powerful pearl that I really want to share this with you all. He says that you can use a bit of Alvogyl. You know that stuff we use for dry sockets, we put inside the dry socket? He suggests putting just a tiny bit of that under the operculum. So where that inflamed tissue is, just tuck it under. Obviously you’ve got to do this after you’ve irrigated, you got rid of the debris, you’ve disinfected the tissues, and now you leave a bit of Alvogyl. And this stuff gives immediate relief to patients. Now, this was so good that community member Dr. Nikhil Misra said that he’s used this technique for three patients this week with immediate relief. And he’s very grateful that that tip was shared. So thank you to everyone on Protrusive community. Thank you Pav for sharing such a powerful little tip. It’s something we virtually all have in our clinics. And now we have another use for it. So once again, if you missed it, Alvogyl for pericoronitis. Now, totally unrelated, let’s get back to endodontics and let’s join our wonderful guest, Dr. Brett Gilbert. You’re going to absolutely love him. I’ll catch you in the outro. Main Episode:Dr. Brett Gilbert from the U. S. So, so good to have you on the podcast. You were recommended to me by Dr. Tom Levine, who’s a member of the community, and he did some CE with you, which I love to hear about. And the more I research and look into you, the more amazed I am. So I’m super, super excited in a geeky way to chat endo with you today. Specifically irrigation, but there’s so many communities, so many, so many questions the community has actually asked, and I can’t wait to dig in. But for anyone who hasn’t heard about you before, tell us about yourself. I see you’ve got your lovely little box there on the cusp podcast and you do so much in education, but tell us about you, Brett. [Brett]Yes. So thanks so much. Jaz excited to be here. And I do think Tom, he was at my AGD presentation and within, after the first break, he came up, he goes, do you know, Jaz? And I said, I’ve heard of him. I’ve seen his podcast. He said, well, you guys have to meet. Cause there’s so many just synergies between your energy and your message. So very grateful to be here. So I’m a full time clinical endodontist. I’m board certified. I’ve been in practice for 21 years. I have a ton of passion for the profession, but as I’ve gotten a bit older into my career and dealt with burnout and the mental distresses and the burdens of the stress of being a dentist, I’ve also become super passionate and a student of personal growth and development and just sort of that ability to manage our stress. And so I really try to balance them both out because I really feel it’s really important to have the opportunity as a dentist to study the X’s and O’s to understand technique, rationale, the way that we approach dental treatment in whole, but before we do that, we really have to make sure we’re also focusing on the human being inside the scrubs. And that’s another area of passion that I have. And so I know you share that and I’m really grateful to be here and to meet your audience and to talk it up a little bit and let’s get into some endo. [Jaz]Absolutely. What I’d love to start with is your journey from the perspective of did you spend much time as a GP before you niched into endo or for you was it like you’re always you’re calling since after dental school? [Brett]Yeah, interestingly enough, so I’m a son of a dentist, general dentist and my whole life I was going to be a general dentist and practice with my dad and then after one year of dental school, I started to feel a little out of sorts. I just felt like pulled in so many directions with all the different disciplines of dentistry. And that’s when the discussion of specializing came up. And my dad sent me to all of his different friends, offices, ortho, oral surgery, perio, and then endo. And I got there and this gentleman, he just was incredible. His name was Barry Jurist. He was doing rotary at this time. He had microscopes. He was showing me videos of his surgeries. And I was just struck. And from that moment on, I was full go for endo. I picked up my studies. I really focused down and I was lucky enough to be accepted right out of dental school into my endo residency at the University of Maryland. [Jaz]Great. It’s nice to learn about someone’s background and story. Now I’ve got a million questions and also it’s just great about your background in or your passion in self development growth, the human perspective. And I’m sure wherever we can weave that in. We should, but I’m going to start with a few questions from the community. So community, which Tom is part of is called Protrusive Guidance. I’d love for you to join on there and help us out with our endo woes and queries. There’s always a radiograph being popped up saying, oh, what’d you think of this? So you’d be great for that. But the first question I’m going to start with, amazing. I’ll make sure I’ll get you hooked up. The first question I’m going to start with is about what I emailed you about. I called it Elective Endodontics. And you introduced me to the term, Pre-Emptive Endodontics, which I’d never heard of before and I really like it. And so from the background, the context of this question is I have always been taught never expose the pulp. Like whatever you do, avoid the endo. And actually an endodontist’s first response responsibility is to protect the pulp and avoid the endo, which is great. And then taking that on board, I had these scenarios where the caries were so deep, the tooth was still vital. And my diagnosis. was still reversible pulpitis at that stage. It wasn’t irreversible pulpitis. So I thought, okay, maybe there’s a chance that by placing a restoration on here, I can avoid the endo. And then a few times it happened where a few days later, the patient’s in agony and you think, Oh man, I wish I just did the endo. So I know in other countries, it’s more popular. It’s more accepted in other countries whereby anytime they’re doing any sort of indirect work, they’re thinking, ah, let me go ahead and kill the pulp off so it’s not going to be an issue in the future, which I think is at the other extreme and perhaps irresponsible, I would say. Where do you lie in terms of, is there a time and a place for pre-emptive endo or elective endo? And how do you assess that kind of situation? [Brett]Yeah, by all means there is. And I think what’s important to remember is that all of these decisions aren’t done just by the clinician, right? It’s a collaborative decision based upon a very specific conversation with the patient. And so the decay issue is different because the more I study restorative, schools of thought, some are comfortable leaving some decay, as part of the underlying parts of a restoration and others are not. But ultimately, I think we have to look at the history of symptoms first and foremost, because if you have a patient that you were describing with reversible pulpitis, that you feel very confident is reversible. We do have to recognize that there’s probably about a 50 50 chance that it either calms down underneath the restoration or it doesn’t. And sometimes that’s a conversation to be had. Sometimes I’ll explain to a patient, listen, we may be able to send you back and have the crown cemented and you’ll be just fine. I don’t know. It’s possible we send you back and you’ll have symptoms as you mentioned a week, a day, a year later, and endo may need to be done through the restoration. So what I need you to understand is, are you comfortable moving forward with the understanding we may have to go through the restoration later? And if not, then understand that there is the option of pre-emptive endo now, meaning we can do the root canal now so that the foundation underneath your restoration is sound. It’s not going to cause problems later. It’s surprising. You can never go into these conversations with an expectation of how they will answer. That’s what I’ve learned. So it’s about giving them the A to the Z. Explaining the situation if they opt to not do endo at that time. It’s fine I do recommend having an extra little consent line that the potential for endodontic treatment after the restoration is place was discussed. Patient defers and will prefer to wait and see what happens. Have them sign it. It’s amazing how helpful that piece of paper becomes later when the patient’s upset and they realize that now their brand new crown has to have a small access opening, but I also do tell patients, listen, it’s pretty non intrusive for us to be able to go in and do endo through a crown. So it’s not like the end of the world, but it’s important for you to understand the situation now where that starts to become more clinician centered as far as the decision is to your point. There was a lot of decay. You’re very close to the pulp. In fact, you might even see it. Our studies would show that really anywhere from about 1. 8 millimeters away from the pulp, there are already destructive changes happening into the pulpal cells. So you have to then take into account, this doesn’t seem very good. [Jaz]Is that a radiographic, Dr. Gilbert, is that a radiographic measurement? [Brett]It’s really more probably just eyeball to be honest, because you’re probably looking at some huge change in the dentine that would indicate where you are. Domenico Ricucci out of Italy has done a lot of work with this, as far as when it’s appropriate to leave the pulp and when the appropriate to take it out, but ultimately in the global scale of dentistry, I think ultimately it comes down to your gut instinct as the clinician with a really good conversation with the patient and allowing them to be a part of the decision making process. [Jaz]In your week to week endodontics, or month to month, I mean, how often does this pop up with the kind of work you do? Is this something that you’re doing on a weekly, monthly basis, or not so much? [Brett]Yeah, I mean, I think ultimately it depends on what kind of restoration you’re placing to, right? If it’s a direct composite, if it’s a standard restoration that does not involve cementation, I think we’re often much more patient before we institute endodontics, because, of course, once endodontics is completed on a molar, then typically some type of cuspal coverage is recommended afterwards. So that’s a lot of dentistry. That’s a tremendous amount of expense for the patient. So really it comes down to more of the cemented type of restoration where this conversation really takes hold. And so, if you’re just doing fillings, et cetera, et cetera, then ultimately a veneer even. Then really the conversation can lean more toward, let’s see what happens. But once it’s full coverage or cuspal coverage, it’s cemented, you know you have to go through it. Then that’s where this conversation of pre-emptive treatment becomes more profound. [Jaz]Well, I’m going to share my screen now for those who are listening on Apple and Spotify. They won’t get to see this, but I’ll describe it literally today on the community, I posted this like hot, cold, like a poll, and I said, how do you feel about elective or pre-emptive endodontics? Example, deep carries and will need indirect, RCT it pre-emptively or no, I’m not comfortable with this. I wouldn’t do this. It’s like a hot and cold. And as you can see, the audience is generally veering more towards cold, not freezing, but towards cold. And there’s a few in the middle like me. And then there’s a few to the right of me, a bit warm. No, one’s hot in it, which is good. We don’t want as a community to be trigger happy doing these endos. We still value and respect the importance of preserving pulp vitality. But then from the chat here, Brett, what came here is a great discussion whereby colleagues, what they’re doing, and essentially here’s the question, what colleagues are doing in those scenarios is yes, it may benefit from cuspal coverage because a lot of these are huge MOD amalgams, recurrent caries. So they’re going to need cuspal coverage. But what our clinicians are opting to do is remove the caries, remove the old restoration, clean everything up, and then just put a well bonded composite and tell the patient, look, It needs something more definitive than this, but let’s see how it goes for a year. What is your thought on this kind of approach? [Brett]I mean, it’s very conservative and that’s great. We always love conservative treatment. You’re going to be in the same situation a year from now, though, when you go to do a more significant prep and place and cement the crown, we often find that the actual, it’s like the last little straw that breaks the bow is the cementation. And what it does to the pulp through the dental tubules. So I think it’s always again about this conversation and about consent and about what’s your gut instinct for the patient because the patient says, I’m so busy. I travel a lot. The last thing I want is to all of a sudden start having tooth pain. It sounds to me like you’re saying that’s possible. So I would prefer just moving forward with the root canal now. And then another patient says, well, my insurance is running out. I don’t have a lot of out of pocket resources. I think I’ll take my chances. And so you have to look at the actual patient’s lifestyle and their thought process, because I do believe in these instances, you are justified to recommend the treatment. You’re not demanding it. You’re not saying it’s dogma. But you’re having a conversation so the patient understands because what happens if you don’t is you do your work, you’re doing it in best faith, patient winds up in pain and they become very angry. They become agitated and they want to blame the dentist and without a conversation, without a dialogue, they’re clueless and all of a sudden they just think you did something wrong. So whether you wind up pre-emptively treating or not having the conversation, I believe is paramount for building the relationship and ultimately managing the patient winding up in pain later. [Jaz]Thank you. And one thing I struggle with in informative years and a lesson I pass on a lot on the podcast, especially for our younger colleagues, Brett, and I think you’d be great to give a perspective with your interests on the human side is when colleagues are communicating this to their patient, I feel as though sometimes our colleagues, our friends, end up owning the problem. They’re thinking like it’s their tooth, right? And I think it’s really important for our mental health, our anxiety, that we’re just there to help to guide the patient, to do what’s best for them and dissociate themselves from the problem. Because if you start stomaching the problem with yourself, and you start being a bit too vested in it, then that can have bad health effects on us. What do you think about owning the patient’s problem when it comes to the ultimate decision? [Brett]I mean, this is the one of the biggest stressors we carry as dentists. We are very empathic people. We want to help people. We also have been trained in an era of we are expected to be perfect, whether it’s been imposed on us in our dental school training or self imposed. And so when something doesn’t work out the way you had hoped, and now someone else is suffering, it’s very, very challenging to separate The human being, the tender soul inside of you and the dentist. And that’s where the identity as a human first is so important. And that only comes with addressing it, feeding that human inside of you so that you can have some separation. I, as a young clinician took everything personally. I went to bed thinking about it. Terrified of what might happen or what had happened, and then I make it a little sleep. And the second I wake up, it’s right there. So the advice is this. It’s important to understand that when you are a dentist, there’s a full spectrum of reactions that an individual patient might have to our treatment. Now, are our treatments ever going to be perfect? Let me just say from my own pursuit of it every single day. Nothing’s perfect. So what we should be striving for is excellence, not perfection. And within the frame of excellence, you have to be aware that there are different reactions. And what’s important is to understand how to have these conversations, just like the pre-emptive conversation. And what I suggest, especially to the younger dentists who haven’t quite been through as many situations, talk to yourself in the mirror. You are the patient and you are the doctor. You are human and you are the doctor. Speak to yourself. Let the words flow out so that you can explain all the different possibilities in a way that the patient feels heard, understood, but also nurtured. And that at the same time you realize this is biology. We are not in control. And so you do your very best. And Jaz, if every dentist that hears this within your community can recognize all that’s expected of you, not to be perfect, not for everything to be 10 out of 10, all that we can ask is that every day that you show up, you have the intention of doing your very, very best. That’s it. And if you do that, then when a patient does have a problem, you can look back and say, yes, Mrs. Smith, I have to say, the treatment that we did looks good, but I understand you’re suffering. Let me explain why. And ultimately, let me give you sort of a view of what might come down the road. I don’t know that you’ll need potentially this tooth to be extracted, but I want to put it out there to you that ultimately, if that were to happen, I just want you to know that there will be a game plan to replace the tooth. But in the meantime, for now, let’s focus on just getting the symptoms to settle down. I’ll have you back for frequent followups. So, you know, I’m here for you, right? I like to say that to patients, just so you know, I’m here for you. I will be here if you need me. That’s all patients need. Sometimes the pain isn’t as much physical as mental and emotional and financial, right? They’ve gone through all of this time, energy, they miss work, they spent all this money and now the tooth hurts when they bite on it. Well, that’s upsetting to them. So it’s important to meet them as a human where they are, but also separate yourself as a human, as someone that has done their best in every moment. And that’s all that was ever asked of us. [Jaz]This is absolutely communication gold. If anyone was multitasking when Brett was given this most wonderful monologue, you need to hit rewind, just go back the last couple of minutes and just listen to this again. And just for a few days, just that was absolutely fantastic. I love that. The whole thing about rehearsing in the mirror, we don’t do that enough. And that connection that you make with the patient and yes, ultimately patients need to have that feeling that, okay, I’m in safe hands here. This guy will look after me and that can’t be emphasized enough just to reflect on what you said. I had a guest Marco Maiolino from Italy on recently and we talked about how we’re always striving for perfection this gold standard but he very much resonates with what you said where if you show up and do our best every day and we call that the daily standard. So what he suggested was Instead of like one or two cases going 10 out of 10 and the rest going four or five out of 10 because you’re particularly putting too much energy. And if you lift your daily standard to eight out of 10 consistently, we will better serve our patients and try and do that rather than chasing that 10. So I just want to remind everyone of that great reflection. And then going back to clinical on that point of pre-emptive endodontics, selective endodontics. So once again, April from our community, she mentioned that actually she has been using biodentine with some good success. So previously when she’d be wondering about, ah, should I be having this conversation with the patient? How much are you using biodentine as part of your armamentarium to further reduce your risk or help this scenario? And based on the evidence base and your experience, is this a silver bullet? [Brett]So biodentine is an interesting material. It’s been around for a while. I haven’t used it as much as I think a lot of other dentists. And I don’t know if it’s a US thing or a global thing. But we do use the bioceramic materials in the same way, right? Like a material that is non irritating to the pulpal tissue, that’s a nice insulator that can sort of rebuild where the natural dentine protection of the tooth structure has been removed, whether by biology or by bur, but these things are nice because in the past, all that we had to put close to a pulp was irritating, something with huge and all, etc. And now what we have is examples of something like biodentine or any of the MTA products, the bio ceramic putties, where we actually can sort of kind of protect the pulpal tissue in a way that’s non irritating so that we could potentially extend the life of the pulp. And so I think that’s a very valid way to go. Again, I think when you’re talking about fillings and things like that composites, that’s going to be a really important part of your armamentarium to maybe put something close to the pulp instead of something that was considered a base back in the day using something like this, that’s a little more biocompatible. But ultimately, when it comes down to crowns and full coverage, cost full coverage, that’s where cementation comes into play and that’s where it becomes a little bit trickier. So I think bio dentine is a wonderful material. I think one of the reasons it’s not as in vogue is just because to my knowledge, still, it needs to be triturated. And a lot of the bioceramics, you just basically just push a little bit out of a syringe already premixed, but I think you get a similar result. And so I think it’s a valid comment and definitely a material worth having in your office. [Jaz]Here’s a real world spit off from that question. We have an international audience here all around the world, and some countries, it’s just not something that they can afford in their clinic. And that’s the truth, right? So out of glass, iron and cement, composite, even amalgam if it was your tooth and it was a deep one and the dentists wanted to try their best to give It the shot for vitality. What should the dentist be using in what’s most likely going to be stocked in their cupboard already? What’s the kindest protocol to the pulp in terms of restorative material to place when you are close to the pulp? [Brett]That’s really interesting. I think it’s more of like how close are you and are you actually exposed. So if I have any type of exposure, I want to buy a ceramic cement against my pulp tissue 100 percent because the studies would show over volumes using MTA is the sort of essential baseline. But since then, the bio ceramics as we learn, you know, bio ceramic putty, bio ceramic sealer. They’re all the same material. They’re just different consistencies based on particle size. But what we see is that the pulpal cells will actually grow against it without any zone of necrosis. So to be honest with you, once something like a bio ceramic is up against the pulp, you really need something of a resin to sort of hold it in place and seal it. So there’s been an advent of something called resin ionomer. One example is from Brasseler, USA. They have what’s called BC Liner. And what’s interesting about this material is that it bonds to both the dentine as well as the bioceramic material. So for instance, if we flip it around from a pulpal exposure and you think about like a perforation. Same type of scenario, you would put the bioceramic putty down against the vital tissue, and then with this resin ionomer, you can basically just put a bandage over it, light cure it, and it’s bonded to dentin, it’s bonded to the bioceramic, and now that is essentially sealed. So whether it’s a healthy pulp that you’re trying to seal or perforation, this protocol to me is ideal in this day and age. To your point, though, unfortunately, some of these materials are costly and therefore, some dentists may not have that. So in that situation, I think we have to still go with the old tried and true, which would be something like an I. R. M. Or using some type of base material. But ultimately, we used to talk about pulp exposure or indirect pulp capping, direct pulp capping as death of the pulp. And with the advent of these bioceramic and bioactive materials, it’s just not so,. And a whole nother topic for your podcast would be vital pulp therapy, which really has come into vogue because we now have biomaterials that allow us to actually protect the pulp. And so if you have an immature tooth, you can do the same protocol over a pulp exposure, even like Cvek pulpotomy and actually allow for the natural Apexogenesis to occur because that pulp tissue will remain vital. So there’s a lot of exciting things happening. We’ve learned that, there are parts of the world where even from an endodontic perspective, I still teach hand files and I still teach cold lateral condensation because that’s what they have. So it’s important as educators, I believe, to meet our doctors where they are. We can talk about the highest level of expensive materials and the lowest level. And fortunately, the beautiful part is you can still get a great result with either. [Jaz]Excellent. I mean, that’s very encouraging to hear. And I think you’ve given some good guidelines to consider. The final question I have is from Christos in the community before we talk more about irrigation, right? So that’s gonna be the more like the part two. The final question is, because on the topic of bioceramics, he asked, is this the death of gutta-percha, GP, are we now doing these bio ceramic sealers in the canals or using the bio ceramics as an alternative to GP, which I know many endodontists have been doing for a while now. So is there still a place for GP? And I think just to give you some background as a general dentist, I was recently advised by an endodontist that if a general dentist is doing an endo and you’re thinking, hmm, there’s something in doubt here, I don’t think I can get a perfect result due to a myriad of different reasons, then please use something like Tubli-Seal and GP because the re treatment will be easier. If you, in that scenario, when you can’t get patency or you’re not 100 percent confident, if you use a bioceramic material to fill it, then that re treatment may become more difficult. So I want to learn from you in terms of how far have we come and how have we moved away from GP? [Brett]So a couple of things on this. So GP, what you have to look at it as, and the way I like to teach it is the gutta-percha is simply a vehicle and it’s a vehicle to essentially drive the sealer against the walls into lateral canals into dental tubules into apical rarifications and all kinds of apical deltas. We know that there is such a tremendous amount of anatomy within the root canal wall. So you’re using a match cone system, ideally in modern systems where the gutta-percha and the final file that you finished with are the same dimensions, which means that what you’re depending on the gutta-percha to do is to fill the bulk of the center of the canal. While allowing this hydrodynamics, this condensation of hydraulics to push the sealer against the walls. That’s the goal. Gutta-percha doesn’t seal to anything. So the reality is when bioceramics came into vogue, we started to see this concept of single cone, but the cone was tiny. So it was a bulk of bioceramic sealer and a tiny little central core of gutta-percha. And that’s where the whole retreatment argument began. Because the reality is, you can’t remove cement from the inside of a canal. So we shifted our thinking and thought, well, we actually could probably get a very similar effect by using a normal size, a match cone gutta-percha to actually drive the sealer against the walls. But still retain the ability to retreat if necessary. And so that’s essentially what most endodontists are doing. We do the single cone, we put the bioceramic material in the coronal third of the canal. And if you’ll see any of my videos, you can actually see as the gutta-percha comes in like that piston, you see it actually carry the sealer down. And then start to spread it out. In fact, even getting some extrusion, which we don’t see as harmful at all. In fact, especially with a lesion where it’s more common to happen, it actually has osteogenic potential to actually help the body to form bone because it has hydroxyapatite. That forms on it within about 24 hours, and the body sees that hydroxyapatite as self. And so it actually instigates healing. So to answer the question for the doctor, no gutta-percha is not going anywhere only because it’s that really nice inert material that can actually facilitate the movement of the sealer where we want it most into the apical rarefications into the lateral walls, et cetera. But something exciting that’s come onto the market very recently is actually obturation with neither gutta-percha or sealer. And this is a hydro gel material. So a company out of Switzerland named Odne has developed what’s called OdneFill. And what it is, is it’s actually a liquid that you inject and then it has a laser that goes down and actually polymerizes it. So what you get is an actual root canal filling that is neither gutta-percha and neither sealer. And so we’re seeing some paradigm shifts in thinking. The hydrogel is nice because as it sets, it pushes out just gently, almost like if you think of like oxygen mass being pushed against one’s face to make a seal. Very similar concept, very easily retreatable. The key though, and again, it’s still in the early stages, but Jaz, think about it with sealer and gutta-percha. You do have some risk of extrusion, right? Whether it’s the sealer gets way out, whether it’s the gutter percha point. And with a material like this, it eliminates the extrusion because it’s basically an aqueous solution. If it goes past the root, it’s simply absorbed and it can never be hardened because the laser doesn’t go beyond the apex. So just putting it out there to the community, there are some new developments, but right now, what’s nice about the bio ceramic sealer with the gutta-percha, is that there is, and it’s basically, it’s considered single cone, but it’s really called hydraulic condensation. And the reason is, is you can put some pressure on that gutta-percha and find that the sealer actually can spread. So that’s where you’re seeing these lateral puffs on instagram and you’re seeing these anatomies just get filled with sealer because of the hydraulic nature of the bioceramic sealer, and that’s very exciting isn’t it? [Jaz]That’s only possible with the heated techniques, right? We can’t achieve that with lateral compaction. We are, if you don’t have the know how or the kit to do it in the hands of the cold lateral compaction, is bioceramic sealer still a good option for a general dentist to use? [Brett]Yeah, as long as you can sear off the top of the gutta-percha, you really are not putting like an apical penetration of heat. It’s really just, again, that piston of gutta-percha. And when you just condense it, it just puts a little more hydraulic force on the sealer. So yeah, it’s exciting time and just wanted to share that because I think it’s important to open the minds of what’s in research and development. And this is actually an approved material that’s available. And it’s a very new paradigm shift. Obviously, we don’t have a tremendous amount of evidence on any of it, but it’s exciting to think about de risking the endodontic procedure, especially for the GP. [Jaz]Well, the future of endo is certainly very exciting and that takes us very nicely to irrigation. Okay. So, I know you’re really hot on this. So the proper disinfecting protocols, let’s talk about where we are in 2024. Cause I was taught that sodium hypochlorite is the gold standard. So the first question is, is there anything better yet? Are we still relying on 3%, 5. 25%, wherever it is, sodium hypochlorite? Jaz’s Outro:There we have it, guys. Thank you so much for listening all the way to the end. How good was Brett? I told you you’d love him. His direct way of responding is absolutely fantastic. And hopefully now you have a more informed opinion about the relevance of pre emptive endodontics today. Is there a time and place? Yes. There might be, but it’s all about that patient communication. If you’d like to claim 0.5 CE credits, cause you’ve done all the hard work of actually listening and hopefully we made it just that little bit fun. Head over to the Protrusive Guidance app. Now, if you’re downloading it on Android, you need to first make an account on the website, protrusive. app. You can actually access it from your laptop, but then once you get your account, you can access it on iOS, Android. And about 99% of the episodes have quizzes. I’ve also got my masterclasses section for those who want to learn further. If you enjoyed this episode and you like what Brett’s doing, then firstly, give it a thumbs up and subscribe. But don’t forget to join us for part two, where we talk about the latest innovations when it comes to irrigation. But even if you’re not using anything fancy, how can we improve how well your irrigation and disinfection protocols are working in your clinic? today, right now. So it’s another juicy one with Brett coming next week. I will put Brett’s podcast and links to this episode as well, but the next one he talks more about all the wonderful things he’s doing to support the world of dentistry. Thank you again. I’ll catch you same time, same place next week. Bye for now.

Oct 23, 2024 • 45min

Diamond Burs Made Tangible – Clinical Applications and Guidance – PDP201

Are single-use diamond burs more efficient at cutting? When should we throw away a bur and pick up a fresh one? How long are they supposed to last? (it’s measured in minutes!) Are expensive brands a con? Tiny, but one of the most important tools of our trade…BURS! In a world full of different identifying numbers and names, it can get confusing and even overwhelming. https://youtu.be/Ol0_XcIbSD8 Watch PDP201 on Youtube That’s why on today’s episode, we welcome Günter and Marcela from Intensiv, a globally recognised manufacturer of dental burs, where they take great pride in bringing the latest tech to help make our dental procedures that much easier and effective. In this episode, we cover how diamonds are sourced, what the differences are in colours of burs and how the grain size of diamonds can change our results. There’s lots of amazing tips and tricks here given by the team at Intensiv, so you’ll definitely walk away from this one with something new up your sleeve. Need to Read it? Check out the Full Episode Transcript below! HIGHLIGHTS of this Episode: 01:24 Protrusive Dental Pearl 02:03 Introduction to Team Intensiv 05:40 Understanding Bur Codes 10:49 Bur Colours 15:10 When to Use Different Grit Diamonds 18:40 Single Use Burs vs Reusable Burs 24:59 Sourcing Diamonds 29:18 Fixing the Diamonds to the Metal Shank 32:40 Is my bur fit for purpose? 37:30 Drilling Zirconia 39:30 Final Tips 41:20 Contact Intensiv This episode is eligible for 0.75 CE credit via the quiz below. AGD Code: 250 Operative (restorative) Dentistry (Preparation Technology) GDC Learning Outcome: C Learning Outcomes Identify the appropriate dental burs for different procedures, considering grit size and material composition, to ensure efficient and safe treatment. Evaluate the impact of bur selection on patient comfort and procedural outcomes, minimising trauma and maximising efficiency during dental treatments. Implement best practices for the maintenance and replacement of burs to ensure optimal performance and longevity, thereby improving clinical results and patient satisfaction. If you liked this episode, you will aslso like: PDP117 – Dental Ceramics in 2022 – Which Ceramic Should I Use Click below for full episode transcript: Teaser: Are single use burs better or really more cost effective than our traditional multi use burs? I think the answer is actually going to surprise you. And my biggest pet peeve, the thing I hate the most, is using a bur and it has like zero cutting efficiency. I work in a clinic where we share our burs and we have like different bur kits made up. Jaz’s Introduction:And so sometimes I use a bur and I hadn’t inspected it and I find that, oh my goodness, this is taking way longer than it should. And of course I have to ask my nurse to go to the stock room to get a brand new bur. But this is frustrating. Like when you are using a bur with less cutting efficiency. It is annoying and it’s actually downright dangerous for the tooth. So how can you tell? Is there an objective way to tell and subjectively, how can you tell exactly the moment when you should bin a bur? So you avoid that horrible scenario. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m joined today by Günter Smailus and Marcella Roba who represent Intensiv. Intensiv is a Swiss based company which specializes in diamonds, so who better to find out more about the use of diamond burs and everything to do with diamonds. It’s a very geeky episode, but I feel diamond burs and diamonds in dentistry, we use them so much, we rely on them so much. I think it’s worth an episode, it’s worth discussing about different diamonds in dentistry. I have no financial interest with Intensiv, this is not a sponsored episode. But this is very much for the pursuit of knowledge and disseminating information to Protruserati, i. e. you guys, and making everything to do with diamonds clinically relevant. Dental PearlThe Protrusive Dental Pearl I have for you is when you’re cutting off a zirconia crown. I know that dreading feeling, that anxiety you get about drilling off zirconia crowns. And the top tip is, do not be tempted to use a coarse or a super coarse bur. Maybe you know this already, but actually when you use a coarse bur or a super coarse bur on a zirconia, you are not being efficient. You will be slow and it will generate too much heat. Instead, go for finer diamonds, go for standard blue grit or go for even red grit diamond. You will actually end up being more efficient at cutting that zirconia. To find out the scientific explanation of why this happens, you’ll have to wait till the end of the episode to find that out. Let’s join now the main interview and I’ll catch you in the outro. Main Episode:Günter Smailus and Marcella Roba, welcome to the Protrusive Dental Podcast. I mean, for those of you listening right now, Günter is this tall man wearing this lovely red bow tie and in a slightly difference in height, but probably just because Günter’s so tall. We have Marcella and they’re both looking very slick and they’re joining us today from Switzerland. How are you guys? [Marcella]Thank you very much. Doing great. Thanks. [Günter]You’re great on the sunny side. [Jaz]Well, I’m fantastic. I’m really looking forward to a nice geeky discussion about diamonds, because as I was telling you before we hit record, trust me, no matter what you think. When we qualify, we know nothing about the bur codes, about which diamonds indicated when there’s little intricacies. I think this would be a nice geeky chat and there’s a lot in there for any dentist, because we rely so much on our tools. We rely so much on diamonds. And we ought to know a little bit more and this will actually, I think, make us better clinician. The most frustrating thing ever is when you’re drilling a tooth, removing caries, right? And things are going slow. And that is not only damaging to the patient’s pulp and the tooth, but it’s also losing us money because time is money. So there’s so much we can gain from this conversation by using the right materials in the correct way. And diamonds are a big part of that. Before we delve in deeper, Günter and Marcella, please can you tell us about yourself? Günter, let’s start with you. Tell us about yourself. [Günter]Okay. My name is Günter, as we said. I’m in dentistry since more than 40 years now. Let’s say I grew up in dentistry. I’m running this company and the third generation, the company that was more than 80 years on the market. And my background is not dentistry, my background is economics. So I get it. I’m running the company here with 45 people. And as I said, the third generation and I took already 20 years duty and still I have to do one other 10 years because the first one gets 10 years, 10 years, 30 years, and then myself 30 years or 90 years is my goal here. [Jaz]Very good. And Marcella, tell us about yourself. [Marcella]Hi. So I’m Marcella and I come from Italy, but I live here in Switzerland. I’ve been working in Intensiv since 11 years now. I started off as quality manager and now I’m responsible for regulatory affairs. My background is biomedical engineering and surface science, and I’m in this field since, yeah, 11 years. [Jaz]Fantastic. And I first met you Günter recently, in Valencia. I know we saw each other online and stuff, but we saw each other in Valencia. We did a really cool IPR workshop working with the Swingle and that’s creation by Intensiv. So, before I discovered Intensiv diamonds, I just saw, oh, the Swingle. And then I discovered that, oh my goodness, Intensiv is this huge brand in diamonds and burs and stuff. And so that kind of came to me like, whoa, that’s so fascinating. In terms of the range of products that you guys do. So you are in a great position to teach us about diamonds. And what I like about you Günter is when I had that chat with you in Valencia planning this, the position you came from was very much education. Let’s educate the dentists about diamonds and stuff because it’s an important topic rather than from a commercial background. Yes, you represent Intensiv. Yes, you own a company. But you were very much on board that yes, education, education is so important. And I saw that in action teaching with you in Valencia. That was real good fun. And there was so much I’ve never seen anyone. I told you this. I’ve never seen anyone plan a lecture minute by minute by minute. Please. I was amazed. You literally made all the slides for me. I just had to enter my photos. That was fantastic. [Günter]Yeah. And then growth by growth almost. [Jaz]It was phenomenal. It was a lesson on leadership as well. So I admire you as a person, as a leader as well. And it was great to have some good food and drink with you there as well, but getting back on topic. Okay. Where do we start? I think we should start here, right? Basic, basic, basic bur codes, right? So when we are using, let’s say a bur for a crown preparation or a round diamond, for example, to remove some caries, can you just tell us about how the bur codes, the system of naming a bur? [Günter]Okay. The system of the bur is historical. Historical because in the beginning, when it starts with the burs, we had only let’s say five or seven different forms. And I just said the ball, the cylinder, or as you see here, the football or the egg, we had only five or four. And they said, then this is 800, this is 801, this is 802. And then they start creating more and you say, okay, did you call that 023? And this is called size 010. So it is a really grow up, step by step. And we still orientated on this. Standard codes for the different forms in total. [Jaz]So that’s the first part. So like a bur code is actually quite a long number, full stop, long number, full stop. So that’s the first part. The first part describes the shape. [Günter]That’s right. That’s the shape. But you’re referring now to the number, which is called ISO number. The ISO number is something different. This is complicated stuff because this is almost 12 different digits. And they start actually not with the form number, they start with the shank, if it is in friction grip or the low speed bar, which you have in the contra-angles, that’s a little bit different. [Jaz]So the friction grip is 314, from memory it’s 314, right? [Marcella]Friction grip is 314 and 204 is the RA. So the right angle, these are the most common, let’s say, so yeah. [Günter]I believe me, even if we start teaching, we talk about that since the decades already and dentists, they’re never aligned to the ISO codes. So we do have some companies in the sector that have the ISO codes. Intensiv, never jumped into the ISO codes. We do have the standard form numbers, which we follow, which is a very easy to learn, and then we have our own article numbers. There are companies outside, they have their own article numbers. For example, when you see this thin bur next to me here, the long one, this one, this is called, well, that’s a D6. Just a D like Delta and then six, that’s easier. So we try an Intensiv to bring barcodes more closer to the customer, making the ball is just a 200 or 199 or 201. It’s more easier, more easier for the assistants instead of having the 12 digit number, because they can error very easy. So I can tell you, I must tell you, all students, it’s almost better to start with the form numbers and then getting the idea of the different numbers from the industries, because in the industry, they do a lot with ISO codes. None of them works with ISO code. This is something which has been invented sometimes and then was never really followed because there’s a reason behind it. Just guess just if we would use the ISO code and my colleague my competition would use the ISO code for the same instrument the ball there would be a confusion. Because if I don’t say this is the Intensiv ISO coder, this is the Komet ISO code, that’s not possible. So the ISO code makes a reunification of one Industry, but it’s not we have very many industry and we differ a lot. So one of them could use a different setup from the other one. [Jaz]That’s a really insightful and just to talk about that difference. So it is an 802 with one company, the same as an 802 with another company. [Günter]The phone number. Yes. [Jaz]So it would describe the same shape. [Günter]Yeah, the shape. We have about one of the different shapes in the line. And even our competitors, they have, it’s about 100, some they have 90, some they have 110, depends what you define as a shape or a different shape. But these numbers, they are common. They are common because they are historically grown. And then we have it called the article number or the reference number, and everybody is free. Everybody is free to choose. His own reference number and Intensiv being 80 years on the market far before ISO came in place, and why should we change our article numbers because generation of dentists, they know that this wonderful diamond here is called D6. So when we start making a 12 digit number for that article, we would lose a lot or they would not cite of that anymore and they would just send it out and they would get from any industry something because they have the same ISO code. ISO code is just telling you this is the length, this is the form, this is the grid size. And that’s it. [Jaz]You were pointing to the red grit diamond behind you. So let’s talk about the different colors. If you just describe, do they like K files, for example, they follow ISO colors, basically do diamonds generally follow the same coloring system, i. e. white would be the finest and going up to green and black. How many different grits of diamond are there and is this standardized? So is a green grit with one company, the same as a green grit in another company? So I want to know that as well, but just give us a little overview flavor of different coarseness of diamonds. [Marcella]Yeah. So yes, the colors identify the diamond crystal grain sizes, and they are given by standard. There is an eyes of standard, which specify which color corresponds to which range. In the eyes of standard, there are six colors, which identify a certain range, which is quite broad. Here in Intensiv, just to give an example, we range from finer diamond grain sizes, which is 8 microns in orange, and then we go up to the 150 micron grain size of the diamond crystal, which is identified with the black color which is the super coarse, let’s say, and then there are all these grains in the middle. So the standard gives six color specifications. What happens here in Intensiv is that we follow the standard, but we also have more colors because we have a special feature. Maybe I could start mentioning something about this now, which is about the dimension distribution of the grain sizes in a lot of diamonds. So here at Intensiv, we have a very narrow distribution. So if you think of the Gaussian distribution curve, which shows the percentage of diamond crystals inside the population, which have a certain size, the Intensiv Gaussian distribution of its diamonds, it’s very narrow and tall, meaning that, for example, if we’re talking about a 40 microns, a really high percentage of diamond crystals in this plot, they are actually 40 microns. And you have a very, very small percentage, which differ and are a bit lower or a bit higher. [Günter]In other words, ISO says, okay, if you have the red ring, that gives you medium, medium grit size and the code then for 25 to 60. So the grade coarse goes from 25 to 60, and in the middle you got most than 40, but you have 25 and 60. Intensiv, they have 25, we have 40, we have 50, and we have 60. So we have instead of one red, one for all four, we have four different ones because we are able to get that crystals much better sorted. [Jaz]Are there any advantages? So, for example, if you have a bur that’s red grit and it has some percentage 25, some percentage 40, some percentage 60, how will that result in a clinical difference to a burr that has just 50, for example, throughout? [Marcella]Maybe, yeah, so if you have a bur, which is very precise, it’s in its distribution. This is fantastic because this means that you are very precise and very efficient with your cutting with the abrasion performance. If you have a bur where the distribution of the diamond crystals is not so precise and it’s broader, then you have a high percentage of crystals which are lower in dimension. This means that the bur is less efficient and then you have also a high percentage of crystals which are higher in dimension. This means that the surface is not As smooth as it should be, because maybe you have some cuts and some scratches given by these bigger sizes of crystals. If it is very precise, you don’t have this problem. Efficiency and precision. [Günter]This is especially valid for medium and fine grit because of the scratches. If a dentist relies on a red ring bur, they say, okay, this is medium. And they find two, four, five, ten crystals. I enlarge it in, they get scratches on the composite fillings. And that’s always bad, you know that, they take this and that, smoothen that, another rubber polisher to get it smooth because a scratch on a filling is always bad that bad notice, so with Intensiv, we guarantee that there’s no scratches. Absolutely not. When it comes to- [Jaz]It makes sense. And I imagine if you were to blow it up and zoom in on a scanning electron microscope, you would see that difference based on uniform, grit versus a variable grit. Just give us an overview if you don’t mind both of you on when bur producers are making different grit burs. Just a classical indications. For example, when I’m finishing a composite, I might like to use a red or a yellow. When I’m preparing, I’ll pick up the blue green or when do you recommend the black? What is the indication for the black, the super coarse one? I don’t see many of those burs around. Is it because they’re more expensive or is there because there’s not much use in dentistry? [Günter]Well, there are not much use. Let’s say that, in the past we had a tendency to the coarse grits because the speed of the turbines, everything was not that good developed and dentists tend to get coarse grits to get the job done as you said before. We count in minutes maybe five or ten minute blocks. I would like to get that preparation done so when they choose when the dentists choose the one the 150 or 125 black or green marked grit they get it faster done, of course because of the corset grain. But it is some kind of traumatic as well for the tooth because it’s really rough that get some cracks. It is a risk of cracks, and you know what a crack mean after 10 years. And that’s why we from Intensiv, we recommend for preparation, the blue one, the blue is 80 micron. It’s wonderful. Today, it drove by electric tow bike. Red ring is a constant 200, 000 or 160, 000 tons a minute. And that’s wonderful. That’s a wonderful job. The actual bike, I understand that the actual bike, you tend to get that coarser because when you press, you come down from 200 to 100, 000 or 80, 000 turns because you’re pressing, you’re blocking that air system. And that’s why the trend with the red ring contra angle. It comes more and more to the smoother grains like 80 or we call it standard grain means silver, no color on the bur. And that’s, that’s, I’m happy to see that I must tell you, after all that years being in the sector, I do not like the cost first. Because even for the patient, it’s really tough having that vibration because they’ve got a lot of vibration in the jaw, and that’s not comfortable. So I always teach dentists, especially young dentists, start with 80. You’re good enough. It’s fine for abrasion. So when you start abrading something, take the 80 micron, the blue ring, and then right here, you can take them the 40. For the red ring for shaping and then the yellow one for finishing and polishing. We have then in between the 60 micron, the gold bar, we call it gold ring, gold bur. And this is more something in between. You can guess it. That’s 80, that’s 40 and we have 60. Guess what? Veneer preparation, we’d like to have a minimal invasive prep done, just a little bit, maybe partial just a little bit, so we take the 50 and that’s it, we just start with the 50. We do not need a smooth surface for that because we have some adhesion and then that’s why we have that medium grits in between. [Jaz]Very good. And I think the next question from this is when we are looking at the different types of burs, because it makes sense to me why there’s so many blue now that I see because your answer just answered that. But now we’re seeing also some clinics that are using the disposable one time single use diamond. So I would love to know when I speak to some clinicians, they say, I am a prosthodontist and I need to prep quickly. And so I don’t want to use a diamond that’s already been used because the efficiency is less. So if I’m using single use diamonds, yes, it might cost me initially to open the packet. And this is single use, you don’t get to use it again, but because the efficiency benefits it gives me, they prefer it. Do you think there’s any truth to this? Do you have any opinions or arguments in terms of, okay, what is better for a clinic? Or does it depend? Is a single use better or something that is a multi use like we traditionally have in clinics? [Günter]We would say that the single use is probably, if you’re in the high performance, it’s good for a very short job. Let’s say if three minutes or five minutes separation, that’s okay. But then the performance starts going down. So in multiple use bur, they have much longer performance. From Intensiv, you can easily count on 30 minutes performance. So just guess, making a crown preparation and choosing a single bur half of the job or quarter of the job, you need to reload a new bur. Then you get the second bur, then you reload again and get that bur you know, that’s what we know, that what is feedback from our clinicians that the single bur drives me crazy because I have to reload always because they get weak very fast. The multiple job bur gets works much longer for longer jobs. For the shorter jobs, of course, it’s wonderful because we have multiple use. You would name the cost, single burs. I always tell dentists when they come to me and tell me why I’m taking seeing it, but cost only $1 that you’re very rich, you know, we are really rich because a multiple bur costs you $10 and use it 20 times. So you pay half, so okay. I didn’t know that. And maybe sometimes people then do not make really calculation what it means having a single per year, maybe the one cost, maybe good. [Marcella]Then I’ll supply it by all the time you need to get a new bur. And another thing is that the feedback we have from our doctors and clinicians we talk to, we feel that multiple use is still the major direction that dentists are going towards. And for various reasons what Günter mentioned now, but also, the fact that to have a sustainable, just single use on the market industry is not ready yet. Because this would mean a lot of raw material. Think about all the burs that we need to multiply by 10, 20 in comparison to what is already now around. There might be in the future, we don’t know, maybe for regulatory reasons, some pressure worth to go in that direction. But, not so far. [Günter]Not seen on the horizon. Nothing seen. And we see some trend in some countries, especially the United States, the United States, you may divide already a little bit half of them, they’re using single coarse, but not really single, what we know is they take it a second and third time, and then the other one, they take the multiple ones. What Marcella said is about the industry, it’s right, if you would guess 500 million words per year in production worldwide, just the guess, I don’t know that this is exact, but more or less it should work. And then you multiply that by 10. The industry is not ready. We do not have the capacity to do that. And the other point is we can’t get the cost down, you know. What I have heard from many friends from myself is that they say, you know I would go for single bur if I pay 30 cents or 40 cents per bur. It makes sense to do that, I say yes, this is probably the multiple bur cost by time. It’s okay. But yeah, we have metal as raw material. We have diamond crystals. It’s not feasible. The raw material doesn’t deliver that cost. It’s simply not possible to do so. [Jaz]I bet that most of the Protruserati, our colleagues listening and watching today did not know that a standard bur should be used for 30 minutes before it starts to lose its cutting efficiency. So, I will include that as one of the questions in the quiz for the certification at the end. So for those listening, watching, remember this answer of 30 minutes at the end. And I think, you know what? There’s always a role of something, right? And I do think that perhaps the kind of environment where the single use could be beneficial is if you run an emergency clinic. And trying to disinfect things is maybe a bit more difficult between patients. And you need to literally go inside and get to the pulp and put some medicine in and that’s it. And you’re just drilling time is two, three minutes only. That might make sense in emergency clinic. But for someone who’s doing preparations and crown preps, it makes sense that you get more, a better cost effectiveness of using a more traditional bur. Now, when we are talking about cutting efficiency and time of cutting. Basically, you mentioned something very interesting at the Valencia lecture, and you meant you were talking to the dentist. You were saying that your diamonds are I think you used the word natural. Is that right? Your diamonds are naturally sourced. And later I asked you is I have no idea what that means. What’s the difference between naturally source and what’s the alternative. So teach us about where your diamonds come from and why is that significant? Interjection:Hey guys, it’s Jaz. It’s interfering to ask you, have you joined Protrusive Guidance yet? It is the community, the nicest and geekiest dentist in the world. We have kind of geeky discussions just like these. We talk about cases, we talk about clinical techniques to improve our success and ultimately benefit our patients. We do manually verify that each person applying to join the community is a dentist. So we will ask for certification and we will look you up. So bear with us in our manual verification checks, but this is super important to create this a safe and thriving network. You can access on your laptop or your phone by going to protrusive. app. That’s the website, or you can just download it on iOS, Android by typing in protrusive guidance. If you love Protrusive, you’ll love Protrusive Guidance. I hope to see you there. Let’s join back to learn more about diamonds. [Marcella]Yeah, I can start. So, first of all, diamond is the solid form of carbon in a crystal matrix, okay? So, it, in nature, it is produced over time with extremely high pressures and extremely high temperatures down underneath in the earth mantle, 150 to 250 kilometers usually. And in billion years they develop and then after volcanic eruptions, maybe they come up third phase. They are brought up by the volcano and then they can be harvested and then they can be used .So, through this process you get a natural diamond, which has a very unique feature. Well, in general, diamond is the hardest material on earth, and so it can basically abrade any surface, any material. This is why it’s so important in dentistry. And also, the diamond crystals are very irregular, and they have sharp edges. And these features make natural diamonds perfect for doing this abrasive job in dentistry. I don’t know if you want to add something. [Günter]Maybe the audience may be interested how we get that, how we get that small pieces, so that’s in it. We do not take this one, the brilliant, no, no. This is for jewelry. Everything what is found larger than a millimeter or two goes to jewelry. We get these piece of very, very small crystal, like a sugar crystal, or even less, more than a little bit crystal. And this you find in the sand of the desert. For example, in the desert of the southern Afrikan part, it was million of years, this was volcanic area. There’s a lot of diamonds, the most diamond mining is in that areas. And they find it in the sand in the sea sand in the desert sand. So let’s take 20 tons of sand filter that and get then the crystals out, the small small 1%. This is for industry a big profit from this we get it from this. Then these are sorted out in different microns, we take out all the 14 microns all the 16 microns. And as Marcella said, we are very good at making the sortings, the sorting of it. The other companies, they say, okay, ISO allows me to get a broader range, so I can make a more or less sorting, and Intensiv would take a very precise sorting of these crystals. But interesting is that we take it really from nature. Industrial means that they just take carbon, put it in the oven, making heat. Making pressure and get it out some hours later. So the difference is millions and some hours, and then that’s- [Jaz]And so how does that relate to the, is that actually imparting difference in the quality of the final product in terms of the cutting efficiency, this in the oven, a couple of hours versus millions of years. Is that actually a difference? [Günter]Well, we would say, yes, there is a different, especially in the shaping and in the pureness of diamonds. When you get that naturally done, you need to get forms for that. And you need to build that into forms. Normally they use metal forms. Then all these diamond crystals, they have metal substances in. And you’re taking the bur on 200, 000 turns per minute, and with the metal substances you get heat. You have much more heat and with the diamond crystal from nature, it has nothing just carbon. And although that that’s one of the major difference in using the heat, the cutting, the performance of the diamond is different. You can take the natural diamond is probably more compact than the crystal of the industrial diamond. So when we say to our dentists, they say, sometimes the diamonds are smaller on the bur. No, no. It’s not, you’re just seeing the diamonds deep into the matrix. You just see the iceberg, not really the diamond, the other diamonds, which has been before on the earth, they’re gone, they’re off, they’re not used up, never a diamond, the natural diamond never used up, they won’t break. [Jaz]And so I guess the next logical question is how are the actual diamonds fixated to the metal shank? What’s the technology used to actually put the diamond on the metal? [Günter]That’s something for Marcella. [Marcella]I can try to explain. So we use the electroplating technique. This means that we have a special electroplating containers containing the liquid for electroplating. And then we have diamond crystals inside this liquid and of course we have our instrument inside as well which needs to be coated. So the electroplating starts, we have metallic ions, which are deposited through electroplating on the surface of the bur, and as they deposit and they form a metallic layer, they embed the diamond crystals, which are inside liquids. Now, to give you an idea, maybe it would be nice to have a picture, like an image in mind. So, we can think about a nice mountain lake, for example. So this lake has all sorts of parts, pieces inside, wooden pieces, for example. Yeah, they’re floating on the surface, or maybe inside if you’re soaked with water. What happens when winter comes? So the lake, the water freezes, and as it freezes it gets harder, and these pieces which are embedded inside, they get fixed. They are stuck inside the frozen water. So you can think of the diamond coating on a bur just as this mountain lake. So the frozen water is like the metallic matrix and the wooden pieces inside are like the diamond crystals which get fixed, embedded and fixed and hard, very, very hardly stuck inside the metallic matrix. And I hope this maybe was a nice picture to imagine how the process works, but the official term is electroplating. [Jaz]And so when we’re using these burs, and they are losing their efficiency, so let’s say we’re getting to a bur that’s been used for maybe 40 minutes, beyond that 30 minute, is the diamond, and maybe you’ve already mentioned this so I apologize, but is the diamond actually becoming smaller, or is it becoming less sharp, or is it actually breaking away from the metal? How is it losing its efficiency? [Marcella]The diamond is staying exactly the same. It’s not getting smaller in shape, it’s maintaining its sharp edges. It’s just the fact that it’s been released from the matrix. [Günter]Break out. [Marcella]It breaks out. [Günter]Yeah. It breaks out with the time. We have an outbreak already in the first minute, because we have some always on the shank, which is not anchored that much into the lake. In the frozen lake, let’s say, and then there are pieces that are much deeper into the frozen lake, it’s half in or two thirds in, they stay down there. So then you can estimate that at the end, you may believe that they are used up or gone bad, you’ll see only the small tips out of the frozen lake and then the hot the large pieces inside. So because you can’t use up the nickel matrix, oh, that’s not possible. You can’t get the other ones, the ones and the nickel markets inside. They’re gone They are in. [Jaz]This is when we’re looking at a bur that we’ve used for a long time, we see that the color, there’s almost like a color difference, right? You’re seeing more metal show through. So my final question is a very clinically relevant one is the following. And we have this problem in our practice where we use burs that go to the autoclave and they come back and we have these certain bur pots and all the dentists use them. And the most frustrating thing as a dentist is picking up a bur and it’s no longer fit for purpose or already been used too much. And I hate that so much. So I’m very hot on, if I see a bur that is a bit knackered because look, the bur does not tell us, oh, I’ve been used for 27 minutes. I’ve been used for five minutes. I’ve been used for four or five days. We need to look and guess. And so can you give us any clues for our dental assistants, nurses, and dentists, when we are looking at a burr, how much magnification do we use, what are the telltale signs that maybe it’s time to order a new bur? [Marcella]So I can mention maybe about the signs, which allow to understand if a bur needs to be replaced. When you see that, if it’s totally metallic in color, you don’t see any more diamond means that it’s totally worn out. When you see 50 percent of diamond coverage, that means that it needs to be replaced. Half, more or less half. This means that it needs to be replaced. I would say that. May I add also another thing that if the bur looks white, then this means that it has enamel or ceramic debris clogged or composite clogged. And so maybe, okay, it’s not no longer efficient. The doctor tries to use it and has to apply a lot of pressure to compensate. It looks like it’s no longer working. And it will give heat, exactly. But the only thing is that it needs to be rinsed. And cleaned, and this debris and clogging removed. To resume it, to make it proper. [Günter]Never accept the white bur. And should never accept the silver bur. And absolutely hate the black bur. Because when the bur comes, black is burnt off, that’s gone, ultimately gone, but if you arrange between white and silver, it’s really good to tell the assistants, if you have a white bur, clean it until you can’t see any white spots on that, because we do not need them. It’s from the patient before and then the other one is if you see less than half average, take a new one in my bur block because it’s better for me, with the half coverage, I can’t work anymore. So it’s- [Jaz]I like this guideline of a half coverage. So this is a visual inspection that we do. I imagine it’s better with magnification, using loops and having a good look and seeing, yes, what kind of coverage there is. I wish there was like a quick test that you could do like, okay, yep, this is gone. This is not, but we have to rely on visual and hopefully before we start using the bur and realize that way. [Günter]We have the same wish, the same wish. So far we haven’t find the right feasible technique because it’s too much reflecting. The diamond is transparent, the metal is reflecting and whatever we try to do, it doesn’t work because it gives us different results. And, but anyway, what is properly nice for the office, for the assistant in the sterilisation room, you place some two photographs, the good one and the bad one, the half coverage and the full coverage. And they said to their assistant, when you see that with a half coverage, that’s gone. Whenever you see close to what I see completely, leave it, place it again, please. So to support that with the picture, because people love picture like this. [Marcella]People love picture. [Günter]Just telling them, look, is this half? I don’t know. Maybe just start this one. I don’t know. [Jaz]Comparison photo makes a lot of sense. If anything, someone’s going to be a superstar. Here’s what they do. They get a brand new bur photo and then they use it for like one patient and then they can photo, and then they use the second page, take it to photo. And then they have a series of the same bur. That would be, then you’re like the nurse kind of charting it. Like, where is it? Like a scale. That would be cool. Maybe you have this photo already and you can send it to me. [Günter]We haven’t done that yet, but we could make it, but please, there are more parameters, not just the usage, you know. I must admit that the 30 minutes with a status, it’s variable. There are dentists, they have good muscle. They are, right, strong, and they press. And then the 30 minute goes down to 20, because the burs goes off easier, because you’re pressing too much. Then there are very feminine dentist, they have a soft plan, very nice, very sensitive, they even give you 40 minutes, no problem. [Marcella]It’s actually the diamond which is doing the work, the creation, not the strength. So this is a very important concept. [Jaz]And the other thing to bear in mind here then is depends what you’re cutting, the substrate. Like if you’re cutting soft caries, that’s not going to do anything to the diamond. Whereas if you’re cutting ceramic and metal and you’re removing all, you’re cutting old crowns off and you’re having to work hard, that would obviously reduce that time. Is that a fair statement? [Günter]That’s absolutely correct. The most worth is zirconia. Zirconia is the most worth for diamond burs. Then we come really in the multiple yield bur becomes a single yield bur because of the material. However, industry is especially intense that we place a special bur for that with a special coating, a special extra coating to get the bonding better done. Because the key for zirconia bur is to leave the crystals in place. That was our goal and we found that after years of testing we found the bonding, which is more expensive of course, but it works much better to cut zirconia. So many dentists- [Jaz]I’ve heard and I’ve tested as well that a red grit or a yellow grit diamond is going to be better and more efficient at cutting zirconia. And, but yes, you’ll need to use a few of them than using a coarse burr to cut zirconia. [Günter]Of course, because the coarse is clogging, the coarse is clogging. In fact, in seconds, the fine grid, you must just imagine that’s fine or medium grid. You have many crystals on that piece. And the part in between the crystal is not that large. If you have larger crystals, automatically the path between the crystal becomes larger. But there are large neighbors, the neighbors. So that’s why the coarse ones are clogging much faster than the fine ones and the medium ones. You’re absolutely right. We are from the industry, we say the blue one. The blue one is the ideal one to start cutting zirconia. Oh, it’s good. And double water. Double water helps because of washing of the instrument. Yeah, the rinsing is really important. And then for secondia, just have an extra water supplied. It works better. It’s not because of the heat, it’s because of the cleaning. [Jaz]That’s very helpful because often in this scenario, we may need to cut off a zirconia. I personally have been using red grit diamond with good success. Yes, I’m able to use two, but I’m much quicker. Yeah. But if I change that bur quickly, I can get the crown off sooner than if I use, like, if you use a green, like just like you said, it makes sense. Like it’s too coarse. The clogging is happening. So, you’ve given a scientific reason for that. So I appreciate that. That’s all the questions that I had. Is there anything else you’d like to add that dentists should know about when working with diamonds. Like we covered a few important working tips, like, how to recognize when the diamonds worn out a few little tips about to think about the minutes we learned a little bit, a bit more about diamonds in terms of how it’s made and how it’s affixed to the bur. Is there anything else that you think educationally we should know? [Günter]Yes. We have many different sizes in the bur, the bur line. So many days that they ask and say why do I have a long cylinder short cylinder and so on and this is because when the time of burs used you better use a full surface of the bur. Never use only the tip or only the middle part, you know. That’s not good for the bur, it’s not good for the tooth. So, whenever you have the application, watch on the tooth. The tooth at that size, then choose the right dimension of the bur for that, to applicate the full bur on the tooth. When we have the occlusion to be done here, larger occlusion, larger egg. Smaller occlusion, smaller egg place. So, it helps a lot, because the burnout of the bur- [Marcella]More uniform. [Günter]Yeah, more uniform. The other one is, never use a bur for Endo, Exos because then you just get all this, I thought it grew out to make it old. [Jaz]So basically don’t use the standard crown prep bur that you rely on for making your margin for the endo access. Because yeah, you’re right, because we look at these burs and 99 percent of the bur looks amazing. And the most important bit, the tip is looking like pretty much metallic, the diamonds are gone and that’s not very good either. [Günter]Yeah, that’s right. That’s my addition here. Yeah, that’s right. [Jaz]Very useful. Very helpful. Günter and Marcella, thank you so much for your time. I appreciate learning about it. Please tell us more about dentists who want to start looking into different diamonds, your brand, how is it distributed? Where can they get in touch? Learn more about Intensiv. You obviously look after your product very much, your brand very much in terms of the quality of diamonds that you produce. I use your Swingle a lot in for IPR, as you know. Which is why we did the workshop together as well. But tell us more about how dentists can learn more for you guys. [Günter]Okay. Mostly dentists can learn on further education courses. We do support a lot of courses from university, from other institutes, but mostly dentists get our products in all markets through dental dealers. So we do work for dental dealer networks, like Shine Dental or Dental Director in UK or GACD in France or whatever, you know, name it. But this is, we never sell directly to the dentist. However, we are in touch with dentists. We have a website, www.intensiv.Ch for Switzerland, and we get contacts to many dentists. So whenever dentists have questions, of course, they’re invited to contact us directly. We love that. We love to talk to dentists. We go on exhibitions every year, maybe 20 or 30 days of the year. We are outside in exhibitions. We’re making ourselves a Congress in Lugano, which is a nice place to be because Intensiv is located in the south of Switzerland, in Lugano, in the Italian part. And we run a two day congress here every day, every year, with about 10 to 15 speakers from four different countries almost. And that’s a lot of things to get closer to Intensiv. And to learn more about application, about our instruments. [Jaz]I appreciate your time. And Marcella, you’re pretty much working full time with Intensiv at the moment. You’re a very scientific role. Thank you for your time. [Günter]Great. Thank you to the audience. A great thank you to you. You had wonderful work. Loved it. You are challenging us here a lot and look forward to getting more of that. Because it’s really good to get challenged and getting this discussion done. We love that. It’s nice. [Jaz]Amazing. [Marcella]So yeah, we look forward to more, hopefully. Jaz’s Outro:Appreciate it. Thank you so much. There we have it, guys. Thank you so much for staying all the way to the end. We now know why we should be using finer diamonds and not the super coarse diamond that you can find when you’re cutting off zirconia. And hopefully now we can actually be a little bit more astute when it comes to assessing our diamonds and knowing when it’s time to say goodbye and opening a fresh pack. Ultimately, your efficiency will be better and you’re actually not heating up the pulp so much. I want to thank Intensiv for giving up their time, Günter and Marcella. And of course, I want to thank you, the Protruserati. You can get CPD. You can get 45 minutes CPD or CE credit and a certificate sent to you by answering our quiz on Protrusive Guidance. There are hundreds of hours of CPD to be gained just from the episodes alone, let alone the premium content and the mini courses that we have on Protrusive Guidance. You can either pay monthly or pay an annual, and you get a bit of a discount when you pay annual as well. So if you’re not already part of the nicest and geekiest dentists in the world, do check out Protrusive Guidance. And I thank you again for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.

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Protrusive Dental Podcast

Episodes

Mentioned books

Step by Step Functional Crown Lengthening – PDP207

Exodontia for Beginners – Extractions via Avocados! – PS012

White Patches – When to Refer + Diagnoses ORAL MED – PDP206

Making Awesome Dentures – Border Moulding and Beyond – PDP205

Implant Occlusion that Makes Sense! – PDP204

Principals vs Associates – How to Foster Positive Relationships and Flourish – IC054

Endodontic Irrigation – How to Get Better Success – PDP203

Radiology and Radiography for Students – PS011

Elective Endodontics? It’s all about Communication – PDP202

Diamond Burs Made Tangible – Clinical Applications and Guidance – PDP201

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